Tomorrow my four year adventure in rural medicine will come to an end. It will be bittersweet. I will complete my four year service obligation for the National Health Service Corps (NHSC). The NHSC is a federal program that provides scholarships and loans to physicians and nurse practitioners willing to provide primary medical care to under served communities. I was in their most competitive program, the Scholar Program for Physicians: the NHSC paid for me to attend medical school in exchange for providing psychiatric care to a community on a “critical need” list.
I decided to pursue medicine after my two oldest daughters were born, and without the NHSC, I would not have been financially able to attend medical school. I was thrilled to discover that my area of interest, psychiatry, was on the list of required specialties. The financial support from the NHSC felt like a luxury: they paid my medical school tuition and fees up front along with a monthly stipend. This made medical school extremely enjoyable for me. I didn’t have the shadow of mounting student loans looming over me, which made me almost giddy as I immersed myself in anatomy, pathophysiology and clinical rotations. It wasn’t until I was in residency, exposed to critically underserved populations that I began to consider the rigorous job options that awaited me.
At the beginning of my last year of residency, I learned that psychiatrists in my cycle of service would be required to serve in remote rural communities. This had a profound impact on my family. There were absolutely no rural communities which had a Jewish community. My best option was to be placed in a community one and a half hours from a Jewish community. I chose Southwest Missouri, 85 miles away from where my children would be living. This meant I would be living alone as I completed my service obligation.
This turned out to much more difficult than I ever imagined. When I arrived, I was convinced the commute would be easy, that this would be no different than when I did my rotations during medical school in Los Angeles and regularly did 3 hour round trip commutes due to traffic. Well, it’s a completely different story when you’re the only provider and 20 to 30 people need your care on a given day. You can forget about making that commute. And, when you do make that commute, be prepared for something worse than traffic: no other cars at all. No one to help you if you hit a deer or get a flat tire, or, worse, you fall asleep and fly off the road. All of those things happened to me at least once.
When I arrived in my community, I assumed I would pursue multiple hobbies with all my “spare time.” I had hopes of making a quilt, joining the gardening club, riding with the local cycling group. Well, again, that huge patient load made all of that impossible. I never even had time to go inside the quilting store, something that still makes me sad. I rode my bicycle alone in the pre-dawn hours.
I spent many days when the only people I had conversations with were my patients and the nursing staff. I ate most of my meals alone, while I completed charts. I engaged in stress eating, which caused me to gain weight.
While I did manage to visit my children at least twice a week for the entire four years, I did miss quite a few parent teacher conferences, school performances, and even a couple of birthdays.
So, why am I not absolutely ecstatic that my service is over? The patients. I was able to start an outpatient psychiatry clinic from scratch, and provided face to face care to people of all ages. I provided inpatient care to patients from all over the state who typically arrived in a state of crisis. I never had even one hour when I felt I was useless or superfluous. I learned about the brutality of rural poverty and the devastating effect it has on children and adolescents. This knowledge focused my efforts in a profoundly meaningful manner.
My work in the clinic afforded me the opportunity to treat entire families: children, parents, grandparents, and in a couple of cases, great grandparents. I acquired deep knowledge of their hopes and struggles, of the fierce family loyalty which survived substance abuse, incarceration, chronic unemployment and severe mental illness. I witnessed the miracle of children growing and thriving despite their many obstacles.
I fell in love with my patients. I will never stop being inspired by their admirable struggles to overcome the challenges of mental illness. Their hope and optimism in the face of considerable adversity will inform my practice of medicine from this time forward.