Book Review
Rural Medicine Revisited
A collection of essays takes us into the lives of small-town physicians.
Review by Charles R. Meyer, M.D.
His tanned, cracked hands shook slightly as he held the emesis basin, vomiting bright red blood almost continuously. Stoically, he swallowed the large-bore oral gastric tube we used in those days to lavage the stomach with iced saline in patients with a GI bleed. Stoic was the cardinal word for this Iowa farmer who, for the past several weeks, would pause briefly while driving his tractor, vomit blood, and then continue his plowing. Only when he was too weak to walk did he come to the Mayo Clinic, where I was the admitting resident.
My Iowa farmer patient from long ago surfaced in my memory when I read about Elwin, a farmer described in Donald Kollisch’s story “Good Will,” one of the essays and poems about the practice of rural medicine contained in Therese Zink’s collection The Country Doctor Revisited. A victim of valvular disease and congestive heart failure, Elwin insisted on baling hay, more than once triggering a bout of pulmonary edema. Reluctantly, he came to the hospital, telling the ER staff through his gasps that his stay would be short and that he would return to his John Deere. Patients from the farm seem to be made of different cloth. And, as all the pieces in this multi-authored collection show, medicine in the crooks and crevices of the U.S. countryside has a different weave than that of urban or suburban practice.
A family physician and associate director of the University of Minnesota’s Rural Physician Associate Program, Zink explores this countryside drawing from widely scattered sources to highlight the heterogeneity that is rural medical practice today and to portray the beauty, struggle, and pathos of the daily lives of rural practitioners. In her introduction, she says that she hopes to “inspire young men and women to learn more about being healers in rural communities … and pursue the education to join the struggling labor force of rural health care practitioners.”
Rural physicians have unique challenges. They see their patients at church, in the grocery store, and at the barber shop, seemingly never separated from their practice and always under the watchful eye of the community where “you have to be careful about a bad PR rep at church or in the beauty shops,” according to North Carolina family physician Tom Bibey. Yet most of the authors in Zink’s collection such as Maine family physician David Loxterkamp see the small-town connections as advantageous and pleasurable. “It is easier to be a family doctor and to feel a sense of connection and interdependence in a small community than it is in a large one,” he writes, “just as it is easier to sustain one’s religion in a monastery than in a mall.”
But those connections can hide ethical land mines as physicians take care of fellow townspeople who are such good friends that the professional and the personal intersect. Pediatrician Megan Wills Kullnat explores those dilemmas in her essay “Boundaries,” which is drawn from her experiences during a medical school rotation in rural Oregon. She discusses the pitfalls of the lack of privacy and the conundrum of what to say when. For example, she emerged from her rotation convinced that small-town patients liked encountering their doctor in “social situations [that] reinforce trust and confidence.” She writes: “If you don’t know your physician, how do you know you can trust him?” Physicians “have to follow the standard of care as you would with any patient. If it’s a friend, you have to be extra conscious. Keep asking yourself, am I doing enough here? Am I doing more than I would for anyone else?” Kullnat concludes that this is controllable.
Whether on a house call or in a small clinic, rural physicians need to work with less, Zink and family physician Tara Frerks note in their introduction to the section “Whom We Serve.” They write: “The geography isolates you, you confront the limits of your knowledge and your resources, even with today’s technology. You learn to work with what you have and discover the confidence and creativity it takes to ‘go it alone.’” Go it alone is what Joseph Gibes did in “If You Don’t Have What You Want,” performing a home circumcision on an Amish infant with an eight-inch steak knife, the only sharp instrument around, or what Emily Kroening did in delivering an Amish baby by oil-lamp light and wood-stove heat.
To a city doc like me, some of the scenes in these pieces sound like cuts from a foreign film: “Kent raised the manure-splattered tailgate of the livestock trailer to let his cows enter the chute into the Farmers Livestock Auction stockyards. This was the last truckload of his 130 cows that were scheduled to be sold at today’s auction.” Yet any physician will find familiar strains in these rural docs’ stories about their professional lives; for whether we take care of Iowa farmers or Minneapolis executives, we need to be connected to our patients. As David Loxterkamp said so eloquently in his piece “A Vow of Connectedness”: “Most of what the doctor accomplishes is infinitesimally small, barely a quiver, broad and trickling like the St. John’s River for those who are succored in the watershed of our care. We are stewards of a human ecology. Our practices are strengthened by diversity, interdependence, and the desire for our mutual long-term survival.” MM
Charles Meyer is editor in chief of Minnesota Medicine and practices internal medicine in Edina.