••Summer 2007/Vol. 11, No. 3

Clinical Medicine

By Ronald Blum, MD

Medicine Around The World

It is easy to believe that what we do and believe medically in the US must generally be the way medicine is viewed and practiced all over the world. In our efforts to understand the diversity of the practice of medicine around the world, we continue to explore the experiences of physicians around the world as they describe their medical practices, that we all may better understand the wide range of what we do.

Several months ago, back in "moose country," I met Ronald Blum, MD, a big city doctor practicing in a tiny and obscure town in rural Maine. His professional life was so different from the typical large US city practice that I thought he had a tale worth telling and even suspect that some of us might be a bit envious.

-- Vincent J Felitti, MD, Senior Editor

I was raised in an eastern Pennsylvania city of 100,000, in a nuclear family, my parents honoring their marriage vows ‘til death did them part. I had a typical conventional education--public school, liberal arts college, then medical school in "the big city"--Philadelphia. In the days before family medicine had declared itself a specialty, I emulated my family doctor--who also graduated from my alma mater, Jefferson Medical College--and strove to prepare myself for general practice and community service. I chose pediatrics for my internship, with plans for a year of internal medicine and perhaps surgery, as well. I soon learned that kids weren't just little adults, but adults were really just big kids, at least for the most part, and stayed in pediatrics for the full three years. My residency in the Bronx (an even bigger city) enabled me to take two months of electives each year in adult medicine disciplines, so I felt reasonably prepared for independent primary care practice when the time came. But I couldn't have predicted the location.

Northern Maine

"What do you mean you want to practice in northern Maine?" was my father's reaction to the plan. "You gotta be crazy!"--he had hoped I would open an office in our Pennsylvania city. But I was disgusted with the polluted air, high crime rates, and disconnect from nature that city life represented, and sought the freedom of country living. Besides, there was a real need for modern, quality medical care (I flattered myself, but I felt well trained) in rural towns where the cost of living was reasonable, people were honest and sincere, land was cheap, and outdoor recreation was literally at your doorstep. So I agreed to become the first and only physician at a newly established Rural Health Center in a town of 1200 in the foothills of Mount Katahdin, Maine's highest peak and the northern terminus of the Appalachian Trail. Was I naive?--sure, aren't we all at this stage?--but more so politically than medically.

A Chainsaw Challenge

What I lacked in confidence I soon gained in experience. One of my first challenges was provided by the manager of the local auto parts store, around the corner from my office. While cutting his firewood, a universal chore in these parts, he managed to bounce the moving chainsaw blade across the back of his left hand. When he came running into our one-exam-room office with his hand wrapped in a bloody rag, I had barely learned how to recognize a chain saw, let alone attend the dirty, ragged result of serial steel teeth dragged across soft flesh. I was confident in my ability to assess the wound, so I dutifully unwrapped his makeshift bandage to expose what looked like hamburger on the back of his hand. At least wounds in the Bronx were from smooth knife blades! Most of the epidermis was torn away from about one-third of his hand with stellate irregular lacerations at the edges and a few islands of intact flesh. I did a superficial rinse of the wound with saline and Betadine and applied a sterile dressing to hold him until he could get to a real surgeon. Thus began my first "woods lesson." There was no way he was about to drive the 35 miles to the nearest hospital for surgical treatment. "You can treat it best you can doc, or I'll get by on my own." And he clearly meant it. Well, medicine had not yet become so liability conscious, and I was, after all, in a small village in northern Maine, where legal consequences were a distant concern. With renewed determination, I re-examined the wound. Tendons, though exposed, were intact. No significant injury to vessels or nerves was apparent, and all finger functions were preserved. So after generous local infiltration anesthesia, I carefully debrided devitilized tissue and wood chips, and scrubbed out soil and oil, and flushed, and flushed again. I then carefully sutured what viable fragments of epidermis I could capture, generously covered the wound with nonadherent dressing and hoped for the best. Needless to say, none of my New York City experience had specifically trained me for this. When he was too busy in his store to come in for my required daily wound checks and dressing changes, I called on him. The wound healed. It never got infected. He had full motion and use of all digits and wrist. And his comment to me on the day of discharge, "I knew you could do it, doc." Well, now I knew I could do it. And that's how I gained confidence, patient by patient.

I was less prepared for dealing with local village politics. There were a variety of needs and expectations among the clinic's community Board members and clientele, and I was neither aware of nor capable of meeting them all. Although my practice grew successfully that first year, advisers to the Rural Health Center opted for applying for a National Health Service Corp doctor (at no cost), and chose not to renew my (private pay) contract. But I had come to really appreciate the community and the rural lifestyle--the nearest traffic light and McDonalds were 35 miles away. And besides, I had no particular place to go. So, much to the surprise of many local residents, and to the delight of my patients, after a brief stint in the hospital Emergency Room, where, by the way, all medical staff of any specialty still took a turn staffing, I went into private practice. At first, with a local general practitioner from a town ten miles south, who shared his wealth of experience, and then after his retirement two years later, on my own. Over the ensuing 28 years I have had a variety of associates from time to time--doctors, physician assistants, nurse practitioners--and a variety of students of similar ilk.

My Own Private Practice

My practice has been busy, stimulating, and gratifying. For most of my years here the only other providers serving the area's 5000-6000 residents were staff at the still-operating Rural Health Center, which sits on the opposite corner of the block from my office. Although they get cost-based reimbursement from Medicare--currently about $108 per visit--I get less than $30 for the same code. Being a rural provider has allowed me to practice an incredible breadth of medicine, an experience not even approached in an urban practice. The absence of nearby specialists (the nearest tertiary care hospital is 100 miles away) has allowed me to be involved in all aspects of my patient's care. This location has afforded me the opportunity to forge close relationships with the other physicians and provided unending learning opportunities. I have administered IV chemotherapy protocols weekly, every two weeks, or as needed, in my office, to patients who visited the oncologist only quarterly. I have performed a wide range of outpatient surgeries in my office, including trauma repairs, biopsies, vasectomies, and even an inguinal herniorrhaphy under local anesthesia. I've ridden ambulances, resuscitated newborns, attended the local Amish community at their farms, set fractures, and grieved with family members when resuscitation failed. I've completed surgery by flashlight when we lost electric power (a more frequent occurence earlier in my career); I've fabricated custom splints so farmers can continue their harvest in spite of an injury. I attended patients in the local nursing home and mentally and physically handicapped adults in the group home. I serve as a Medical Examiner (coroner) for the area, school doctor, and as a public health officer. In all these roles, I never have hesitated to seek advice from colleagues, and only rarely have been refused assistance.

Professional and Family

My opportunity for professional advancement has not been limited. I've served as preceptor at the Family Medicine Residency Program, as well as to students in my office. I've been involved with a variety of specialty organizations, serving in local, state and national positions. I became a Fellow in the American Academy of Family Physicians (AAFP). I have had opportunities to teach in those venues and interact with some of our nation's leading physicians. I served as president of our hospital medical staff and of the Maine Academy of Family Physicians, as advisor to the American Hospital Association, and on the Board of the New England College of Occupational and Environmental Medicine. I am one of Maine's two delegates to the AAFP and Vice-Chair of the Work Fitness and Disability Section of the American College of Occupational and Environmental Medicine (ACOEM).

Meanwhile, back at the homestead, my wife and I raised four great kids--children, that is--along with some kids, chickens, turkeys, rabbits, and an occasional sheep. Although it was a concern at first, I can say assuredly their education did not suffer for being raised in the country and attending a small school. If anything the advantages outweighed the compromises. The eldest have attended prestigious colleges and university and are well set to succeed in life. Our youngest are still at home, so we continue to watch soccer and basketball games and help prepare for proms and parties. I've pursued my interests in gardening, camping, fishing, canoeing, sailing, and photography, served as a scoutmaster, and been active in our congregation's religious life.

The Business Side

No, I don't think I was crazy for settling here, although separation from our families in Pennsylvania over the years has presented some hardship. If there is a negative, I've alluded to it above--the business side. When I went into practice with "Ol' Doc Daniels" in 1978, we decided to raise his standard office call fee (we now call it a 99213) to $7, more than double what he charged when he started practice. Office care was busy, and we supplemented that income with service at the hospital, nursing home, school, and local industry.

Over the years rates (and expenses) have increased exponentially, but the payor shift and practice climate has changed dramatically. As economic changes have brought closures in area farms and pulp, paper, and lumber mills (our major local industries), there are fewer working-age families with indemnity insurance or Worker's Compensation coverage. Many of my current population of patients are enrolled in Medicare and Medicaid, which in the current political structure are no longer profitable, usually representing a financial loss. Another shift in care delivery is the employment by the hospital of almost all the nearby physicians. Their hours and responsibilities no longer dictated by practice demands, they are not particularly interested in sharing patient care or covering my patients in my absence. However, those practicing hospitalist care are perfectly willing to accept my patients for admission. Thus I reluctantly relinquished inpatient care, sacrificing the patient's continuity of care and satisfaction for the political reality of modern medicine, and sacrificing an income source, as well.

My financial stability has been the result of alternative practice pursuits. While others of my colleagues (no, I am not alone in this lifestyle choice) have supplemented their practices working in the Emergency Room or teaching, my niche has been Occupational Medicine. Working part-time over the years with several local employers, in some cases on site, I have developed expertise and a reputation in this relatively unpopulated specialty, providing an unusual service for a rural area. Income is not filtered through third parties, and as an independent contractor I can maintain professional and ethical independence. Supplemental education has allowed me to become a Fellow in ACOEM, an independent examiner for insurers and lawyers seeking objective assessments, and part-time Medical Director for a large area employer with multiple plant sites.

Sincere Service

My varied interests and flexibility have served me well in this unique and welcoming setting. I get a lot of satisfaction (and occasional garden products or moose meat) from my patients, some of whom I've cared for their entire lives and and are now returning with their new families. Most local folks carry on multiple tasks to survive--one or two jobs, cut firewood, garden and hunt to supplement the larder, yard sale, perhaps sell some arts or crafts, all in order to continue this clean lifestyle in a beautiful environment. Well, my practice is not much different. My life is full, my service sincere, my main regret is that the government rural health programs should be complementary and cooperative, rather than competitive and adversarial. But I have maintained a medical practice with honesty and integrity, without depending disproportionately on taxpayers, and demonstrate by example the plausibility of rural private practice. Nah, I'm not crazy.

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