November 21 was National Rural Health Day. Dr. Sandra Balmoria spoke with VCU students about her family practice on the Eastern Shore of Virginia.
Read more on page 3
Latest Health News, What's We're Reading,
Past and Upcoming Events
Brooke Hess, M1
Highlights from a talk by Dr. Sandra Balmoria
Highlights from an osteopathic workshop
Choosing Family Medicine is Choosing Not to be Limited
Where Allopathy Meets Osteopathy
Victoria Ngo, M1
An M3 reflection on a rotation in FM
table of contents
My Month in Family Medicine
Nicholas Nowell, M3
Highlights from a recent AAFP webinar
Tiffany Tsay, M1
Rural Medicine on
the Eastern Shore
SFMA is the Student Family Medicine Association at VCU. The SFMA is a student chapter associated with state and national organizations of family physicians known as the American Academy of Family Physicians and the Virginia Academy of Family Physicians. We offer workshops, lunch lectures, and volunteer clinical experiences to foster and support an interest in Family Medicine.
To learn more, visit the SFMA website.
VAFP 2020 Winter Family Medicine at Wintergreen Resort
Have a wonderful Thanksgiving!
Osteopathic Manipulative Medicine Workshop (page 10)
with Dr. Jef Groesbeck, DO and
Dr. Joy Elliot, DO
Rural Medicine Lunch Lecture (page 3)
with Dr. Sandra Balmoria
Gender Incongruence: What Healthcare Providers Should Know
with Elke Zschaebitz, DNP, APRN, FNP-BC and Afton Bradley, RN
patient walked into Atlantic Community Health Center for Dr. Sandra Balmoria – he didn’t have an appointment, but he did have a thirteen-centimeter laceration she would stitch up that day. Without insurance, he would have received a thousand-dollar hospital bill if she had instead sent him to the emergency room. “It took forever, but it was really fun,” she said, as if the event was simply an average part of her everyday practice.
In fact, it was.
That day, she would also insert an IUD, follow up on three patients with diabetes, discuss mental health with three other patients, see a patient with PTSD and alcoholism, measure the INR for a patient with atrial fibrillation and adjust medications, discuss hospice with another patient, follow up with someone who had a heart attack, look at a football player’s injured toe, and of course, care for several children with upper respiratory complaints. Her days are often so full of variety because she chooses to shape her family medicine practice to be as broad spectrum as possible. From stitches to monitoring endocrine and cardiac conditions to providing hospice care, she does everything. Excluding obstetrics – she likes her sleep.
Dr. Balmoria is part of the 9% of United States physicians who practice in rural communities. Despite how spread out the population tends to be, there are fewer than 40 physicians per 100,000 rural Americans. As a result, family practitioners in rural areas, like Dr. Balmoria, have broader scopes of practice compared to their urban counterparts. Yet, many physicians practice even more broadly than Dr. Balmoria. “I know plenty of people who are doing everything from C-sections to appendectomies to colonoscopies to hospital work. You can do whatever you want,” she said. The more a physician is willing to do, the more convenience they allow their patients. In Dr. Balmoria’s case, the closest hospital is two hours away for some of the Atlantic Community Health Center patients. For uninsured patients, the closest safety net academic institution is VCU Health, a four-hour drive across the Chesapeake Bay. Having a local healthcare provider is clearly vital to sustaining a functional rural community.
However, 80% of rural America has been federally designated as being medically underserved, including where Dr. Balmoria works. The Atlantic Community Health Center, is a Federally Qualified Health Center (FQHC), which means they have agreed to provide comprehensive primary care services to every patient, regardless of the person’s ability to pay. It also means they offer services to address social determinants of health and spend time assessing community needs. So, in addition to her everyday patient panel, Dr. Balmoria organizes resources for her patients who struggle with traveling, like home visits or figuring out how patients can get regularly injected medication without driving to the nearest specialist. She works in diabetes education and teaches physician assistants and nurse practitioners how to insert IUDs to improve access. She is involved in a project to address the low birth weight of their community, and she makes herself available for a local transgender support group. Physicians in rural America have bountiful opportunities to collaborate with their communities outside of the clinic to make a difference in their patients’ lives.
Dr. Balmoria’s schedule can seem like a lot for one physician to do. But despite the challenges that may come to mind when picturing serving the underserved, Dr. Balmoria pointed to facing the challenges as her favourite part. “I love my job because we see every patient that wants to be seen. We don’t turn away patients because they can’t pay their bills and we very rarely divorce patients for other reasons.” Some practices refuse patients after behavioral incidents or repeat tardiness or skipped appointments. “That generosity is something that is important to me,” she said, and that generosity is important to the community as well. Fish, crab, oysters, vegetables, eggs, and all the other sorts of things that show up to the clinic with gratitude.
In addition to the community, living in rural America isn’t so bad either. Dr. Balmoria spoke of having downtime to relax with her friends and going to the beach often. She plays in the orchestra, eats out, and attends concerts. There is a farmer’s market, a doughnut shop, and microbreweries that she frequents. And of course, she watches Netflix (while canning her tomato sauce). And with Amazon’s prevalence even in rural America, the relaxed nature of living in rural areas does not come at the expense of convenience. Perhaps all of that contributes to why physicians in rural practice report a lower rate of burnout than physicians in urban areas.
So, what’s stopping newly minted physicians from flooding into rural America? There is definitely a need: more than 100 rural hospitals having closed since 2010 and half of rural physicians of age 50 or older. A Perspective article in the New England Journal of Medicine predicts retirement will account for 23% fewer rural doctors by 2030 as fewer younger physicians enter rural practice. First, some medical students worry about being alone out there, without any support. It’s not an unreasonable concern. Between May and September of 2019, the Washington Post published four articles on the dearth of medicine in rural America, one of them even titled, “Out here, it’s just me.” But Dr. Balmoria pushed back on that stereotype. “There’s this mystique of rural medicine, where you’re the only doctor. That’s really not the case. I have lots of specialty colleagues who are really happy to talk to me on the phone and are happy to take care of my patients with me.” Where she is located, Emergency Medical Services can be at her office in less than 3 minutes. UVA radiology is always available for stat reads. And when things are really weird, Dr. Balmoria can always refer patients to VCU or Johns Hopkins University Hospital. There are varying degrees of support that physicians can choose when deciding where to practice.
Secondly, some students wondered if they could handle the broad scope of practice. And they’re not alone in feeling overwhelmed. “Even my colleagues from residency are intimidated because I can tell some elaborate fun stories about ridiculously complicated things I took care of, and it’s scary,” Dr. Balmoria admitted, “But the truth of it is you don’t have to be willing to take on these huge complicated patients to be a family doctor in a rural area. I don’t want people to think that if they want to work in a rural area, they have to be able to do everything themselves, that they have to know how to do everything.”
Other students wanted to practice broadly, but worried if they would know enough before starting. The reality is that students don’t need particular training before entering rural medicine. “You don’t have to know special things to do what I do,” Dr. Balmoria reassured the students. “You just have to be willing to show up and do it. Literally everywhere in the country that is rural, they need doctors and they will take you however you want to arrive. They will teach you, and they will give you time and resources to learn more.” But if students did want to explore rural medicine, there are several avenues for students to do so, including the AAFP Rural Member Interest Group forum and Project ECHO. For experience, Dr. Balmoria suggested rotating at her clinic or any other rural site, including Indian Health Services, or simply living somewhere rural for a few weeks. And if you express interest in rural medicine during residency, most physicians are delighted to teach you what you need to know about their specialty if you are the only doctor in a community. But again, even without prior rural training, it is extremely possible to transition into and out of rural medicine as a practicing physician. Dr. Balmoria uses textbooks, PubMed, UpToDate, and NEJM to continue her education, and allows her network of friends and colleagues to support her when she has any questions or concerns. A physician is always learning.
Rural medicine isn’t for everyone. Perhaps students prefer a different lifestyle or have spouses with jobs that require a more urban setting. Maybe it’s just not a good fit. But full of strong communities where you will feel taken care of as you provide care, rural America might just be where some of us belong.
on the Eastern Shore
Improving the Doctor to Patient Ratio in the African American Community
Virginia Public Radio examines structural issues that impede health equity, featuring VCU SOM's Jared Bourke, M2, and Dr. Michele Whitehurst-Cook, MD.
Leadership in Family Medicine
A podcast by American Family Physician interviews Dr. Kara Odom Walker, MD, MPH, MSHS, to discuss engaging in public policy, leadership, social determinants of health, community engagement, mentorship, and flower arranging.
Family Medicine Lens
Pulse founder Paulius Mui looks at what family medicine has to offer in his multimedia blog.
Parental Leave in Family Medicine Residencies Varies Widely
Study authors urge institutional change in creating stronger guidelines around parental leave to better support our family physicians, particularly those caring for vulnerable populations
Gene-Edited 'Supercells' Make Progress in Fight Against Sickle Cell Disease
CRISPR has been used to induce protein production in a patient with sickle cell, sparing her from agonizing attacks of pain associated with the disorder. Although long-term effects must be studied, researchers are hopeful.
"[W]e see every patient that wants to be seen...That generosity is something that is important to me"
"You don't need to know special things to do what I do. You just have to be willing to show up and do it."
"the breadth of the practice cultivated a sense of...of seeing [the patients'] entire lives as more than just the sum of narrow, discrete problems"
ick Nowell is an M3 at VCU School of Medicine and recently finished his family medicine rotation at Front Royal Family Practice in Front Royal, VA.
Where was your family medicine rotation and who did you work with? Was there anything unique about the patient community?
My rotation was in Front Royal, VA, a small town about 2.5 hours northwest of Richmond, up near western Maryland and West Virginia. The town itself is quaint, lovely, and comfortable -- lots of restaurants, stores, coffee shops, a theater, a few bars, a brewery, etc. -- but the surrounding area is very rural, filled with sprawling farms in addition to miles upon miles of state and federal park land (Shenandoah National Park, George Washington National Forest, part of the Appalachian Trail).
I felt that the practice drew its patient population from a large geographical area. There were patients from near Staunton, close to 90 miles away, and from West Virginia. Many patients commute over an hour from D.C. Anecdotally speaking, my impression is that the area overall is less affluent than northern Virginia or Richmond. A small proportion of patients went to college and many get married and start families by their early 20s. Medically, I don't think the patients were any more or less ill than patients anywhere else, but I do suspect there was a high incidence of undertreated mental health issues.
The practice itself was a residency program, so there were 15 residents in addition to 8 or 9 attendings. This was in contrast to the experience of other students who worked in one-physician practices in very rural or underserved settings. Because there weren't too many other providers in the community, the practice handled a lot of pediatrics, OB/GYN, and acute care issues that may have been referred out if we were closer to a city. Additionally, the FM residents and faculty also staffed the ED and wards at the adjacent community hospital, and they oversaw a nearby skilled nursing facility and low-cost community healthcare clinic. Overall, I think the breadth of their practice cultivated a sense of truly "owning" the patients, a sense of seeing their entire lives as more than just the sum of narrow, discrete problems, and being able to appreciate the surrounding community and how the patients and their problems fit within that space. The TV in the waiting room showed reminders about registering to vote and some news about school bus routes. Many offices in the clinic had high school football schedules tacked to the wall. The practice was very much a part of the community, and the community was reflected in the practice.
What was your typical day like? What were your hours?
A typical day was split into two half-days in clinic, roughly 8am-12pm and 1pm-5pm. Each half-day was spent working with either a resident or an attending. Generally, I'd see about 3 patients per half-day on my own, gather an H&P, present them to the resident/attending, and write a note for their visit. On most days, we had journal club or lunch talks given by attendings, the clinical pharmacist, or the clinical psychologist. The visits themselves were a mixture of new patient visits, well adult/child visits, OB follow-up, chronic disease follow-up, and acute care or walk-in visits. Many patients were seen just by me and the resident, but one or two attendings were available in a conference room to discuss more complex cases. I liked this arrangement, because it gave the resident and I lots of independence, but still promoted ongoing teaching throughout the day (not to mention more thoughtful patient care).
Do you have any memorable learning experiences or patient stories you would like to share?
My most distinctive encounter was one where I saw a family of three all at the same time: the mother, the father, and their two year old son were all in the exam room and all had issues to address during the visit. The mother had recently started a medication for anxiety and depression, the father was obese and trying to lose weight, and the young boy had a new rash covering large parts of his body. It would have been easy to schedule each of them for individual appointments at different times, but I appreciated the opportunity to treat the family collectively. They were stressed looking for a new home, the father had started a new job, her medication and their stress was affecting her intimacy and their relationship, and all these stressors were pushing him to eat fast food more and care for himself less. Rather than treat each problem in a siloed, discrete way, we had the opportunity to discuss how all these medical, social, and psychological problems interact, the importance of supporting each other and support from external sources (family, church, counseling), and the effects of parental example and environment on kids' dietary habits and future health outcomes. The attending had known this family for several years, so the visit overall had the feeling less of an office visit and more of a family getting to meet with an old friend for some support and some advice.
Did your real experience align with your expectations? What surprised you most about this rotation?
The biggest surprise to me was the variety. I expected a lot of "bread and butter" management of common chronic conditions like diabetes, atrial fibrillation, and hypertension. While there certainly was quite a bit of those items, even these had a surprising amount of variety. For example, one patient had grossly uncontrolled diabetes with an A1C result reported simply as ">15.5", while another showed up to clinic with a reliable log of months of healthy blood sugar measurements in the low 100s. The approach to these two patients and the courses of their encounters, both listed in the schedule just as "chronic disease follow-up: diabetes", couldn't have been more different.
Additionally, every day, I saw such a wonderful cross-section of patients. They ranged from 2 weeks to 95+ years old. I met a World War 2 veteran who served in Italy in 1945. I found that walk-in or urgent care visits were some of the most interesting and unpredictable. I'm not sure why -- maybe they drew patients who avoided doctors until an illness was intolerable -- but I had patients present for the first time with urosepsis, colorectal cancer, uncontrolled asthma, failure to thrive in an infant, and unstable angina. This enormous variety in demographics, acuity, severity, and pathology amazed me and was well beyond what I expected from the rotation.
Do you have any advice for classmates about to start their family medicine rotation?
Family medicine, especially in a more rural setting, has something for everyone, even people who are certain they are not interested in FM. There is pediatrics, obstetrics, post- operative follow- up, mental illness, healthy patients, sick patients, old patients, young patients. When I told attendings I was interested in emergency medicine, they were eager to discuss when they would send, for example, a patient with an asthma exacerbation home vs. to the emergency department, and how management would differ in those situations, Also, the FM department seems to do a great job of finding varied locations to send students. I expected to be bored so far from Richmond, but I ended up hiking in Shenandoah National Park every weekend, visiting several sets of caverns, finding a favorite coffee shop and tapas place and brewery. The four weeks flew by! Aside from learning the ins and outs of family medicine and outpatient care, the rotation offers the chance to see a part of Virginia you probably wouldn't otherwise have visited. My advice would be to take advantage of that opportunity and not to rule out family medicine as a specialty choice until you get to do it for a few weeks.
"take advantage of that opportunity and don't rule out family medicine...until you get to do it for a few weeks"
"we had the opportunity to discuss how all these medical, social, and psychological problems interact"
orking with patients or learning new clinical skills isn’t something that we do often in our first year of medical school, so I find myself seeking out opportunities to leave my books behind and try out a new skill. SFMA’s recent Osteopathic Manipulation Therapy workshop offered something different from other workshops – a small peek into our osteopathic counterparts’ world. Dr. Joy Elliot, DO, from VCU Riverside Family Medicine, began the session emphasizing the fact that DO students are encouraged early on to be comfortable using hands-on techniques to work with patients. Dr. Jef Groesback, DO, from VCU Shenandoah Family Medicine, shared his personal experiences on how he used Osteopathic Manipulation techniques during his everyday practice, noting that patients often left his office feeling better than when they came in – something satisfying for both patient and provider. Ready to get my hands working, I was surprised when we spent the beginning of the session simply observing the patient and how much information we can glean about the body from the patient’s posture, feet placement, and shoulders.
Using our hands and the body’s anatomy, Dr. Elliot and Dr. Groesback taught students ways to relieve patient’s headaches, promote sinus drainage, and ease symptoms of asthma. While using these techniques, a provider can gather a thorough history, check up on ongoing care, or just chat with a patient. These techniques can then be taught to the patient to try at home. Students working on students, we practiced these techniques until our hands were sore. Anecdotally, every medical student left that night feeling a bit more relaxed.
The field of Family Medicine is unique in that providers know their patients intimately over a lifetime in addition to working with other providers from vast backgrounds and expertise. As future MDs, working alongside DOs will invite collaboration and sharing of unique values instilled in us during our training. In the end, you’ll never know when you’ll need a hand.
he American Academy of Family Physicians (AAFP) recently hosted a webinar for medical students, “Primary Care, Fellowships, and More: Opportunities in Family Medicine”, to showcase the diversity of opportunities family medicine offers. The webinar featured Dr. Joe Skariah, Director at Oregon Health and Science University’s Family Medicine Residency Program and Dr. Michelle Roett, Professor and Chair in the Family Medicine Department at MedStar Georgetown University Hospital. Both Dr. Skariah and Dr. Roett highlighted the plethora of opportunities pursuing family medicine has afforded them. They see patients, deliver babies, publish research, work on community-based projects, provide care in long-term care facilities, and are community leaders. They both noted that specializing in family medicine has allowed them to shape their own scope of practice with the flexibility to change and evolve based on their interests.
They shared that family medicine physicians can practice in a large variety of settings: from rural to urban practices and even international settings. They can work in office-based practices, community health centers, urgent care clinics, emergency rooms, and university-based systems. Furthermore, family physicians can be leaders in public health and are in a unique position to advocate for patients in the context of their communities and practice population health management – something that is becoming increasingly important for insurers and health systems.
Major areas of training within family medicine residency programs include maternity care, hospital medicine, outpatient care, mental health care, surgical procedures, community medicine, and end-of-life care. With more than 600 family medicine residency programs across the country, Drs. Skariah and Roett highlighted that each residency program can offer different areas of focus, whether it is advocacy training, academic medicine, or working with refugee and asylee populations. But regardless of focus, an emphasis on the continuity of care is fundamental to family practice.
In addition to being general practitioners, family medicine graduates have many options for specialization and can pursue a wide variety of fellowships. Some of the fellowships that were highlighted during the AAFP webinar are listed in the table to the left. The American Board of Family Medicine and other partner medical boards also offer subspecialty certifications to family medicine graduates ranging from Clinical Informatics to Addiction Medicine.
However, irrespective of your personal interests in family medicine, one important takeaway I got from the AAFP webinar were key questions to consider as we are selecting our specialties. Dr. Roett challenged us to reflect on what we look forward to as physicians and what brings us fulfillment:
· Is it the intellectual challenge of the undifferentiated patient?
· Is it forming longitudinal relationships with patients?
· Is it the public health implications of the work?
· Is it the lifestyle?
· Is it following a patient through treatment?
· Is it using scientific evidence in practice?
Answering yes to most of these questions can be strong reasons for pursuing family medicine but more importantly, reflecting on these questions might help you determine what you are passionate about and identify what you are looking for in your future career in medicine. To hear more from Drs. Skariah and Roett and learn about their career paths in family medicine, watch the recording of the AAFP webcast and access other resources about family medicine training here.
*table recreated from slides shared during webinar
Highlights from Recent AAFP Webinar
Choosing Family Medicine is Choosing Not to be Limited
is a medical student-run newsletter for archiving stories related to family medicine, showcasing inspiring role models, and embracing diversity of background and thought.
click to explore past editions
Victoria Ngo, M1
Tiffany Tsay, M1
Sarah Beaverson, M1
Caitlin Syptak, M1
Judy Gary, M.Ed