Imagine this: You are a young doctor who has recently graduated from medical school. An excellent student, you could choose to practice almost anywhere—including Atlanta, where your advising professor has connections. Instead, you set up shop in a small southern town, much like the one you grew up in. It’s the kind of place where the neighbors all know each other, where families have lived for generations and still attend the same church. It’s also a place where a young doctor is unlikely to get rich.
In this town of Ocilla, Ga., there are a host of health challenges: obesity, drug abuse, depression—the usual troubles that doctors have to manage, except you’re doing it without the benefit of specialists to advise you. As one of the only doctors for miles around, you are on call every night and need a range of skills that no city doctor would dream of having: Your patients depend on you for everything from putting a cast on a broken bone to performing surgery. Still, you like the idea of knowing your patients, knowing their families.
But two decades pass, and the job has gotten harder. The per capita income around here is roughly $15,300, and unemployment is over 12 percent. Insurance companies have been chipping away at your earnings, and a growing number of your patients are now battling chronic diseases like diabetes and emphysema. Things would be easier if you closed your practice and took a position with the regional medical center 30 miles away. At times, you’ve been tempted. But then, what would your patients do?
These questions are ones that Howard McMahan, M.D., has lately begun to contemplate. Now 58, McMahan has spent more than 20 years caring for the residents of Ocilla, a rural town (pop. 3,414) three hours south of Atlanta. Tall and spry, with short gray hair, he looks the way you’d imagine a country doctor might. His manner is courtly; he says “yes, ma’am” and “no, sir” and favors bow ties and shirts that have been neatly pressed.
As a doctor who knows all his patients by name—and often their parents and grandparents as well—McMahan occupies an increasingly rarefied niche. Over the past 15 years, the number of new general practitioners (physicians trained to handle a wide range of ailments) has been significantly declining, as med students drift away from the field in favor of more lucrative and less demanding specialties. By 2020, the Association of American Medical Colleges projects, the U.S. will be short 45,000 primary care doctors. The scarcity is felt keenest in rural areas, home to nearly 20 percent of the nation’s population but just 9 percent of its M.D.’s.
On the Monday I arrive, McMahan has been in the office since 8 a.m., seeing patients and reviewing some of the 23 lab and X-ray reports that have arrived over the weekend. His office, a low-slung brick building located across the street from a pecan orchard, is filled with framed photos of Ocilla’s championship baseball and wrestling teams. Farming is Ocilla’s main industry, and patients often show their gratitude in country ways. McMahan once arrived at the office to find a load of homegrown watermelons left as a thank-you. It wasn’t the first time. “Homemade fudge, peanut brittle, pecan brittle, jellies and jams,” he recalled, moving briskly between exam rooms. “It’s a regular occurrence.”
McMahan’s 10 a.m. appointment is with 79-year-old Wydene Tomberlin, who has come bearing an apple as a gift. McMahan takes it cheerfully, adding, “You can tell I’ve had an influence! She used to bring me chocolate.”
Tomberlin’s ankle had recently been treated for a staph infection, and in the office she admits that the leg is still giving her pain. “It’s okay today, but on Thursday and Friday I could hardly walk on it,” she says.
McMahan kneels to press gently on her ankle. “You soak it or put a poultice on it?” he asks. “You take any pills?” Tomberlin says no.
“Miss Wydene used to take a lot of pain medication,” he explains. “We’ve worked hard to get her off that.”
Though the ankle is no longer tender, McMahan orders a blood test to confirm that the infection hasn’t returned.
Then, to my surprise, he lingers, asking about Tomberlin’s family—he also treats her brother Wycliff and his wife, Ann.
Eventually, McMahan escorts Tomberlin out. “That’s one of the advantages of practicing in a small town,” he remarks. “You don’t just see your patients. You see their family, you see their friends. It can help.”
While such patience can be rewarding, it comes at a cost. Tomberlin’s visit, originally scheduled for 15 minutes, has taken almost 45. Which means that McMahan is already running late. It’s a common problem. “Patients get frustrated all the time because they have to wait,” admits Kay Vickers, a nurse who has worked with McMahan for 18 years. She shrugs. “But it’s a trade-off. When you get in the room with him, he does the same thing for you.”
When I later mention Vickers’s observation to McMahan, he looks sheepish. “The majority of the time, I deliver more care than I bill for,” he acknowledges, adding that he often ends up staying in the office until 8 or 9 at night. McMahan concedes that he could probably get through the workday faster if he were willing to stick to the schedule. But in practice he can’t bring himself to. “There’s too much complicated information,” he says. “I want to make sure people understand.”
McMahan is starting to streamline his practice by offering patients the option of a “virtual visit”: getting their lab results online, for instance, and then discussing them over the phone or even face-to-face via computer video chat. He points out that such a system would spare patients having to take time off from work—but acknowledges that the option hasn’t caught on yet. “Most folks still prefer the hands-on personal touch,” he says.
Concierge Medicine Today (i.e. Concierge Medicine News; Concierge Medicine Canada; CMT; and Direct Primary Care News), is a news and multi-media organization that is the industry’s oldest and most respected national trade publication for the concierge medicine and direct primary care marketplace. Our web site is the online destination for people and physicians to go deeper into the top stories driving the conversation and generating the national buzz about concierge healthcare and direct primary care.