A lot of people, many of them medical students, think that rural doctors don’t get to see many interesting cases.
The opposite is true; if you are the only doctor within a wide radius, people will come to you for help, rather than try to pick the appropriate out-of-town specialist to diagnose their problem. In this state with widespread physician shortages most specialists won’t even see self-referred patients.
Sir William Osler wrote:
“The environment of a large city is not essential to the growth of a good clinical physician. Even in small towns, a man can, if he has it in him, become well versed in methods of work, and with the occasional visit to some medical centre he can become an expert diagnostician and reach a position of dignity and worth in the community in which he lives.”
Today, with UpToDate and all the medical journals of the world instantly at our disposal through the Internet, rural physicians cannot blame the size of their patient panel or of their medical community for not keeping up with the essentials in their field. Rural primary care doctors are usually the first ones with an opportunity to evaluate and diagnose our community members’ medical problems, regardless of their complexity or severity.
In situations when I feel stumped with a difficult diagnosis, I sometimes end up explaining to patients that until I understand better what the nature of the problem is, I don’t even know which specialty is the right one to refer them to, since the delineation of specialties follows disease location or mechanism rather than presentation.
For example, a person with weight loss could have an endocrine problem, an intestinal problem, cancer or a psychiatric diagnosis. The family physician is usually in the best position of all specialists to sort out which is the underlying cause.
It is sometimes quite touching when, after I have diagnosed a patient with a rare disease that only a big city or university-based specialist can manage, patients say “ah, Doc, can’t you treat me instead – I’m comfortable with you, and you’re the one who figured out what was wrong with me”.
Rural medicine, in terms of the spectrum of disease we encounter, is the most challenging and most stimulating kind of primary care medical career available to doctors in this country.
The double-booked visit with the Chief Complaint “I think I have a sinus infection” could be a brain tumor. The woman with chest pain could have an esophageal diverticulum, and the man with heart palpitations could have hyperthyroidism, an arrhythmia, a drinking problem or an anxiety disorder – perhaps even a pheochromocytoma.
It is my job to do the right thing, not too little and not too much, for each one of these patients, who trusts me with their care.
It’s all in a day’s work in primary care.
And, oh, one man with a runny nose just didn’t act right. He seemed vague with some word-finding difficulties. I had never seen a brain abscess before, but that is what he had.