Challenges in Rural Medicine

When talking about the community in which Daniel Singleton practices medicine, the word "underserved" might actually be an understatement.

Singleton, a family medicine physician from Buena Vista, Ga., says the closest hospital to his solo practice is 30 minutes away. "One of the major challenges to providing primary care in southwestern Georgia is that there are no doctors…well very few doctors. We have a healthcare deficit of 35 primary-care providers," he says. "It's significant."

As a young doctor, just four years out of residency, Singleton undoubtedly could have gone down a more familiar path that others his age have taken. He could have worked as an employed doctor, either for a practice or a hospital, in a large metropolitan area. Instead, he went to Buena Vista - his hometown - and opened up his own practice.

Those four years have been filled with ups and downs. Singleton spoke with Physicians Practice about the challenges he's faced in patient education, technology, and whether he can continue practicing independently in today's environment. Below are excerpts from the interview.

What are some challenges you encounter with practicing medicine in an underserved community?

It's the same challenges everyone has working with an underserved population. Generally underserved means lower socioeconomic status. From that, you have [lower] levels of education and understanding of the disease process, and all the other socioeconomic strains that cause most of the [problems] we have to deal with in the healthcare system. It's rural poverty.

I'd say 80 percent have multiple chronic diseases. We're kind of like a food dessert. My patients don’t have access to reliable nutritious food. They haven't had access to reliable primary care for more than a generation. No one has ever told them they can't eat Cheetos if they are a diabetic. And it's not like there are many other options anyway.

What makes you continue to serve in these communities?

This is my hometown. This is where I grew up.  Geographically, we're not that isolated. We're an hour and 20 minutes from airport in Atlanta. … We're 25-30 miles from any big box store you're going to look for.

Also, I was a Peace Corps volunteer. I enjoy challenge. I enjoy service. I enjoy dealing with some of the socioeconomic problems associated with healthcare. This was a perfect opportunity coming out of residency to see if I could make this work as a private practice.

I've been at it for four years and economically we do OK. I am concerned with changes going to happen with MACRA [Medicare’s payment reform] and whether or not practices like mine can survive the changes. It's difficult to meet the human resource requirements to make some of that stuff happen. I try to take advantage of technology all of the time … in order to make my life more efficient.

Speaking of which, tell us about your history with tech at your practice.

My [practice's] first [EHR] had been set up before I got here. My nurse practitioner knew how to use it, so we kept it going when I got here. … There were never-ending compatibility issues, it'd go down and you'd have to restart it four to five times per day. It was never going to meet Meaningful Use standards. It was cumbersome [and] tedious. You'd have to click on little boxes that didn’t mean anything. I knew I didn’t want to spend much time on that system.

I was exposed to an [EHR system] in residency. The physician who ran that practice was level headed and thoughtful, and that's the [system] he decided on, so I felt like if he thought it was a good idea, it probably was a good idea. It had the added benefit of being free. For a small, solo practice like mine … this was kind of an easy choice to [make]. … I'm not afraid to change something that doesn't work. A lot of times, other physicians get in a situation where they don’t understand the product they are looking for. They get sold of bill of goods and it's inefficient, doesn't do what they want it to do. … I'm educating myself and keeping my eyes open to what other people are using.

As a small, solo practice, you've met Meaningful Use standards and figured out a way to not be hampered by technology it seems, what's the secret sauce?

I'm very protective of my time and my mental energy in dealing with something. I see between 25 and 40 patients per day, depending on the day and how things are going. …I'm very protective of my time and I don’t tend to kind of go along with whatever …

We educate patients to follow a certain procedure and do things in certain way, so we can maintain efficiency in order to take care of them ... My time is what generates revenue that keeps going.

For me, anything we've done, I've always looked at how can we make this efficient? How can we make it so I don't have to do everything myself. Doctors sometimes have trouble releasing that control. I have no reason to micromanage things. My staff knows what they're supposed to do and they know behind the scenes, I'm watching. That's a management issue, work with people you trust, train them to do things you need them to do, and make your life more efficient. Get the work you have to get done in order to get paid.  

How do you keep hope alive with all that's going on in medicine, what's your advice to others?

I have only been practicing for four years, so maybe the reason I'm hopeful is I'm not burned out and jaded yet. But to me, the way you maintain – particularly in medicine –hope … a lot of it is to talk about your motivation for being a doctor and what you do on a daily basis. Medicine is service first of all … service is very important. Relationships you have with other people are important to your own mental health and to their mental health.

Where [doctors] run into trouble is when they forget to remember that if you keep the patients' interest as your guiding principle, the decisions are easy. You can't take shortcuts. Whatever the patient needs, whatever needs to be done, you'll try to do to the best of your ability. I think that keeps you from being burned out because you're rewarded by the service you give every day. That keeps you from being emotionally and mentally burned out.

As far as surviving the economics [of medicine], it's important for doctors to advocate for their own benefit. Think about what's important to survive. No one wants to hear about the poor little doctor who only made $190,000 last year. A certain amount of humility and gratitude for the life we're privileged to lead is important to maintain perspective. But a lot of times people get themselves into bad situations and can't figure a way out.

Quite honestly, in the next year or two, I will likely sell my practice. Not because I'm selling out … but without some stronger institutional support, I know I can't carry the burden of entire community's healthcare on my shoulders. The decision to move forward to sell or not sell … it's not because of me. It's not because I want to make more money. It's because the people I take care of deserve better than what I can do myself. It's hard. I feel sorry for the people who are so embittered and resentful to the way things are now. It's a hard job, but at the same time no one will feel sorry for you if you didn't make $250,000 or half a million. Suck it up and be grateful you have a job where you can make a positive difference in someone's life every day.