Was I Underresourced?

I recently transitioned from a rural practice into an urban practice. I spent nearly a decade being told (and often feeling like) I was practicing in an underresourced area, defined here as limited access to specialty care and certain testing as set by urban standards. As a full-spectrum rural family doctor, I delivered babies, staffed the emergency room, admitted adults and kids to the hospital, and still managed to be in the clinic 4 days a week. I have now transitioned into an urban practice in a large metropolitan area where I maintain the full scope of family medicine including inpatient and obstetrics at a level-1 trauma center.

My greatest realization as I have transitioned is that I was never underresourced. I was appropriately resourced in my rural community. I absolutely had times of feeling underprepared, especially in the emergency room or on labor and delivery. But in those times, I had access to a network of colleagues who could support me. We had telestroke services and a number to call when we were managing a complex trauma. We had the direct line to an on-call NICU doctor if we were expecting a preterm baby. Most importantly, I had my rural physician colleagues, whose phones were always on, always ready to offer help. And yes, I still had to manage these cases, but I had support. That support, whether from a specialist via telehealth, a colleague on the phone or a fellow family doctor coming in to back me up on a complicated case at 3 AM, gave me the clinical courage I needed to provide the right care at the right time.

I was once caring for an uninsured farm worker in the clinic who had a red, painful eye. After taking the history and a careful examination including fluorescein, I was 95% certain this person had herpes keratitis. My initial reaction was that he needed to see ophthalmology as soon as possible, but they were an hour away and the patient was uninsured. I called the ophthalmologist and he called me right back. I relayed the patient’s history and the opthalmologist was able to view a secure image of the dendritic lesion I had seen on the fluorescein exam. He agreed with my diagnosis and gave me some tips on treatment, when to follow up, what to expect, and when to call him back if things were not going as planned. It saved my patient a long car ride and an enormous bill. This endeavor put me behind in the clinic but overall it was a joy to be helpful and learn something new about managing a complex problem (which I did again a few years later without calling for help). The patient had a great outcome with me, as their generalist, getting some well-timed guidance from the specialist.

I now practice in an urban setting with dozens of specialists from dozens of practices within 5–10 miles of my patients at all times. I certainly feel less nervous knowing the laborist is in-house and that a cardiologist is only a few steps away. But I also feel less supported in many ways. The patients I serve in the urban clinic, owned by an academically-affiliated, multispeciality group have complicated lives and difficulty coordinating medical rides. While they are not geographically isolated, they often cannot effectively access a specialist. I have experienced the same situation, where I was trying to reach a specialist for timely advice on a complicated patient who was not getting the referral they needed. I called three practices and never spoke to a physician. I spoke to front desk staff, and once a nurse, who advised me to send a referral or send them to the emergency room. I felt an intense diffusion of responsibility where it was easy to say, “they are not my patient.”

I have reflected on this with urban colleagues, many of whom have the same frustrations. A few have stronger connections and networks. I anticipate this will improve for me with time as I build more connections, however I am uncertain it solves the larger issue for our patients of the disconnected care and systematic devaluing of the generalist.

I continue to wonder, was I ever really underresourced? Or are the urban spaces just overresourced? I may not have the answer to this question but I know that I feel far more isolated in this urban space than I ever felt when I was in a rural community.