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Helen Martin, MT, MMS, PA-CThe author practices family medicine in Unionville and Shelbyville, Tenn. She has indicated no relationships to disclose relating to the content of this article.My career as a PA started shortly after I moved to rural Tennessee after my graduation from Nova Southeastern University in July 2001. I work for Dr. Lynette Adams, running her family practice clinic in Unionville, Tenn. Dr. Adams also has a clinic and an urgent care center in Shelbyville, Tenn. I work at all three locations. 8:30 AMMy day begins when I arrive half an hour before my first appointment to finish up any leftover work from the previous day. I also use this time to return phone calls and respond to other messages. Patients begin arriving around 8:45 AM, and we begin seeing them at 9 AM. I generally see between 15 and 30 patients daily. Although we do take appointments, walk-ins are never turned away. The Unionville clinic serves the north end of the county, and I see everyone from small infants to elderly people. Their health concerns range from diaper rash to Alzheimer’s disease, and everything in between. 9 AMMy first patient is a 60-year-old Hispanic man with diabetes who does not speak any English. When there is a language barrier between me and the patient, providing quality health care can be difficult. It’s not uncommon for Hispanic families to come in for care and to have none of them speak English. We have an interpreter in one of our offices, and we can call her when this happens. We are able to treat this patient successfully and to provide him with a plan for diabetes education. My next patient is a 92-year-old white woman who is new to the clinic. She apparently was unhappy with previous health care providers and had switched quite frequently in the past year. She is taking numerous medications and is requesting refills on her medications. My first task is to get copies of her records from previous physicians and to call the pharmacy to see which prescriptions she has had filled. With the patient’s permission, the records and pharmacy medication lists can be faxed to the clinic. This patient apparently has been around town to several health care providers and presents a problem of polypharmacy. I examine the patient and tell her I will evaluate her records. 10 AMA 10-year-old arrives with her mother, who says the child has had a sore throat, fever, and cough for 2 days. I perform a rapid test for strep throat, and the results are positive. I prescribe an antibiotic and tell the mother to follow up in two to three days. I instruct the mother to throw out the child’s toothbrush and get her another one. The mother says to the child, “Don’t worry, honey. We’ll get you your own toothbrush.” Next, a 48-year-old woman returns to the office to go over her laboratory and mammography results. The mammogram revealed a nodular mass in the patient’s right breast, and the radiologist has recommended a biopsy. The patient is referred to a surgeon. I am frustrated when a patient has an abnormal test result and then must wait weeks to see a specialist. Not only are such patients getting the bad news that their test results are abnormal, but they also must go through the mental anguish of waiting to find out what the next step is. This happens many times because insurance companies mandate who patients can and cannot see. 11 AMA 68-year-old woman arrives at the clinic as a walk-in patient. She states that she has TennCare insurance. She produces her TennCare card and is seen at no cost to her. The patient has come to discuss her medications. She says that she went to the pharmacy to pick up her prescriptions and the pharmacist told her that her medications were no longer covered. She is taking multiple medications and is unable to pay for them herself. TennCare is a health care reform program that has essentially replaced the Medicaid program in Tennessee. It was designed as a managed care program to cover the uninsured and uninsurable people who were not eligible for Medicaid. It also covers people who are Medicaid eligible. In June 2005, many people on TennCare received letters stating that they may lose their health care coverage as a result of changes in the program. These changes went into effect August 1, 2005. Those people who were allowed to keep TennCare were told they now had coverage for only five prescriptions per month, and only two brand name drugs. Anyone who needs more medications must pay for them out of pocket. As you might expect, many are going without their medications as a result. Others are asking their health care providers for free samples, so I usually look at a patient’s medication list to see if I might be able to provide some. I also look for pharmacies and drug companies that have special drug assistance programs to help patients who are on a limited income and cannot afford their medications.
12 noonWe usually bring lunch and finish up loose ends before the afternoon rush. We start again at 1:15 PM.
1:15 PMThe afternoon appointments begin with a family of 15 in the waiting room. Mama, Papa, Grandma, Grandpa, grandchildren, brothers, and sisters all arrive to be seen for various reasons. This happens quite frequently—the entire family decides to visit the doctor at the same time. Some arrive right off the farm or tobacco field. Tennessee is tobacco country, and many people literally grew up smoking. It is very difficult to get some of them to understand that smoking is bad for them. Some of these patients never attended high school, cannot read or write, and do not understand the serious dangers associated with smoking. Patients like these have helped me to understand where my patients are coming from. These are country people, and they don’t have the experience or knowledge that I have. Education is so important. The afternoon also reminds me how many of my patients are still using old folk medicine remedies for healing. One mother brings in her 6-year-old daughter to be evaluated for chronic ear infections. She says that she has been putting the daughter’s own urine into her ears to help her sleep at night. A young couple also comes in with their 4-week-old baby, saying that the baby is constipated. They have been giving her soap enemas. But there are also opportunities to practice modern medicine. The last patient is a 16-year-old farm boy, barefoot and without a shirt, who comes in complaining about several tick bites on his back, fever, headaches, myalgias, nausea, and a rash on his hands that seems to be spreading up his arms. He tests positive for Rocky Mountain spotted fever. He is treated and does well.
4:30 PMIt’s time to go to the urgent care center, which is open from 5 PM to 10 PM, Monday through Friday, and from noon to 6 PM on Saturday and Sunday. Many patients who can’t get in to see their regular doctor will come to the urgent care center in the evenings. This evening, a mother comes in with five children who are complaining of rectal itching. The entire family is examined and treated for pinworm. Next, a 48-year-old woman arrives asking to be seen for a urinary tract infection. She has recently lost her insurance and asks how much the visit will cost. She is a single parent with four children and an income of less than $1,000 per month. Many of the patients seen in all three clinics are on TennCare. Changes to this program have caused many to wonder how they will pay for health care in the future. Dr. Adams’s clinics are now charging according to a sliding scale that takes into account the number of family members and monthly income. Using this scale, the 48-year-old woman is seen at no cost to her.
10 to 11:30 PMThe day is done and all the patients have been seen. Rural Tennessee offers many challenges in practicing medicine. I have found that whether I am treating diabetes, hypertension, or any other health condition, the biggest challenge is trying to provide quality health care for those who can’t afford it. So many people have lost their health insurance and have no one else to turn to. As always, I have done my best for them. As always, the PA goes home tired. •
PA Helen Martin stands outside the family practice clinic where she works in Unionville, Tennessee.
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