When my fellow Harvard Medical School classmates asked “what I was up to,” I called it my Rural Family Medicine Adventure Month. More formally, it was my extreme privilege and pleasure to learn Family Medicine across northern Maine and western Massachusetts as part of an independent study in rural primary care in June 2021. My travels brought me to the Jackman Community Health Center, the Northern Maine Medical Center, the Barre Family Health Center, the Behavioral Health Network Methadone Clinic, and the Community Health Center of Franklin County. I explored the edges of Moosehead Lake and ventured as far north as Fort Kent, Maine, before heading southwest to the towns clustered around the Quabbin Reservoir. Across the many wooded miles, a decent number of them on dirt roads, I met so many dear people including brilliant and tenacious clinicians and staff, as well as the quirky, warm, and wonderful community members they cared for.
I had been hoping to explore rural family medicine for years – even before I enrolled at Harvard Medical School. For me, being sturdily rooted in a community that needs an advocate, a problem solver, and a science-nerd-that-gets-the-other-stuff has always been what matters, and is indeed what drew me to medicine in the first place. In so many ways this incredible month-long rotation reawakened that wonder. I settled into the familiar controlled chaos of outpatient clinic, went on lovely hikes, had conversations about contraception and substance use with patients, and did many diabetic foot exams. I saw clinicians who had known their patients for 25 years have loving conversations about end-of-life decision-making. I watched as my preceptors absorbed the newest research and guidelines (often crafted with a focus on urban centers) and thoughtfully translated them to rural communities, framing their analysis through the priorities of the real people they served. I felt how special it was that rural primary care clinicians were multitaskers in the truest sense – pivoting from prenatal appointments to physicals to sick call visits with an expertise that rivaled anything I’d seen among specialists in Boston.
Despite the fact that I created this rotation with help from mentors at the Center for Primary Care, I was continuously surprised and humbled by the new experiences I was welcomed into. I was privileged to work in a methadone clinic for the first time, learning how substance use layers with other chronic health issues. I was able to practice lifesaving interventions like delivering Vivitrol, Sublocade, and COVID-19 vaccine injections. Crucially, I learned how to bundle and tailor the delivery of services to patients in a way that radically expanded my concept of patient-centered care. Before, I imagined a sensitive doctor, leaning in, collaborating with her patients to find shared priorities and make a plan – a just fine, but fuzzy vision. Now my idea of patient centered care has come alive, and includes listening to a patient’s favorite bagpipe music while extracting a scalp cyst, providing online dispensary recommendations and methamphetamine use harm reduction kits, removing skin tags during a hypertension follow up, discussing sexual health concerns during a cerumen disimpaction visit, and so much more.
On my rotation I was also struck by the tension of access – both how much clinicians and communities can do with so little and how wrong it is that resources are so unevenly distributed across geography. It was impressive that Jackman CHC was able to stock EpiPens and Amoxicillin in a special closet, selling them to patients at cost ($12, and $4 for a 10-day course, respectively). At the same time, it felt unfair that the team had to prescribe under the constraint of the nearest pharmacy being one and a half hours drive away. Medications and diagnostic technologies weren’t the only resources in short supply. None of the places I visited had robust public transportation options, nor adequate access to allied health services such as optometry, physical therapy, nutrition supports, or durable medical equipment facilities. Yet for the communities and the health centers themselves, the focus was not on what was missing, but rather on what was in abundance: creativity, generosity, and resourcefulness. Neighbors gave each other rides or swapped supplies and advice, and clinicians consistently held quality and compassion over efficiency and profits. Though systemic issues which played out in the background were largely responsible for the unequal landscape, moment to moment I learned that the shared goal was to thrive here, together.
I learned that practicing medicine in rural communities blurs the line between the personal and professional. In medical school, professionalism is by and large a list of do’s and dont’s. Do dress formally, make eye contact, and inquire about patients’ personal life and work; Do not befriend patients, share about your own life, or accepts calls after business hours. In the small, resilient communities I visited, it would have been absurd to adhere to the black and white (and largely arbitrary) regulations of how clinicians relate to patients. I found that my experiences in the gray area were the most meaningful. Often in these small towns the distinction between roles such as patient, medical assistant, mother, store clerk, janitor, rotary club leader, and clinician was almost non-existent. Everyone I met wore several hats, weaving a rich community fabric that was undeniably interconnected. After clinic one evening, the team and I shared a meal made for us by an elderly EMT, who was both a patient of ours and also a retired school teacher who had taught the medical assistant’s high school English class. We complimented her pretty baking dish, which had been a gift from the clinic receptionist’s aunt at her wedding, 50 years ago. The next morning, one of the providers and I shared a slow cup of coffee in the lounge. With both joy and seriousness, she looked over her mug at me and said, “don’t ever settle for work that does not scratch your soul.” This and so many other quiet lessons I will carry with me always.
I found it refreshing and affirming to step outside the “Boston Bubble” and explore rural medicine. I am immensely grateful to the providers, staff, and community members who opened their hearts and homes to me, donated their time and their delicious food, and who told me that becoming a primary care doctor is a dream worth chasing. My month in the rural was a much-needed antidote to recent (poor) advice I’d received: that idealism would be unsustainable in my future career. In June, I met so many people who were making it work unglamorously and in daily, small, heroic ways. They taught me that idealism is not only sustainable but sorely needed, that we can’t always win or cure, but that we can always be with – and that that is what really means the most.
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Emma Hartswick is a fourth year student at Harvard Medical School pursuing a concurrent Masters in Public Policy degree at the Harvard Kennedy School. Emma is a small town Vermonter, currently living in Cambridge, MA, where she has partnered with city councilors and community coalitions to advocate for greater investments in affordable housing and protections for people experiencing homelessness. She plans to become a physician activist and primary care doctor, and will serve in the National Health Service Corps caring for underserved communities after medical residency.