How much can a rural doctor do? Ask Neil Nelson, MD
■ What it takes to be Country Doctor of the Year is hard work and a strategy for everything — including where not to be seen.
Down an otherwise empty road lined with fields stands the wood-frame house of Neil Nelson, MD, the only hometown general internist and pediatrician for the 3,407 people living in Gibson City, Ill.
Many of the people in the largely agricultural town know “Doc Nelson,” who still lives on the 320-acre corn and soybean farm where he was raised. As the primary care physician to many residents, he's always on call. He positions his car in the gravel driveway so he can respond quickly to medical emergencies, and he always keeps his cell phone nearby to answer patients' calls and text messages. He often sees patients on his days off.
There's no question among those close to Dr. Nelson that he works around the clock. But he doesn't consider it work at all. “This is my passion,” he said. “This is what I think I was supposed to do.”
That devotion helped earn Dr. Nelson the 2012 Country Doctor of the Year award. Staff Care, a Texas-based temporary physician staffing firm, for the past 20 years has used the award to honor physicians practicing in communities of 30,000 people or fewer. Dr. Nelson, 53, won the award from among 40 nominees throughout the country.
For Bob Dickey, a patient and good friend of Dr. Nelson, the accolades are well-deserved.
“When he's working with you, you can tell he's not thinking about anything but you,” Dickey said. And when the visit is over, “that doesn't mean he stopped thinking about you.”
Dr. Nelson's position in the community involves wearing several hats. In addition to being a physician, he's a pharmacist and one of Ford County's auxiliary sheriff's deputies. In that position, he helps guard accident and disaster sites and sometimes helps detain suspects before arrest.
But despite the unique roles Dr. Nelson plays as a country doctor, he faces many of the same problems as primary care physicians practicing in cities and suburbs. He finds he has too little time to spend with patients and complete necessary paperwork. He grapples with the best ways to incorporate technology into his practice. He also struggles with determining whether some patients legitimately need pain medication.
Opioid abuse “has gotten way out of hand [in Gibson City] in the last two or three years. It's terrible,” Dr. Nelson said. He said the problem is so bad that he has been forced in some instances to discharge abusers from his practice.
Challenges of rural medicine
Letting patients go is a difficult decision for Dr. Nelson, because many rural health clinic patients are on public assistance. If he closes his door to them, there are few local physicians, if any, they can go to for care.
Between 16% and 20% of the U.S. population live in rural areas, but only 9% of physicians practice there, said Brock Slabach, MPH, senior vice president for member services at the National Rural Health Assn. Rural medicine is different from what it was a few decades ago, said Slabach, because doctors increasingly are joining hospitals and large clinics rather than opening solo practices like Dr. Nelson, and many no longer are always on call.
DID YOU KNOW:
16% to 20% of the U.S. population live in rural areas, but only 9% of physicians practice there.
Still, in Illinois, as in most states, the rural doctor shortage is expected to persist, with only 1.5% of the state's graduating residents and fellows planning to practice in rural settings, according to a November 2010 study by Northwestern University Feinberg School of Medicine, the Illinois Hospital Assn. and the Illinois State Medical Assn. Deterring some physicians from rural medicine are the challenges that often accompany the job, health system experts said. They can include longer-than-normal office hours due to high patient demand and primary care doctor shortages.
Access to care can be limited in rural areas. Roads might be difficult to travel, and some patients may have little access to transportation. For those reasons, Dr. Nelson and many other rural physicians make house calls.
Limited resources exist in rural communities, including for specialized mental health and substance abuse care, which means primary care doctors need to have broad expertise. Such doctors must be “highly skilled at not only diagnosing and recognizing certain conditions, but actually doing treatment,” said John E. Prescott, MD, chief academic officer of the Assn. of American Medical Colleges, who spent 18 years practicing emergency medicine in rural West Virginia.
Rural physicians have to become familiar with uncommon vocabulary words. While in West Virginia, Dr. Prescott said he learned that the term “leaders” refers to arm tendons and the verb “stove” is used to describe jamming a finger or toe.
Rural doctors often are approached in town by people who want to talk about health issues. Dr. Nelson knew this from growing up in Gibson City, and now finds that he rarely buys his own groceries anymore, because he so frequently is stopped by passers-by asking for test results or diagnoses.
Despite the job's challenges, Dr. Nelson says he has seen the difference he has made in the community since he started practicing there in 1994, and he doesn't plan on going anywhere.
“I just really enjoy this,” he said.
Following a childhood dream
Dr. Nelson recounted that as a child, he often watched the local doctor climb out of his car with a medical bag and walk into what was then his grandparents' home. The physician cared for Dr. Nelson's bedridden grandfather, who was paralyzed after a stroke.
Some days the physician let the young boy look in his medical bag or sit on the bed while he conducted the medical exam. “I began to respect the doctor and decided that's what I wanted to do,” Dr. Nelson said.
At age 5, he told his father about wanting to become a physician, but his dad had doubts that he was smart enough. “So I set out to prove him wrong,” he said.
As a teenager, he began working at the switchboard of Gibson Area Hospital, where he was born and where he now holds privileges. After high school, he studied pharmacy so he would be familiar with the medications his future patients would need. Even during medical school at the University of Illinois College of Medicine at Rockford and a residency at Loyola University Medical Center just outside Chicago, he always planned to come back to Gibson City to practice.
Some physicians encouraged a young Dr. Nelson to forget rural medicine, because they said country doctors have no time for themselves and don't make much money. But he didn't listen.
On a recent Monday in Gibson City, Dr. Nelson's day started about 8 a.m., when he did rounds at the 25-bed Gibson Area Hospital.
He checked on a 55-year-old patient with lupus who injured herself after falling the night before. After listening to her chest for a possible lung contusion, he helped her sit upright and told her she could return home as long as her CT scan and other vitals were normal.
“I call him not only my doctor, but also my friend,” said the woman, a resident of a nearby town who has been a patient of Dr. Nelson's for about 15 years. “If you need someone to talk to, he'll take the extra time to talk to you in the office.”
In the hallway, Dr. Nelson greeted the nurses, including Heather Brucker, RN, who credits Dr. Nelson with restoring her father to good health. Several years ago, her father began experiencing pain so severe that he couldn't walk or work, but he was unable to get a diagnosis.
“He'd been to so many different doctors, he thought, 'Let's come back to a Gibson doctor,' ” Brucker said. That's when Dr. Nelson identified his symptoms as chemical poisoning due to his work as a farmer. Brucker said her dad began walking again after being treated by Dr. Nelson.
A busy medical office
By the time Dr. Nelson drove across the street to his office just before 9 a.m., patients already were waiting to be seen.
He sat down to start signing off on a stack of papers from the hospital, handing each one off to be organized by his assistant, Stasha Taylor. “It's just little things like this that make the day easier,” Dr. Nelson said without looking up.
Similar to an increasing number of primary care doctors, Dr. Nelson's office uses electronic health records. The EHR system was implemented in 2008, although his practice is not yet completely paperless.
Because he sees 25 to 30 patients each day, Dr. Nelson has learned to be as efficient as possible. He gets a head start on paperwork in the morning, returns patient phone calls at the end of the day and relies heavily on his staff. He tries to arrange his exams so that patients in the waiting room who are expected to have quick visits are seen first. To keep office visits moving, Dr. Nelson asks patients to contact their pharmacies before their appointment to have refill requests sent in.
Despite those time-saving efforts, his office visits that day ran as long as 35 minutes. Longer average visits are common in rural practices, where physicians often have deeper relationships with patients and treat multiple generations of families they have known for most of their lives.
Many of Dr. Nelson's roughly 5,000 active patients are from the Gibson City area, but some travel as far as 1,000 miles to see him. “I'm from [Gibson City], so people trust me. They know my background,” Dr. Nelson said, adding, “I relate to a lot of them too. They're farmers. I'm a farmer.”
During appointments, Dr. Nelson talks to patients about farming, family and how they're coping with the loss of loved ones. When patients are upset, he sometimes references the Bible in an effort to comfort them. In an attempt to dress more like his patients, he doesn't wear a tie or a white coat in the office.
Dr. Nelson said he sees many of the same conditions as primary care doctors throughout the country, including cardiovascular disease, diabetes and hypertension. But because he practices in a largely agricultural setting, he also sees farming injuries and skin cancer from prolonged sun exposure.
That Monday, Dr. Nelson wrapped up his final patient visit between 5 and 6 p.m. and then stayed in the office to return phone calls and complete more paperwork. He is not married and doesn't have children, so he says he has more time to dedicate to his job.
He's looking forward to one of the rewards of being Country Doctor of the Year — two weeks off, with Staff Care providing a temporary physician to fill in at no charge. Dr. Nelson said he hasn't taken a vacation in more than 12 years, and he might visit friends in Florida or Colorado.
For now, however, Dr. Nelson has more patients to see.