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Small-town practitioner wears many hats

For Kurt Ellenberger, M.D., practicing pediatrics in a small town is much like doctoring in times past.
“You have longer hours, less pay, but much is expected of you,” said Ellenberger, who joined Beaufort Pediatrics in Beaufort shortly after completing his residency at MUSC.
“You have to be ready to take the phone calls, to feel out your patients’ needs, to adjust your style of practice to deliver the best care. You have to do what you have to do to get the patient what they need,” he noted. “And if the situation warrants it, you have to make house calls.”
It’s a way of life that Ellenberger has faced and embraced for eight years and counting.
In small towns like Beaufort, pediatricians treat patients from outer lying areas, so many of  Ellenberger’s patients travel from Walterboro, Ridgeland, Hampton and other rural towns.
Meeting the needs of children and their families in smaller towns is a challenge he wraps up in two words: access and assets.
“Though MUSC is close, everything is not realistically available,” said Ellenberger. “If a child has, say, a gastroenterology issue, there are some types of testing that we can’t do at our community hospital. And it’s not realistic to send patients up to Charleston every time we need to diagnose reflux or similar problems. We’re more likely to use trial and error, and treat things empirically rather than go for the definitive diagnostic test right off the bat.”
Limitations in consults, radiology and lab studies, not to mention the high cost of gas for rural and sometimes economically challenged patients, puts the pressure on small community pediatricians to be a jack-of-all-trades.
“We have the same ills as bigger city pediatricians, but magnified five or 10 times,” said Ellenberger. The dearth in pediatric mental health care, for instance, which is apparent in bigger cities like Charleston, is acutely more difficult in a small town.
“You’re lucky to have even a few therapists and psychiatrists, and super fortunate if you have one or two specializing in or even willing to see children,” he said. ”We usually don’t have the option of sending these patients across town for care, but we can’t expect them to go to Charleston twice a week for counseling, either.”
The result: “A small-town pediatrician like me becomes a de facto psychologist, gastroenterologist, an ADD expert and more,” he said.
“It’s a double-edged sword because patients and parents really look to you for the well-being of their children, but it’s difficult at times because you don’t have the resources when you have patients who really need more help.”
That’s where the art of medicine comes in, Ellenberger said.
“You can’t turn that into cookbook medicine, because there is no protocol for it. It’s all about being in tune with your patients and figuring out what they need.”
Yet it opens up an opportunity and a responsibility to take a more active part, even when it’s not directly related to medicine.
“Everybody is much more connected in a small town, and my role as a pediatrician here means I have an even closer connection to the community and my patients,” he said. “For instance, I can’t expect to go to a local store and not run into one of my patients. I see that as a bonus, because it allows me to forge closer relationships.”
It’s a role that Ellenberger said he’s been able to fill thanks to his residency training at MUSC.
“I really get to practice the full spectrum of medicine,” he said, “and I believe my residency work prepared me for a lot of what I face now.”
Taking care of patients both in and out of the hospital is a given. Neo-natal and nursery skills, he noted, are crucial.
“If you’re going to get called on to save a life in a small or rural area, it’s going to be in the nursery,” he said. Resuscitating a child is more challenging and rewarding than any other care he provides.
And yet he’s concerned that, with changes in residency shifts, many emerging pediatricians may not be getting the full range of experience they need to prepare them for small-town medicine, particularly in the nursery.
“The new restrictions with shift work, and the idea among residents that they won’t need neonatal skills and, therefore, don’t focus on them, could be limiting,” he cautioned. “I see a shift in a direction away from the patient-centric view that you need to be a private practice pediatrician in a rural area or smaller town.”
He believes shift work makes it easier to slip into a mentality of, “I’ve punched the clock, it’s not my problem anymore.” He cautions that won’t work in small town private practice.
The bottom line: if there’s a skill set residents want and need, they might have to go a little out of their way to attain it in the present atmosphere.
Ellenberger will tell you it’s worth the extra work.
“Being a pediatrician in a small area is particularly gratifying, because of the close relationships and hands-on work,” he said. “I know I can say, ‘That person is better because of what I did.’ And that’s why most of us go into medicine.”
Editor’s note: The article was reprinted with permission  from the May issue of the Children’s Hospital newsletter, Kids Connection.

Friday, June 6, 2008
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