|Author: by Michael Samsot|
|PA Finds Challenges in Rural Medicine|
|There is a large migrant worker population in and around Lyons, Georgia, which brings its own array of challenges to practicing medicine, says Physician Assistant William (Bill) L. Dougherty. "What would be routine expectations in a different setting encounter obstacles here – maintaining regular evaluations for chronic problems, trying to get compliance from patients who are transient, and communicating with patients through interpreters," he explains. "Plus, there's also the problem that many of these patients are uninsured, and it can be very difficult to assess their conditions with their limited resources."
Dougherty has been a PA at Meadows Regional Medical Center in Vidalia, Georgia, since July, 1997, when he retired from the U.S. Army as a Captain. He had been first an orthopaedic technician, and then (after 1990) a PA with the Army. Now he works at the Medical Center, which is a JACHO-accredited, level 3, rural hospital. With four outreach clinics, it serves not just the town of 10,000, but the surrounding rural area that includes several counties.
"One of the biggest problems we have is that the migrant workers—who are a large part of our patient population—are normally here for only a couple of months at a time," Dougherty says. "They're here gathering pine straw [pine needles], or picking tobacco, or pulling onions—and then they move on to another area to help harvest another crop." While there are some workers who do stay in the area year-round, he says, "they go from one area community to another to help with different crops, and it's not easy for them to get back to the clinic where they've been seen before."
Dougherty praises Beatrice Shapanka, who is the Migrant Coordinator working out of the local Health Department. "She's really good about working to get these patients to come in regularly. This is important," he emphasizes, "because a lot of them are diabetics or hypertensive. Usually, while they are here near our clinic, we can see that they get their medications on a regular basis—but that might last for only a few months. Then they go somewhere else, and we might not see them again till the next year, and during that time, they've had no medication. So, when they do come in again, they might already be having organ damage from not taking blood pressure medication or diabetes medication for months."
Shapanka frequently comes to the clinic with the patients because she can translate [from Spanish] for those who speak no English or don't speak it well, Dougherty says. "The workers have to go see her first, anyway," he notes, "to see if they're eligible for the Migrant Program, which helps to arrange and pay for treatment. If they are, they're given a piece of paper to bring with them that basically gives permission for them to be treated under that program."
Sometimes, Dougherty says, "if it looks like Beatrice is going to be really busy, she'll get a group of the workers together and bring them all up for treatment at the same time, so she can do the interpreting for all of them. This is very important, because if they don't understand the medications and the directions, it could be a horrible problem.
"One patient that I just saw just this morning came in with the complaint of a sore throat. After we treated that, he said, 'By the way, I have this small swelling in the groin area,'—and his scrotum was the size of a football! He had an inguinal hernia that needed to be fixed, but he hadn't qualified for payment from the Migrant Program," Dougherty says. "I think, 'How can this guy work like that?' but he said he had no pain, and he wasn't worried about it because it didn't hurt.
"Right now, though, Shapanka is aware that I want this patient to see a surgeon and she's working as we speak, calling local surgeons to see if someone will do the surgery for free. The Medical College of Georgia will sometimes do surgery free for our patients," Dougherty notes, "as long as they don't feel that we're sending them everybody we've got. Because they see that we are a community trying to take care of our patients—and see that others are helping too—they're good about helping out.
"We're about one-and-a-half hours from the nearest larger medical center—Savannah," he says, "and we do sometimes send patients to a larger facility; but we are surprisingly well-covered for a town this size. The town has four OB/GYNs, three surgeons, a pulmonologist, two cardiologist groups, a number of internal medicine physicians, and a couple of family practices. There is also a pediatric clinic, a urologist, and two ENTs who come in on alternate days. Plus, we just got a new orthopedic surgeon, and a new gastroenterologist who come in on Fridays."
Within the four clinics of the Medical Center itself, the healthcare providers are "two doctors, two PAs, one nurse practitioner and four LPNs," Dougherty says. The clinics are the R.T. Stanley Health Center in Lyons, the Treutlen Medical Center in Soperton, the John W. McArthur Health Center in Mount Vernon, and the Tattnall Family Health Center in Reidsville. "All are outreach clinics, and I spend three days a week at the one in Lyons." Dougherty, who lives in the nearby town of Vidalia [home of the well-known Vidalia onion], says it takes him two minutes to get to work on those days. For the other two days each week, he rotates among the other clinics.
"The R.T. Stanley Health Center, by the way, is named after a man who was one of the biggest Vidalia onion growers in the area," he comments. "The community thought a lot of him. He's deceased, but his daughter, Barbara Dismuke, works at this clinic now as the insurance representative." Another person Dougherty mentions is his own supervising physician. "Still going strong, my supervising physician will be 82 years old in December," he points out. "Dr. Doralea Harmon—she's been here at the clinic since 1994, and when somebody's on vacation, she often works 12 hours without a break. She's amazing."
Besides clinic practice, Dougherty also precepts students preparing for careers as physicians, physician assistants, nurse practitioners, and nurses. "I enjoy this a lot," he says, "because their views often make you think of things you might not have considered otherwise."
He describes the process. "In the beginning, students observe what we do, then we encourage them to do the same things they have seen. We ask them questions and try to get them to come up with patient evaluations. When they're new, initially they tag along with us, but as they become more familiar with the procedures, we want them to do more. We have a saying with preceptored students: 'You see one, you do one, you teach one.' While we want the student to do as much as possible, we still go behind to make sure the diagnosis and proposed treatment are correct," he says. "After seeing a patient, the student must go through four steps: Present the patient's case history to me—including family history, pertinent past history, allergies, current medications, etc; Present a review of systems—including chronic problems that the patient may have in each body system; Present a review of the patient's examination; Come up with what their own diagnosis is and with what they think is the appropriate plan of treatment.
"If I feel that their recommendation is appropriate, even though it might not be exactly the same thing I would do, I don't make a change. I would stop a student," Dougherty says, "only if I thought they were doing or ordering something that was unnecessary, inappropriate, or harmful. At the end, I sign off on the students' charts and my supervisor reviews all charts, mine and the students'. It's a good system."
Dougherty recalls the early days of his own medical career, which started in the Army, where he trained as an orthopaedic technician—and later trained to become a PA. Just after graduation from PA school, Dougherty recalls, "I was stationed in Germany. After about a month there, I was shipped out to the Gulf War and arrived in Saudi Arabia in January of 1991 and had desert duty for several months. After that, my next assignment was back to Germany for another two-and-a-half years."
In the summer of 1993, he headed for Ft. Campbell, Kentucky, where he had several duties: "I was a Battalion PA, for a brief time was an interim Division PA, and then I became an air medical PA, for which "we received the same basic training that flight surgeons receive," he says. "We went through the flight surgeon's school in Ft. Rucker, taking a short course that taught us about aviation and about how to do the aviation physicals. We got to do a little front-seat flying—of a helicopter—because to maintain your credentials as an air medical PA, you have to have four hours of flight time each month.
"Each pilot has to have a flight physical once a year—and I did these for about two years. It was a lot of work, too, because Ft. Campbell had the largest aviation brigade in the world. With three or four of us working together, a mixture of PAs and surgeons, we were sometimes seeing 60-100 patients a day. The PAs learned how to do drug screens, which we performed when the flight surgeon wasn't available. We learned to watch for signs of pilot fatigue, which can hit when a pilot is working too many hours.
"It didn't happen often, but sometimes either a flight surgeon or a PA would go up with a pilot to do some medical evaluations in the air—like how the pilot was mentally handling going back up after being grounded, or checking out a range-of-motion problem. Either an air medical PA or a flight surgeon can ground a pilot," Dougherty notes, "but only a flight surgeon can actually give the certification to put a pilot back up again."
After he retired from the Army in 1997, Dougherty landed in Georgia, and says that the particular patient makeup in his region elicits from him some of the same medical questions he had to consider in the Army. "Some of these people live 20-30 people in a house. Because of this, I have to think 'TB' with every single patient from the migrant population. I have to think 'hepatitis' a lot—we probably get one case of hepatitis a month, occasionally more. TB is about the same, or maybe a bit higher. When a patient comes in with an intermittent fever, I have to think 'malaria.' I have to think like I thought when I was practicing in the Army."
Dougherty says that being alert to the possible unusual diagnosis can be of tremendous importance. One particular patient he remembers had symptoms that sent up flags for him. "I was treating a gentleman of about 50, who had just finished a 'tour of duty' in a correctional facility—a long term for a drug offense. He had been there for five or six years and had been complaining for some time about very severe, chronic back pain.
"The first thing you often think in a situation like this is that the patient is exhibiting drug-seeking behavior. But we went beyond that and did a rectal exam. I found a nodule, which indicated prostate cancer. We ordered a PSA, and it was really elevated—and he did have prostate cancer, which can cause low back pain. He was treated with chemo, his cancer is completely in remission, and his back pain resolved.
"You realize that while you are looking for the common diagnoses, you also have to be alert to the possibility of something out-of-the ordinary," he points out. "You have to remember a frequently-quoted saying that 'When you hear hoofbeats, it's not always horses; sometimes there are zebras out there.'"
William L. Dougherty was U.S. Army-trained as a Physician Assistant. He earned his Bachelor of Science degree in the Physician Associate Program in 1990 through the Army program. He attended Phase I of PA school at Ft. Sam Houston, San Antonio, TX, and Phase II at Ft. Hood, Killeen, TX; the school is affiliated with the University of Oklahoma, Oklahoma City. Dougherty had previously been an Orthopaedic Technician, also U.S. Army-trained, in 1978, at Fitzsimons Army Medical Center, Aurora, CO. His wife, Cynthia, is also retired from the military, and was a laboratory technician.
Michael Samsot is a freelance writer in Fairfax City, VA. She is on the Editorial Staff of NEWS-Line for Physician Assistants.