What Does Rural Pediatrics Look Like?

Session 55

Dr. Ekta Escovar is a general Pediatrician in rural Texas. We talked about her desire to work in a rural setting, the challenges that come with it, and the benefits it presents.

Being a rural physician is unique on its own so Ryan decided to add this into the mix outside of the basic academic vs. community setting.

By the way, this podcast is now on Spotify. So be sure to subscribe to this for free! Also, check out all our other podcasts on MedEd Media Network. If you have suggestions you think would be a good guest here on the podcast, shoot Ryan an email at [email protected].

[02:05] Her Decision to Get Into Pediatrics

Getting into medical school, Ekta has always been interested in pathology. But she went to medical school, she realized she loves talking to people. What’s more, she loves talking to kids. They’re so interesting and there’s no filter. What you see is what you get.

She adds it’s a refreshing field to be in. She doesn’t have to put on as much of a professional front. The less she looks like a physician, the more comfortable they tend to be. She gets to talk to the kids on their own level based on what their age is.

What’s interesting with pediatrics, Ekta adds, that if the child is your patient, you need to do what’s the best thing for that child. So part of your pseudo patient is the parent.

Although you’re getting the history and the physical from the whole family and from the patient, your plan at the end of the visit is really geared towards the parents. This said, being able to switch gears constantly back and forth and talk to the patient at their level and the parents at their level, keeps you on your toes. You also try to get the idea of the parents’ educational level, what their understanding is of medicine is, and what the problem may be for that visit, and then approaching them at that level would be key. Because of this, you need to be good at reading people to figure out how to best get them on the same page as you.

[04:57] Why Pediatrics in a Rural Setting

Ekta’s husband is also a physician in their area so it would have been impossible for her to practice in a rural setting if she didn’t have a spouse who was okay with living in the middle of nowhere. So it was a team effort for them to get there.

They met back in medical school and he has always wanted to work in rural medicine. Being a Brazilian, his dream job was to float up and down the Amazon River, helping tribal people. As they started dating and got engaged, they realized they wanted to do it all, staying as a general pediatrician, but not just doing the basic, bread and butter cases. She wanted to be somewhere she could do it all, without necessarily specializing. She found she loves the different kinds of pediatric rotations, so her interests were just as broad as what her gut was telling her.

When they were looking for jobs, the specifically looked for a population of 10,000 or less and at least 1 1/2 to 2 hours away from the next tertiary care center or metropolitan area. They ended up looking in the south and narrowing their choices down to where they are.

Ekta explains there are a few residency programs set up to have you come out to be a general pediatrician. She trained at Pennsylvania which was the largest rural hospital in the country. They’re attached to a children’s hospital. And they wanted to produce self-sufficient general pediatricians in a rural setting.

She looked at programs that were not in larger cities. Her goal was to train in a rural setting to get a feel of how it is to live there day to day. At the same time, she was looking for a program where she can see all the depth and breadth of all the different types of pediatric diseases and conditions so she won’t lose her experience by isolating herself in a small town. And that program set her up perfectly.

[08:55] Challenges in a Rural Setting

For Ekta, the biggest challenge is not knowing what’s going to come in that day. And she has to somehow manage any patient that comes in. Whether it’s a broken bone or a baby not breathing, or a car accident, or whatnot. She’s the only pediatrician in the area and she covers about 75,000 square miles. Patients and families will sometimes drive an hour to an hour and a half to their hospital, being the closest hospital to them.

All this being said, Ekta points out that you have to be very comfortable with what you know and with your basics. You need to be able to keep them stable enough until you can transfer them to a larger setting.

Out of all the rotations in pediatrics, she loved NICU the most. In fact, she did extra rotations in an ICU setting. And if she wasn’t going to do general pediatrics, she would have ended up there.

[11:00] Typical Day

Her day is split between clinic and hospital. They have a very non-traditional way of setting up physician jobs in the rural setting. It’s very hard to do just outpatient or just inpatient. A lot of their family physicians do both as well.

She’s in clinic four days a week. Outside of that, she’s available to round on any patients. So everyday is very different for her. Some days, she won’t have many patients so she’d just be in her clinic and go home. Other days, she has a couple patients in the hospital and ends up rounding on patients and coming back to clinic. It’s a little bit of a juggling act for her

[12:12] Traits that Lead to Being a Good General Pediatrician

For Ekta, the biggest one is to be able to make yourself comfortable and keep your heart rate down no matter what situation you walk into. You have to be able to build good relationships with specialists, without ever meeting them. She has obtained phone numbers of specialists from the closest tertiary care centers. And they don’t mind when she calls them directly to discuss her patient’s case. Instead of doing the formal route, she’s able to do this since they know she’s so far away that they’re willing to make that exception to the rule. That said, you can’t abuse that. So you have to be able to make judgment calls whether you really have to call them or just put the referral in for the patient.

[13:37] Sending Patients to the Nearest Big Hospital and Taking Calls

Because of their small population, they’re not that busy. Their small rural hospital only have 25 beds. They have a 2-bed labor and delivery, a 2-bed ICU, and 21 beds in their main floor. So their day to day senses is not that high. In a given month, she would probably be sending two ill patients to a larger tertiary care center. Usually, one of them is a baby. On the other hand, the outpatient side varies depending on certain factors like if it’s winter, they’re getting many respiratory diseases.

So she does take calls 24 hours a day, 365 days a year. But the good thing is they have family physicians so if she’s unavailable or out of town, local family physicians handle most pediatric cases just fine on their own. And if it’s a pediatric patient, they’ll only call her if they feel they need her opinion or help on the case. So sometimes, she’s called as a consultant sometimes. That said, she’s not as busy as one would be expect being on call 24/7.

She also describes going out of town or going on a vacation as a stressful time knowing the whole area is losing that resource. So just expect phone calls from family physicians since you can’t physically go down and see their patient. They’re basically losing two doctors (her and her husband). Consequently, they have to make sure they plan things out better ahead of time.

[16:40] Stability of Docs in the Rural Area and Work-Life Balance

Ekta says there’s a lot of stability in their place in terms of physicians working in that type of setting. They have two physicians who have been there for over two, almost three decades now. They’ve been there for 20-30 days and they’ve delivered multiple generations within the same family. They’re referred to as “the doc.”

And there’s this huge split. The test of the physicians tend to be younger. They came in the last ten years, where they’re younger and have young kids. Of those, four are physician couples, including her and her husband, and another couple both family doctors. So there’s a stable set of physicians. Mainly because they came there looking to settle long term. Add the fact that there was a spouse involved that’s just invested and wanting to be in a rural setting.

Ekta loves her work-life balance. Being on call 24/7, 365 on paper may be so stressful. the first year she was there, it was stressful to be “on call” constantly. It’s that pressure that got her. But as she got used to not being ever off, that’s okay. Since sometimes she won’t get phone calls for days at a time. So you get to mentally adjust to that sense of lack of boundary between your personal and professional life. It just all blurs together.

And because it’s a rural setting and their town is very small, she can get places very quickly. They love 1.3 miles from the hospital. So she can still do her role as a mother and be there for her kids. And at the same time, she still gets to be there for her patients without sacrificing one or the other. In a rural setting, you have a little bit more leeway, to be able to get both of those things done.

[20:05] The Residency Path

Ekta explains going down the residency path in a rural setting is the same three years of the same pediatric residency program. Knowing she wanted to be in a rural setting, it was when she went to interview for residency programs, this was the point of view she kept in mind as she went through programs.

She did interview at a couple larger programs since they saw a lot of interesting cases. She thought it would build up her repertoire of diseases and conditions and understanding how to treat them. But she went into every single residency interview in the perspective of how it’s going to help her in the rural setting, which she thinks is very important. Since some programs will set you up in not necessarily a rural setting, but as a self-sufficient, very well-rounded general pediatrician. Then you can apply that in a rural setting. But she didn’t want to live in a large city. Her dream was to live in a rural location as much as possible.

So there’s no special track or program in order to be a good rural physician. But you always need to interview with that point of view in mind so you can take things and filter through that perspective.

Ekta actually grew up in a tertiary area, in El Paso, and she was growing up she couldn’t wait to get out of there feeling it was a very small town. She wanted to move to Dallas or Houston. She realized she didn’t want to be just a physician. And she realized it’s great to be fully ingrained into the community. So she went through medical school and residency, she realized she didn’t like she was seeing. She figured that maybe rural medicine is a way to become a physician in a very different sense of the word than what she grew up understanding it to be.

[23:08] Working with Other Primary Care Docs and Other Special Opportunities Outside of Clinical Medicine

Working with doctors in tertiary areas, Ekta wished they understood the amount of sacrifice it takes for some of their patients to see specialists in a larger city. It could be a 2-3 hour drive to the next metropolitan area. And some of them, even don’t have specialists there. So some of her patients drive to Dallas, 550 miles away for a specialist or San Antonio which is 475 miles away for a specialist. These are families taking their day off from work to be there and take a day off before and after to drive there and back.

So it takes extra work for Ekta to explain to specialists sometimes that it’s taking a lot for them to convince families that they need to go to their specialists. When it comes to scheduling, she wished there was a way to especially accommodate families either on a Monday or a Friday, and not on a Wednesday for instance, since they’re losing time at work.

Sometimes it’s a little bit hard for offices in larger hospitals to understand and be able to accommodate those requests. This is a huge point of frustration for them but also for their patients and their families.

Ekta goes on to say that there’s always potential benefit for loan repayment in rural areas. Medical school residency is expensive. So this may be a great time to go to a rural setting and work there to see if you like it or not. While you’re figuring that out, you can get large chunk of your loans paid off. It’s a win-win for everybody, both to your patients, the families in the area, and for you as well.

Another area outside of work dear to Ekta’s heart is the nonprofit organization that she started locally, where they help improve their local outdoor spaces. All of the physicians in their area actually have their own niche where they’re committed outside of work. Another family physician is part of a local band. They help put on concerts around town. Ekta points out being able to find your passion outside of work. It’s easier to find and work towards being in a rural setting and this is great for work-life balance.

[27:00] What She Wished She Knew

One of the things she got more comfortable with now is knowing what she knows and knowing what she doesn’t know. It can be intimidating when you’re the only person in your specialty for hundreds of miles. This was her first job out of residency so she found it very nerve-wracking since you’re looked upon immediately as an expert. But you’re still feeling your way through what you know yourself. So she wished she could tell herself to just trust your gut.

Now, she’s more comfortable to tell families whether it’s out of her realm as a general pediatrician. But it was hard for her to learn how to say to families when she first started this job. Especially in a rural setting, since you’re supposed to be the person to do everything versus an urban center where everybody is there and you can lean on colleagues. She can’t just send somebody to a specialist 15 minutes down the road next week for them to get checked out. It’s not as easy as that. Plus, she has to make sure the specialist’s plan is the same as her plan. So you have to make that judgment call of at what point can you still care of them locally and at what point do you need to have them drive to go see a specialist. They have a lot of kids with special needs too. Some children are on oxygen. So it requires an ambulance with oxygen support and things, driving them for 2-3 hours to a specialist and back.

This said, you become very aware of your resources locally and you don’t want to waste them and waste everyone’s time and money if you don’t need to. Being very sure of that judgment call. It takes time and experience to build up.

[29:45] The Most and Least Liked Things

Ekta loves being integrated into the community. She sees her patient families but she also sees them as self-standing families and people outside of just being patients. She feels a real sense of belonging not just as a physician but also as a customer or friend or a mother. And it’s good for her mental and emotional health.

She feels she wouldn’t burn out there faster or sooner just because of being in a rural setting. She even thinks she might do this forever and not burn out.

On the flip side, what she likes the least is being the only pediatrician in the area. She finds it stressful in a sense. Especially, when they’re debating whether or not they take some vacation or fly internationally. She would like to take her vacations but not have to worry about how long they’re going to be gone. She took a shorter maternity leave because she felt the need to be available both in emergency cases and just day-to-day in her clinic for a lot of her complex pediatric patients.

She wished there was at least one more pediatrician there so she could rotate the responsibility so it’s easier to take a break when they needed it. Because of the geography of West Texas, they have a lot of towns in the area but they’re spread out. So her dream scenario is to be able to absorb one more pediatrician and have a mobile clinic. One of them stays near the hospital and the other one can take a mobile clinic. It’s a van that has an exam room and a lab area and drive it an hour and a half away to the next town. This way, they could increase their availability and cover more patients. But at the same time, there’s two of them that could hand off responsibilities too especially at times they need to go on vacation or have a baby.

[34:10] Ekta’s Advice to Students Considering Practice in a Rural Setting

Ekta recommends to students who may be interested in general pediatrics and/or being in a rural area but still trying to figure things out, is to try to do a rotation. Even if you’re just shadowing a pediatrician in a rural setting between your first and second year or setting up an actual clinical rotation. She has some students coming from medical schools around Texas who come and do a rotation with her as a rural pediatrics rotation.

There are rural settings in every state in the entire country. So finding a pediatrician in a rural setting would be great. Spend some time with them and during downtime, try to explore the town in the area. This way, you get a feel for what’s there and what’s not there, and whether you’re going to miss out or not.

[35:05] Major Changes in Her Practice

They have been trying to work on telemedicine for the last 18 months to get it in their area. Obviously, it can’t be done in a lot of other specialties since they’re very hands-on. But they’re hoping to do it with mental health.

One of the big projects she’s working with the hospital right now is some sort of telemedicine psychiatrist or psychologist to help teenagers dealing with depression or anxiety. They’re getting outside of the realm of medications. So she thinks telemedicine is going to be a huge way to open up doors in terms of resources which they wouldn’t be able to have otherwise.

Additionally, they tend not to get a lot of trauma cases or abuse cases. So sometimes, the better technology they have to help with their decision-making skills on the fly or as the patient walks into the doors. As EMRs continue to improve, there’s a way for her even as the only pediatrician, to have a computer and double check her dosing. She doesn’t have that other physician who has that expertise. So being able to tailor her EMRs can help big time in double-checking what she’s doing because she could be wrong.

Lastly, she says that if she had to do it all over again, she’d still choose the same specialty in a heartbeat.

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