In a time when a small town is shattered by violence toward its most precious asset, and babies nationwide are under threat of formula shortages, it is impossible to underestimate the power of community.

The tragedy in Texas belongs to other voices to tell. We salute them and send solidarity as their stories unfold and their arms go around one another.

Community is how rural people survive challenge. Being part of a community is not a “soft skill.” Like the mountains that surround our towns here in Southwest Virginia, community gives us backbone. And hope. And solutions.

In the baby formula shortage, people in my rural town are texting one another: this brand is at this store. I just found X at Y.

They can’t buy them for each other, because WIC vouchers don’t transfer, plus most stores have limits. So they do the best they can with the location and time alerts. With the high price of gas, a couple of neighborhoods have, when the “it’s at this place” message comes, will share gas prices in a single van ride to the store some 40 minutes away.

This is a place to be proud of, these strong, kind towns and hamlets that make up Southwest Virginia. We’re all in this thing called life together. Community is our watchword, and our go-to. We don’t take it lightly. If you are lucky enough to be studying here, don’t miss the opportunity to understand this life force in action. It will change your life.

Wendy Welch, PhD
GMEC Director

Before I joined the Lonesome Pine Family Medicine Residency Program in Norton, I took a long career break. I thought my biggest challenge would be getting back into medicine with younger, “fresh out of med school” residents. It turns out, that was not it at all.

I live in Kingsport, TN. Most of my rotations are in Big Stone Gap or Norton, VA. 50-mile door-to-door distance, it takes nearly an hour drive through mountain roads. I was excited about restarting my medical training, so the distance or drive was not going to dampen my spirit. Over the next 3 years, I tried different things to utilize those two hours a day. I tried it as my “thinking time”, to mull over various matters of life, friends, colleagues or patients, so by the time I am home, I am not carrying them in my head anymore. I also tried it as my talk show catch up time. I would pull them up in my phone and listen through the car audio. But near exam time, I started listening to the AAFP Board Preparation audios in the car. They were very useful, and they were presented by some great physician educators. Some of the presenters were faculty who make the board and in-training exam questions. I made it my routine to listen to them during all my drives to and from residency rotations. As I advanced in my residency, I started to feel intimidated by them. If they talked about something I was not familiar with, I would feel shame. They spoke about various medical topics as if they were common knowledge, yet I did not know anything about them!

Life became increasingly challenging between the pandemic turning normalcy upside down and trying to balance my residency and personal life. I began to get nervous about my ability to pass the exam. With a lot of encouragement and help from my wonderful colleagues and faculty in my program, I continued with my “prep”. I took my board exam in April and was expecting the results in 6 weeks. Imagine my surprise when I got a preliminary result of pass, one week after the exam!

I got the results during the day, and on my drive back I turned on the AAFP Board Prep audios. This time it felt different. I was not intimidated. Instead, it felt as though I was having a casual, knowledgeable conversation with colleague.

And now, I am ready to travel far as a doctor, in every sense of those words.

Manju Pushkas, DO

“…when the visit is over, I have solved one real problem.  Just one, maybe a relatively small one.  But that grateful patient, on that day, leaves armed with concrete information that will improve their health.  I didn’t rewrite history, but I put a ripple in the water. “

I had the audacity in my youth, to believe I could reform the US healthcare system.  I would personally crusade for–and open access to–high quality primary care for every American.  The federally qualified community health center, a model for comprehensive primary care, already existed; it just needed expanded access for all.  The necessary shifts in policy, payments and infrastructure were simple and obvious.  It was unfathomable that any American could not or would not agree on such a basic human need that benefitted individuals and communities both now and generations in the future.

I thought, as a physician, that I would prevail as the voice of authority and reason with policy makers, payers and administrators. Working in the trenches as a rural family doc in Appalachia would lend me experience and credibility.

I could not have been more wrong.

I am now a “mid-career” physician: tired, cranky and always behind on paperwork. I’ve seen so much that–while I haven’t seen it all–rarely does anything still have power to raise my eyebrow. 

From interest and necessity, I have worked hard to understand: clinical medicine, healthcare policy and healthcare administration, the intricacies of Medicaid and Medicare, how drugs are priced, the Affordable Care Act, and risk management, among other topics.

What I have learned after countless phone calls, letters, faxes and meetings, is that our healthcare system is a gigantic balled up wad of Christmas lights no one has the inclination or motivation to detangle.  It is impossible to penetrate, cannot be understood. It is illogical, redundant. Attempts to decipher it lead to a dead end and often a big shock.

I’m a slow learner, so it took time to accept that I failed to reform healthcare because it cannot be done. The realization put me in a brief slump, feeling as if I’d wasted my life hiding in the mountains instead of campaigning for justice for all.  What if I’d tried harder?

I could have chosen differently, spent my career crafting policies impacting entire populations.  But, at the end, did my work matter would still have been the haunting question.  I’m not convinced that my non-career as a policy maker would have gotten me much more than migraines and a retirement pot luck.

Instead, I’m a middle-aged country doc. No one outside my community knows my name.  My patients call me Ma’am, Hon and even Sweetie. I call insurers, pharmacies and specialists in front of my patients so they know I am their advocate. I have no special authority or power, repeating my identifiers and waiting on hold just like everyone else.

But when the visit is over, I have solved one real problem.  Just one, maybe a relatively small one.  But that grateful patient, on that day, leaves armed with concrete information that will improve their health.  I didn’t rewrite history, but I put a ripple in the water.  I find deep satisfaction in knowing that I made a difference for that patient on that day. 

And it is enough. 

Melissa L. Zook, MD, FAAFP, FASAM, HIV-S
Family Practice Physician 
London Women’s Care – London, KY

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Dr. Zook will be speaking at the
2022 Head for the Hills Conference
on November 4-5th in Abingdon, VA

Click here for more details on this year’s conference!

With myths of outdated equipment, poor quality of training, and little variety in clinical cases, Rural Medicine often comes in last place on the list of dream jobs.  Of course, this couldn’t be further from the truth.  As a former Internal Medicine resident in small town, rural America, I found that Rural Medicine provided an idyllic scenario with a high autonomy of patient care, a wide variety of patient cases, and endless opportunities for procedures and “hands-on” training. 

Not appreciating what I had experienced during my training, I chose to practice in an urban area with lots of amenities and larger hospitals.  I’ll summarize my experience with the cliche “the grass wasn’t greener”, and you can guess what happened – physician burn out.  Having now transitioned to Academic Medicine, I am often reminded of my rural experiences as I hear medical students gush about their experiences in rural hospitals – being a vital part of the healthcare team, immersed in direct patient care, first in line for procedures, and in close relationships with their patients and colleagues. 

A 2019 study from the University of South Dakota Sanford School of Medicine reported that physician burnout rates were lower in rural areas (25%) in comparison to urban areas (51%) with the following contributing factors: having more autonomy in your job, having closer relationships with patients, and having a greater variety of duties at work.  Of course, this study had reported exactly what I had found to be true.  My please to you – when it comes to choosing your career, please don’t make my same mistake. Instead, rewrite your list of choices with Rural Medicine at the top – your Field of Dreams.   

Cassi Jones, DO, FACOI
Director of Clinical Affairs
Assistant Professor of Internal Medicine
DeBusk College of Osteopathic Medicine

The Graduate Medical Education Consortium board met recently for a strategic retreat. Since we had new members, the dreaded icebreaker appeared, that activity collegial strangers detest in professional gatherings.

It was a simple icebreaker: answer the question HOW DID YOU GET HERE?  As the nine board members described their routes into medicine and academia, a pattern emerged: a spiral.

Not a one of these high flyers took a straight path to their destination. One read a book in sixth grade that made her decide—with no background in the family and limited opportunity in her secondary education—to become a doctor. Another left his job as a mail carrier after a chemistry professor told (perhaps even kindly bullied) him to take the MCAT. One drifted toward law school, only to be diverted by a family friend who said he would make a good surgeon because of his interest in working with his hands. Three or four of us were pushed into academic roles by people we had casual friendships with, who encouraged us to exert influence on policy as well as students.

The point being, the path to any career satisfaction is rarely a simple straight row, more like a big squiggly line that involves numerous fallbacks, moments of questioning, and without fail an advocate. Usually this voice guides and supports from within an existing relationship. And quite often, the job one winds up doing is not based on any prior knowledge of how to do it. (Uhm, that’s not true for the surgeons, btw.)

One board member described her learning curve going from the ministry into medical education as steep, fast, and friendly, because she was hand-picked by a colleague to take on a difficult role, based on his observations of her skills. She had not aspired to the leadership thrust upon her, but a decade later is adept at running the department, even though she described herself as “still feeling more lucky than skilled.”

Imposter syndrome abounds, but as the stories emerged, so did that spiral pattern, circling a core of relationships and networks. As one board member observed, “once you’re inside the field of medicine, you can go about anywhere. The opportunities are daunting, so many exist.” A fellow board member (provost of a regional college) added quickly, “Or Academic Administration” and the board members laughed and agreed.

It is as true in Southwest Virginia as it is in any part of the world: relationships build careers, and careers build relationships. That’s a good thing.

Wendy Welch, PhD
Editor
“Masks, Misinformation and Making Do: Appalachian Health-Care Workers and the COVID-19 Pandemic”