The Rural Surgeon: Surgical practice in the Indian Health Service



Only last week I thought to myself: an almost perfect surgery day. A few endoscopy cases, a breast case, a parathyroid adenoma, and a gastrectomy. I remind myself from time to time how fortunate I am to have the diversity of cases that I am afforded by my unique rural location and employment in the Indian Health Service (IHS).

Over 2 decades ago with what seemed to be an upheaval in health care, I decided to either leave surgery altogether or find some alternative to the business side of medicine that I was experiencing in the world of my private surgical practice. It was 1993 and the Health Security Act was being formulated with a task force with a paucity of physician input. It looked like medicine was headed to a period of increasing bureaucracy and decreased autonomy.

Dr. Hope Baluh

While thumbing through one of the recruiting magazines, I noticed an article about an internal medicine physician and his wife, an obstetrician/ gynecologist, who together joined the Indian Health Service. I made some inquiries.

I knew nothing about the Indian Health Service. I had a picture in my mind of a remote barren reservation working with doctors who couldn’t get a job in the real world. What I found was the best career I could have imagined.

I landed in a rural community in Oklahoma. The colleagues that I have come to know have been some of the best I have seen anywhere. I have had the distinct privilege of taking care of patients who are for the most part very grateful for the care I can give them.

I can recall during the interview process I was concerned that as a non-Native, I might not be accepted by the patients in this part of the country. My concerns were dispelled. I have felt accepted and appreciated.

What I found was that in many ways, my Native American patients are similar to the rural patients I have had in private practice. In the Native American culture, elders are respected. Family is very important – not just the nuclear family but the extended family, cousins, and multiple generations. Patients are proud of their heritage. There is a sense of interdependence and connection. I have been blessed to be a part of healing ceremonies that have left a lasting influence on my approach to disease, health, and spirituality.

Many of these patients have limited resources and astounding health burdens. Native Americans are disproportionately afflicted with diabetes, cardiovascular disease, and obesity. Because of these health problems, programs that address these specific issues have been developed within our system. We have a diabetic clinic that includes foot care, eye care, nutritional counseling, general medicine, and pharmacy needs as well as extensive education about prevention and disease control. We have also developed a Healthy Eating for Life Program (HELP) involving a multidisciplinary approach to weight loss that includes a cognitive behavioral health program, one-on-one education with a certified bariatric nurse, support groups, nutritional instruction, and for some patients, surgical intervention.

Patients may access the Indian and Tribal Health Systems regardless of insurance status. While our practice is not totally devoid of the business aspects of medicine, most of the time we are unaware of the patients’ insurance status. Procedures or diagnostic studies that cannot be done onsite are sometimes covered through contract health services.

Our facility was built with the intent of providing health care for the adjacent counties, but by the time it was completed the need had already outstripped the resources. While funding has improved over the years, the rising costs of medical care and increases in the volume of the service population have continued to translate into unmet needs, especially for services not directly provided in our facility.

There are many physicians who have come and gone during my tenure. Some have Indian Health Service scholarship paybacks that they fulfill and move on, and others may be in transition from one greener pasture to another. The surgical service has grown from two surgeons to six. We have a good mix of youth and seasoned doctors, with half the group over 40 and half younger. The gender mix is also balanced with three females and three males.

There is a plethora of pathology. Most of us have carved out niches of surgical interest. We average 150 referrals per week, which translates into plenty to do. There are no turf battles. We have not adopted the hospitalist model. The surgeons here round and follow their own patients, which is great for continuity. Our patients appreciate seeing the same doctor. We are not, however, tethered to the facility. The surgeon on call will graciously cover any patients if needed, and we are fortunate in that we all have similar practice styles. Thus, we have cross coverage by surgeons who think and operate similarly.

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