Rural Doctors Steeped in Tradition
“William’s leg is infected. I think he’s got gangrene,” the caller says. She is distraught. Scott Anzalone, a family physician in Logan, tells her he’ll be right over. The woman on the phone is one of his patients, and he knows her family. But he doesn’t recall anyone named William.
That’s because William, he discovers, is a chicken. But not just a common bird. The woman and her husband raise show chickens. William is a prized breeder.
And now William has a serious problem with one of his feet. What should she do, the woman asks. Call a vet, he suggests. But can’t you take care of him, she pleads.
So the physician agrees, and snips off the infected foot and bandages the stub. William lives, and adjusts to life as a one-footed Casanova.
Just another day in the life of a rural doctor in Appalachian Ohio. Anzalone and others like him do not just treat medical conditions, they treat families. These doctors are embedded in their communities, and for better or worse, that means they are on constant call for their patients and their problems, medical or otherwise.
“You go into the city, you’re providing a service,” Anzalone says. It’s different for rural doctors. “If you want to be successful as a physician in a small town,” he says, “you have to be part of the community.”
An epidemic of hardship
One of the biggest challenges doctors face in rural Appalachia is dealing with the issues of poverty and mistrust, which are deeply intertwined.
“The poverty issues here are tremendous,” says Jane Broecker, an obstetrician-gynecologist and professor at Ohio University’s medical school. “Understanding poverty is essential to being a respectful physician.”
Understanding poverty also helps doctors deal with some of the choices their patients make, without being too judgmental, Broecker says. “They’re not being cynical when they’re smoking a pack a day and then say they don’t have money for their medicine,” she says. “Tobacco is their coping mechanism. It’s not a good one, but that’s what it is.
“You’re not going to enjoy rural medicine unless you understand where people are coming from, what hardships they face,” Broecker says.
In many cases, people in Southeast Ohio are simply too poor to afford the care they need, or at least not without considerable sacrifice. To that end, rural doctors will sometimes barter for their services, which allows them to provide care and permits patients to preserve their dignity by offering something in return.
Anzalone says he has accepted haircuts, horse feed and pies as payment for medical care. In one case he was going to deliver a baby for a couple that he knew had little means to pay for the birth. The husband pulled Anzalone aside one day to discuss a barter. “I need a fence,” the doctor told him. “I’ll provide the materials, you build the fence and we’ll call it even.”
“I got a fence for a delivery,” he says.
One good deed
The Amish, a Christian sect that lives a traditional agrarian lifestyle largely removed from modern culture, do not have health insurance and pay cash for their medical care. Amish communities will pool their savings to help cover the medical bills of one of their own. But sometimes those collections are not enough.
Tim Law, a family physician and professor at Ohio University’s medical school, has built a medical practice niche treating Amish families. Among his Amish patients are a couple who have three children with cystic fibrosis. One day he was at the family’s house and mentioned that his daughter was getting married. The husband asked Law where the ceremony would be held. Law said he was hosting it in his backyard, and that he planned to build a new deck for the event. The husband instructed Law to pick him up on Saturday at 6 a.m., and he would build the deck for free.
When Law arrived Saturday morning, the man was there with three other Amish men, standing beside a pile of lumber. Law hauled the men and the wood back to this house, and the four got to work at 7 a.m. Nine hours later, which included a one-hour break for lunch, the men had built, from scratch, an 18-foot octagonal deck with a sunken fire pit and a 10-foot walkway connecting it to the existing deck off the back porch. The boards were cut, including the precise angles to make the shape, using only handsaws.
Building trust the first step
Understanding people’s life situations and being willing to work within them helps cultivate trust, which can be hard to earn in this region, especially for outsiders. Appalachia’s rural communities have a reputation for being insular and suspicious, which is not unwarranted.
“There’s a long history of being taken by outsiders,” says Randall Longenecker, assistant dean for rural and underserved programs and professor of family medicine at Ohio University.
Appalachia’s Amish population, perhaps more than any other, has shut itself off from much of the outside world, living their agrarian lives in a time capsule from the pre-industrial age. The Amish do not reject modern medicine, but earning their trust requires a certain approach.
Law recalls a visit to the home of an Amish family to check on a pregnant woman. He pulled up outside the house in his pickup, dressed in blue jeans, a T-shirt and boots, toting a canvas bag. The husband eyed him up and down. “You don’t look much like a doctor,” the man says. “I looked him square in the eye and said, ‘Well, thank you,’” Law says. The man paused for a second, then started laughing. Law knew he had made a good impression. “They appreciate you more if you’re just a real person,” he says.
Lives left to fate
Generations of poverty and struggle also have bred a sense of fatalism that permeates much of rural Appalachia, doctors say. Suffering and tragedy are woven into the narrative of daily life for many, along with a belief that there is little they can do to alter their fate. “Sometimes young people come in and say if pregnancy happens it happens,” Broecker says. “There’s a sense that they can’t control what happens to them.”
At the same time, many Appalachian parents, like parents anywhere, still hope for a better life for their children. Broecker says she has had 30-year-old mothers bring their 15-year-old daughters to discuss birth control, who say, “I brought my daughter to you because I was a teen mom, and as much as I love her I know how hard it was for me. I’m bringing her to you so that she will not be a mom until she’s ready.”
Such cases illustrate the exception to fatalism, in that the women are choosing elements of their own fate. Yet as census numbers show, much of the rural Appalachian population never stray from their communities. Home is what they know. It is familiar and comfortable. It is where they fit in. Some have a fear of the outside the world, and big cities in particular, that is difficult to fathom for people who have not grown up in their world.
“I’ve had patients who’ve never left the county in their lives,” Anzalone says, recalling a patient who had a heart condition he feared would soon lead to a heart attack. Anzalone recommended the patient go to Columbus for treatment, but she would not make the trip. The thought of going to the city was too much for her. “You know doc, you just do what you can do,” she told him.
Home visits offer insight
Working as a rural doctor also means making the occasional house call, which can be a window into a patient’s world that provides valuable insights into their medical care and their decisions. A look inside a patient’s home, at their living situation, may bring into sharp focus why they are not tending to their medical needs with the urgency they should.
“Unless you can identify the problem by understanding the patient’s home situation you’re not going to meet them where they are,” Broecker says. She cites one patient, a young mother who was breastfeeding her newborn but wanted to stop. It wasn’t until Broecker discovered the girl was living in a trailer with several other family members that she realized there was no private space at home to nurse the baby. Broecker showed the girl how to nurse more discretely with a blanket over her shoulder.
It is easy to forget that a patient’s medical condition is part of a much larger tapestry, that it may be the symptom of something not found through clinical exams, Longenecker says. Medical students tend to focus mostly on the content, on mastering the diagnoses and treatments, he says. “The challenge is not so much the content,” he says, “it’s the context.”
Navigating traditional beliefs
Another barrier to earning trust in rural Appalachia is that many people’s beliefs about medical care are shaped by stories that get passed around among friends and family that may have little basis in science.
“People in Appalachia learn from stories,” Broecker says. “Here people believe what their sister said. … What they heard from their sister’s best friend’s aunt. What they heard from their neighbor next door.”
Sometimes the best approach is to respond with stories of her own, Broecker says, about how she took care of another patient with the treatment she’s recommending and how well it turned out.
In his work with the Amish, Law has had to learn how to negotiate beliefs and customs that are not only foreign to his own, but sometimes run against his medical instincts. For example, an Amish father brought his 14-year-old daughter into Law’s office one day. The girl had sliced her index finger on a Mason jar, right through the tendon. The finger was hanging by a flap of skin.
Law said the girl needed surgery. The father balked. Can’t you just stitch up the skin, he asked. Law said he could, but told the man his daughter might never regain full use of her finger. She’s just a girl, the father replied. Does she really need to be able to point her finger? It was clear the man would not budge, so Law reattached the tendon, secured the finger in a splint and hoped for the best. The finger healed and the girl regained full use. She is now a teacher in an Amish schoolhouse.
Law has also adapted to an Amish custom about pregnancy. He had been caring for pregnant Amish women for some time before a midwife finally pulled him aside one day and politely informed him that the Amish do not use the word pregnant, especially in front of children. The same goes for “with child,” or any other explicit reference to pregnancy. Instead, some will use the letter “P,” or say “PG.”
Birth control is another taboo, at least for Amish men. Law typically cannot see an Amish wife without her husband present, so he is not sure how the women feel about the issue. But as he’s built enough familiarity and trust with some families over many years, he has been able to see the women alone. And some of them have taken the opportunity to ask about birth control devices that their husbands cannot detect.
All in a day’s work
Rural doctors remain generalists in an age of increasing specialization, sometimes tending to needs that extend well beyond their medical comfort zones—such as chickens or, in Broecker’s case, pigs. One day a patient of hers, a young women involved in 4-H, said she had a pregnant sow that was due to have a litter of piglets any day. “I told her I’d never seen a sow give birth, and she and her mother invited me out to the farm when she went into labor,” Broecker says.
When the time came, there were complications. The first piglet was wedged deep in the birth canal and the young woman’s mother was trying to pry it free. “She turned to me and said, ‘Well, you might as well give it a try since this is what you do for a living,’” Broecker says. “She showed me how to wash my arm and reach up for the piglet. This is when I discovered the piglets have teeth.” She managed to maneuver the trapped piglet out and the rest followed with no problems.
Along a hallway inside Anzalone’s two-story Victorian medical office on Main Street is a parade of baby faces, photos from many of the deliveries he has made over the years. On his antique desk sits another memento: a clear vial with a yellow plastic cap. Inside, floating in formaldehyde, is an amputated chicken foot, given to him by William’s grateful owner as a souvenir. “You know you’ve had a good day,” Anzalone says, “when you’ve made a baby smile and saved a chicken.”