An independent family doctor struggles to find replacement

January 06, 2018 - 12:01 am

ST. STEPHEN, S.C. (AP) — In her little brick office building, on the hallway wall next to a handful of exam rooms, Sarah Brown keeps a framed record of "The Legend of Old Doc Brown."

The old Hank Snow song has become her mantra, an adopted philosophy about practicing medicine.

He was just an old country doctor

In a little Kentucky town

Fame and fortune had passed him by

But we never saw him frown

Swap "little Kentucky town" for rural Berkeley County and the 1955 ballad could have been written about Sarah Brown.

Her practice, North Berkeley Family Care, is located an hour northwest of Charleston on the northern edge of Francis Marion National Forest. The office is independent and unaffiliated with any hospital system. Brown employs 10 people and treats thousands of patients a year, but makes very little money. At 66, she wants to retire. But she can't figure out how.

"I would have retired a year ago if I could have," Brown said. "I just have to find someone who can take care of these people."

According to census data, more than 1.5 million South Carolinians live in rural parts of the state. But by the state's last count, fewer than 10 independent family physicians still operate solo practices in rural South Carolina. Between 2007 and 2015, their ranks dropped by half.

Their numbers will likely continue to decline. The S.C. Office of Healthcare Workforce found 67 percent of all self-employed, independent family doctors in rural parts of the state are older than 60.

Simply put, this way of practicing medicine — of hanging a shingle on Main Street, of making house calls, of spending any real length of time with patients — has been largely relegated to history books and black-and-white movies.

"That worked 50 years ago. I'm not sure it works all that well now," said Graham Adams, CEO of the S.C. Office of Rural Health. He estimated that 90 percent of all doctors are now employed by hospital systems.

"The independent solo practitioner is all but gone," he said. "The cost of doing business as a small, independent health care provider is just very difficult."

This makes Sarah Brown one of the last country doctors.

"It's sort of like a mission field, to be here, for me," she said. "I knew I would probably never make any money."

Brown was born in 1951 with a congenital heart defect.

"I had a large ventricular septum defect that probably should have ended my life by the time I was about 12," she said. "That's what my parents were told."

Her father worked for the Navy at the American Embassy in Rome. Her family traveled widely throughout Europe until Brown went into heart failure during a trip to the Alps. Her parents knew she would require heart surgery, so they returned to the United States.

Her family spent the next three years in Indiana while Brown remained on a waiting list for open heart surgery. There simply weren't many hospitals or doctors who performed the procedure 60 years ago.

When Brown finally received the surgery she needed, she developed a staph infection that kept her in a Kentucky hospital for a full year.

"I kind of fell in love with medicine at that time and I knew that I really wanted to be a doctor," she said. "I kept that in my heart all my life. I felt like it was a miracle that I was alive."

Her family eventually moved to Summerville and Brown graduated from Summerville High School in 1969. She studied biology at Clemson University, with the intention of applying to medical school, but said she "chickened out at the very last minute" and became a science teacher instead.

"I thought maybe I could just teach school and that would be enough," she said.

For many years, it was.

She married, had two children, then divorced. When she met a man named David Brown in 1982 and married him two years later, she eventually realized she didn't want to teach anymore.

"I was teaching chemistry at Summerville High School and just said, 'You know what? I need to do what God wanted me to do and I need to go to med school.' "

Brown took the MCAT and applied for a spot at the Medical University of South Carolina.

"My husband got the letter," she remembered. "He took the children to Wal-Mart and got me a Doctor Barbie and came to the school with Doctor Barbie and my acceptance letter. We were just shocked and amazed."

She turned 40 while in medical school and took classes at MUSC alongside some of her former chemistry students.

"My dad drove me to MUSC every day while I was in med school, picked me up after classes and drove me home so I could spend those two hours a day to study," she recalled.

Her mother cooked her children dinner every night for seven years while Brown completed four years of medical school and another three years of residency training in family medicine.

"It was really, really hard," she said. "It was a very difficult thing to do."

For five years following her residency training, Brown practiced medicine with Palmetto Primary Care Physicians in Summerville. But she needed back surgery in 1998 and "basically lost everything."

She eventually decided she didn't like the pace set by the large doctors' group. So she left.

"I'm not the kind of person who wants to see 70 patients a day," she said. "I want to take care of the people I see. I want to work with them and be their doctor for life. I'm not a speedy doctor. I'm just a real thorough doctor."

Her patients attest to that.

Sam Cooper, 77, visits her practice in St. Stephen at least once every three months.

"It's lovely," he said. "You feel right at home."

Calvin Witherspoon, 80, drives 20 miles from Jamestown to see Dr. Brown. He used to see a doctor in McClellanville but didn't like how the staff there made him fill out new forms every visit. At Dr. Brown's office, it's different, he said.

"They appreciate you coming."

Leola Spencer, 92, who lives in nearby Pineville, said her son asked her to move to New York and live with him.

"No," she told him. "They don't have a doctor like Dr. Brown.'"

After Brown left Palmetto Primary Care, she worked at a pain clinic in Charleston for a year — the one year of her life during which she said she made a lot of money — but quit that practice eventually, too.

Then, Brown heard about an opening in rural Berkeley County.

Maybe, she thought. But she knew nothing about St. Stephen.

"It's a ghost town," she soon found out.

Only 1,700 people live in St. Stephen, according to the 2010 census count. While Berkeley County, with its 211,000 residents, has become one of the fastest growing counties in the Carolinas, the population in St. Stephen has remained virtually unchanged for decades. More than one-third of its residents live below the poverty line. Nearly 60 percent are black.

Brown bought her practice in 2006 and moved to nearby Alvin a year later. The Browns paid cash for their small white farmstead, where they raise dogs and grow figs, peaches and pears.

"It's my joy," said her husband David, a forester and a bluegrass fiddler.

The Browns have no intention of leaving their farm, but David admitted that his wife needs to retire. Her own cardiologist, worried about that lifelong heart condition, demanded it.

"She doesn't seem able to let it go until she can sell it," David said. "She can't stand the idea of just closing the doors."

State leaders have long identified that primary care doctors are leaving rural South Carolina. Lawmakers have invested in loan payback programs and telemedicine technology to improve access in these underserved areas. But none of these programs have completely solved the shortage.

Meanwhile, hospital systems in urban parts of the state keep getting bigger and rural hospitals keep closing.

Two new multi-million dollar hospitals are under construction in the Lowcountry. And Palmetto Health in Columbia and Greenville Health System in the Upstate are moving forward with a huge new partnership.

Adams, the CEO of the S.C. Office of Rural Health, conceded that these trends aren't unique to South Carolina. But he worried about what they mean for residents in rural areas.

How can South Carolina leaders ensure that large hospital systems won't pass over patients in these isolated communities?

"I don't have the simple answer to that," Adam said, "but that's what keeps me up at night."

Brown doesn't have an answer either.

A doctor affiliated with Palmetto Primary Care operates another small clinic in St. Stephen, but Brown said he hasn't expressed an interest in managing her patients, who are mostly poor, old and typically covered by Medicare and Medicaid. Sometimes they have no insurance at all.

"It destroys your practice because you don't make any money," she said. "I think that my lowest paid employee makes more than I do."

She has received informal offers from "big organizations" that want to manage her Medicare patients because "apparently there's money in Medicare," she said. She hasn't accepted any offers.

Still, Brown is slowing down. She recently cut her hours in half and tries to stop seeing patients after lunch. She still wakes up at 6 a.m. and leads a devotional with her staff before patients arrive each weekday morning. A Bible verse greets them as they walk in the office door.

"Verily I say unto you, inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me."

The verse speaks to her, in much the same way the lyrics of "Old Doc Brown" resounded the first time she heard them many years ago.

"I sort of felt like God gave me the chance to live and this is my payback," Brown said. "This is my calling."

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