You’ve probably heard that nurse practitioners and physician assistants are increasing access to healthcare for underserved populations, primarily because they’re much more likely to work in rural settings than physicians. For example, 12% of PAs and 18% of NPs practice in rural communities compared to 9% of physicians.

Tammy Bartholomew, DNP, is one such primary care provider. After starting as a medical assistant, she graduated from NP school 12 years ago and now runs her clinic in Steelville, Missouri, two hours south of St. Louis. She’s the only source of healthcare for most of the people in her community of 1,600.

At the American Association of Nurse Practitioners’ national conference in Indianapolis last week, Dr. Bartholomew received the 2019 State Excellence Award for Missouri, partly for her full-practice advocacy and collaboration with the local school district. She sat down with us to discuss the pros and cons of being a family care provider in an underserved area.

The Nursing Beat (TNB): How did you end up in your current practice?

Tammy Bartholomew (TB): I did a lot of ER time and felt like it was disjointed. I didn’t know what happened to the patient when they were done. I had no continuity of care. I wanted to go into family practice so I could follow the patient, see where they ended up, and continue to follow up.

TNB: What do you like about working in a small town?

TB: I love being in a small town. I can go anywhere, and people know who I am. Sometimes that’s not always a good thing — I get shown rashes at the gas station — but it’s really nice to be able to tell folks, “Oh, just give us a call, and we’ll get that taken care of.”

Another nice thing is I take care of a multigenerational group — grandparents, parents, the kids, the grandkids. It’s really helpful to know the whole family dynamic. For example, even though a kid might technically live with Mom, I know Grandma is really taking care of him, and she doesn’t have the physical ability to do certain things.

TNB: What’s the hardest part about working in a small town?

TB: There’s not many options for healthcare. We have patients who doctor-jump from one practice to the other, whoever can see them faster that day. I keep seeing same-day sick openings every day, and it tends to get me other clinics’ patients, but then I don’t get to follow up with them because they go back for their regular stuff to their regular clinic.

Also, Missouri is the worst, most restricted state to practice as a nurse practitioner. I have more autonomy than most practitioners in the state of Missouri because I’m the only provider in my clinic. But that’s very unusual. There’s mileage restrictions for how close your assisting physician must be, and in rural areas, the limit is bigger because physicians don’t want to work there.

TNB: What are the pros and cons of family practice in a small town?

TB: I never know what’s going to walk through the door, and I actually find that rewarding. I don’t think I’d enjoy just doing the same thing over and over. I like the diversity.

The hardest part is noncompliance. When you’re watching somebody sink, and you’re trying to help them, but they won’t or can’t do their part, that’s very hard to watch. Unfortunately, we have a pretty large meth population. If the kid’s not in any current harm, we really can’t do much. We call child services when it’s needed, and then they make the decision, but the kids don’t get pulled as often as you might think. Usually, it’s the grandparents bringing in the kids instead of the parents, and you work around that.

TNB: What health issues do you encounter most often?

TB: It’s a very poor community. The food intake is not the healthiest. We have a lot of major obesity, even in our kids. I had a kindergartener who I had to put on blood pressure medicine who was on cholesterol medicine by second grade. The parents come in and go, “I don’t know what’s wrong,” and I think, “Well, you just bought them a 44 oz. soda and a big bag of Cheetos.” It’s an ingrained thing because the parents don’t know how to eat properly because they were raised that way.

When I did my doctoral program, my project was looking for pre-diabetes in overweight kids. The pediatric guidelines make it very difficult if you’re not in an at-risk group, and I work in a very Caucasian population, so none of my kids met the qualifications. But I checked them for pre-diabetes just based on their weight alone like I would an adult, and the first kid I found had an A1C of 12.5%. They went to Children’s for a week because they were a new onset diabetic. This child had no symptoms.

TNB: What advice would you give fellow PCPs based on your experience with diabetes?

TB: Guidelines are just that — they’re not hard and fast rules. I check all of my kids who are overweight for pre-diabetes. Whether you should do the same depends on where the problems in your patients and community lie. If you’ve got a morbidly obese kid, I don’t think it’s unwise to check for pre-diabetes, regardless of race or ethnicity.

TNB: What are some of the biggest barriers to your patients seeking healthcare?

TB: Being in a small community, we have transportation issues. Half of my patients walk to their appointments because they don’t have any vehicles. Second, being able to afford the medications we prescribe. We have to be very cautious. Our group no longer takes samples, so that cut down on me being able to prescribe good quality medication. Yes, there are some diabetes medicines that are cheap, but in my elderly population, it causes large hypoglycemia. There are a lot safer medications, but the patients can’t afford them, and if they can’t afford them, they’re not going to take them.

Working with drug companies and having patients fill out the financial assistance forms can help. It takes effort, but if we can convince the patients to do that, then a lot of times, just because of how poor the area is, they do qualify and can get their assistance and medication.

TNB: What other types of care do you provide?

TB: The lack of psychiatric care is a large problem in our area. For pediatric patients, it’s a nine to 12-month wait to see a specialist and then a two-hour drive to St. Louis. That’s not super helpful when you have a teenager who’s cutting, so I treat a lot in my office even though I’m not a psychiatrist. Family practice ends up being a lot of psychiatric care.

TNB: What’s it like to dabble in a wide range of specialties?

TB: You have to roll with the punches and hope that you garnered enough knowledge in your program to learn as you go. I also try to surround myself with people I can reach out to. I collaborate a lot, not just with my physician, but I have a cardiologist on speed dial. You build relationships with the other providers in the community.

TNB: What other community programs are you involved in?

TB: I have a great relationship with the school. I have a program where I have priority appointments for the teachers so they don’t have to get substitute teachers. I will see them above and beyond anybody else who has an appointment, and they’re in and out in 15 minutes, so they don’t miss any class time.

I’ve been the vice president of my local nurse practitioner regional chapter for 11 years. I’ve been on the board of our state NP organization for four years. I’m the liaison for legislative information to my hospital group. I precept every semester. New students usually drive two hours to precept with me because it’s so hard to find a preceptor in St. Louis. I take my students to the Capitol if it’s the season. I give them a full-credit day of clinical time because if no one takes you to the Capitol to learn how to talk to your legislators, then you’re not going to be involved.

TNB: What advice would you give fellow clinicians, especially those just starting out?

TB: Building a community of resources is important. Be involved in your local and statewide groups and get involved as a student. That’s where I found most of my preceptors, and that built me to be the NP that I am. There’s a large group of us that now have our doctorate degrees. Come to events and socialize. If you have the opportunity to shadow a specialist as a student or new grad, please do it.

TNB: How do you deal with burnout?

TB: I’ve made my schedule so that I don’t tend to get burnt out. I want 30 minutes for my chronic patients, and I don’t want to rush. I only see three chronic visits in a row, and then I give myself some reprieve with same-day sick or non-chronic problems, which gives a nice balance. I don’t take my charting home.