The Lessons I Learned Practicing Medicine in Rural America

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People in these parts of the Western US seemed to care much more about preventive health measures.
People in these parts of the Western US seemed to care much more about preventive health measures.

Shortly before 6:00 am, a distinct and unmistakable smell would waft into the residents' call room from the cafeteria in the basement below — bacon grease.

This was my "olfactory alarm clock," my cue to splash some cold water on my face, comb whatever hair I had left, and gather my dwindling resolve. 

For each morning at 7:00 sharp, we had a meeting to review cases seen by the resident on call the night before.

By this point, I'd typically been awake for 25+ hours straight. My whole body ached. And I probably smelled like a combination of unpleasant ward odors, my own sheer unbridled adrenaline and the bacon grease.

The cases were presented to my family medicine residency director and her husband, a rheumatologist who generously joined most of our morning meetings, as well as to my fellow residents and rotating medical students.

I presented whatever case I could find, usually the most unusual or educational one. Specific cases are omitted here to comply with HIPAA regulations and out of respect for the patients themselves. That said, some of the cases were so bizarre that no one would believe them anyway.

As a family medicine resident in a rural Kentucky hospital located smack-dab in Appalachia, I worked with the internal medicine service while on call, seeing and admitting patients through the ER.

Each time my pager went off — typically ten or fifteen minutes after I had finally had a chance to fall asleep — I knew it was time to go down to the ER to evaluate and admit another patient.

Once the patient was tucked in upstairs and all my orders had been written, I would head back to the call room to record my notes on the phone dictation system — an anachronism by now, I'm sure. 

Some poor soul would later have to transcribe my middle-of-the-night doctorly ramblings for the patient's record. Medical residents are known for their very thorough histories and physicals, and for covering every imaginable base in their notes. 

That's because they know their work is under constant scrutiny and subject to criticism if the slightest detail is neglected.

Getting back to the bacon grease. Almost everything in the hospital cafeteria was cooked in bacon grease, even the vegetables, arguably the healthiest food there.

People would eat biscuits and gravy — the gravy having been made with bacon grease — plus a large side of bacon, wash it down with Mountain Dew or some other beverage high in sugar and caffeine, and top it off with a cigarette or two.

No wonder the incidence of coronary artery disease was so high in this part of Kentucky.

Many patients were admitted with severe chest pain, some with four or five cardiac stents already in place. Presenting to the ER with another MI had become so routine for them that it was almost like just “another day at the office.”

There was also a very high incidence of tobacco dependence, drug and alcohol abuse and, not unexpectedly, obesity, diabetes, and liver disease.

The contrast with where I grew up, attended college, and went to medical school — Los Angeles, Denver, and Phoenix, respectively — was striking. People in these parts of the Western US seemed to care much more about preventive health measures — eating healthfully, getting enough exercise, trying to stay slim, and visiting a dentist at least occasionally, if not every six months like clockwork.

Far too many of my Kentucky H&Ps contained the words "edentulous" or “very poor dentition.”

Yet, despite the cultural and dental contrasts, it was a wonderful learning experience for me. I saw and treated the sickest of the sick. I learned about Appalachian culture. I took photographs of the unspoiled Kentucky wilderness. And I came to love the engaging openness of the Appalachian people.

Over the course of my residency, challenging though it was at times, I was gradually transformed into a real doctor. By “real doctor,” I mean someone who does what is right for the patient.

But the bacon grease I never got into.

And to this day, the smell of bacon or anything even slightly reminiscent of it brings back memories — some good and some bad — of my long nights and early mornings in rural Kentucky.

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