Healthcare in the United States is in disarray. Even before the COVID-19 pandemic, costs were on the rise while outcomes deteriorated. Lack of access to timely, affordable care has become a harsh reality for many. But making do without much-needed resources is a way of life in rural America. And fewer areas in the country have been more affected than Appalachia. While politicians prattle on in Washington, one PA is making a difference–Dr. Sarah Buch.
Meet Dr. Sarah Buch, DMS, PA-C
An Appalachian native herself, Dr. Buch began her medical training at Alderson-Broaddus University in Phillipi, West Virginia. She first considered a career in nutrition and dreamed of teaching medical nutrition classes and working with patients with metabolic diseases. Deciding on a career in medicine, she chose the PA route over a traditional medical school for its fast-paced training and ability to work in different specialties.
Her clinical education took her to some of the most rural areas in West Virginia, which has profoundly impacted her career. “Being in a rural and impoverished region, I had the opportunity to be directly in the line of action,” says Dr. Buch.
What is a Physician Associate?
Physician Associates, or PAs, receive their medical education in an ultra condensed 24-36 months, typically earning a Master’s degree. While some go on to optional residency or fellowship programs, there is no time to waste in PA training. As a PA student, Dr. Buch recalls drawing blood and giving injections in the Emergency Department as well as incising abscesses, repairing lacerations, and removing foreign bodies. She also participated in traumas and codes. The rest of her clinical rotations were equally demanding.
“But I also learned to be humble,” recalls Dr. Buch. “I helped transfer patients, clean spillage from ostomy bags, and change bedsheets when others were busy.”
As a PA student, Dr. Buch would often train with medical students but quickly rose above the pack. Her clinical preceptors took notice and the future PA Doctor was often the first choice to scrub into surgery or to see an interesting case. But time after time, what she saw in rural Appalachia were the bleak conditions in which many residents lived their entire lives.
Social Determinants of Health in Appalachia
“Children would come in with a mouth full of rotting teeth, dirty clothes, malnourished, reeking of smoke,” Dr. Buch remembers. “I once participated in a code for a 7-month-old who had asphyxiated in her car seat while her young parents got high. As we were doing CPR, I remember seeing her feet covered in dirt and stool.” Dr. Buch frequently cared for teenage mothers bringing their own children to the clinic. “Many children were accompanied by their grandparents, as the parents had succumbed to addiction and no longer had custody.” It was not uncommon for patients to miss scheduled appointments as many families lacked transportation.
After completing her training at Alderson-Broaddus, PA Buch moved to the northern panhandle of West Virginia where she worked in rural urgent care for several years before moving into a surgical position. As a surgical PA, Ms. Buch was part of a team that provided general and bariatric services as well as covering the trauma service.
But family ties called PA Buch back to southern West Virginia where she had first trained as a student. Knowing firsthand the great need of children and families in the area, PA Buch wanted to better equip herself with the tools to care for them and so began her quest to become a Doctor of Medical Science.
A New Kind of Doctor–PA Doctor
The Doctor of Medical Science (DMS) is a post-professional clinical doctorate for Physician Associates. The DMS program at Lincoln Memorial University, where PA Buch enrolled, offers experienced PAs in-depth training in internal medicine, emergency medicine, and primary care. Originally developed with support from LMU’s DeBusk College of Osteopathic Medicine, the DMS at LMU is entirely clinically focused and was designed to close the gap between physician and PA training, especially in underserved areas throughout Appalachia. “I wanted to feel more confident in treating and educating my patients,” states Dr. Buch. Like many other PAs, the future PA Doctor often found herself alone, the sole provider for an entire clinic.
“I needed to be more confident in my ability to treat a population with significant comorbidities, and a significant lack of previous medical care,” says Dr. Buch whose doctorate was focused on primary care medicine. “With my DMS degree, I am better prepared to assess patients as a whole.” Medical specialists are scarce all throughout Appalachia where wait times are measured in months. As a Physician Associate and Doctor of Medical Science, Dr. Buch now feels capable of managing complex patients as well as performing a more comprehensive workup prior to referral, if necessary.
“I think the DMS will be a standard in the future–we’ve seen this with many other professions, such as the AuD, DPT, and DNP,” she predicts. “I would also like to hope that in the future, PAs with a DMS degree can be autonomous providers, as we are highly trained, and can provide exceptional care in settings such as Family Medicine, Emergency Medicine, and Internal Medicine.”
During her doctoral training, Dr. Buch’s research focused on the impact of fad diets on blood sugar and insulin response in type 2 diabetics. “I want to expand that research into the long-term effects such diets have on metabolic syndrome,” reports Dr. Buch.
As a new Doctor of Medical Science, Dr. Buch recalls many positive relationships she’s had with physician colleagues. “When I worked in urgent care, we all performed the same job. They did a great job training me and were always available and helpful when I had questions. When I worked in surgery, the roles were a little different, but all of the physicians in our group respected the PAs and stood up for us multiple times.” She also reports that many of her physician colleagues have been excited about and impressed with her additional training and respect what she’s accomplished as a doctorally-trained PA.
Take Me Home Country Roads
Now residing in Scott Depot, WV, the new PA Doctor took a position with FamilyCare, a federally funded health center that started as a birthing center for impoverished mothers in 1989. FamilyCare provides comprehensive medical care all across southern West Virginia. But Dr. Buch isn’t your average country doctor, she’s the sole provider on FamilyCare’s new mobile health unit serving schools in Kanawha County.
The FamilyCare mobile health unit is a retrofit RV that allows patients in underserved areas a chance to receive regular check-ups, screenings, immunizations, and physicals. And it’s not a moment too soon–many of the patients on the mobile unit haven’t had medical care for years. “Many are behind on vaccinations, and acute illnesses are often dismissed because they’re unable to be evaluated by a medical professional,” reports Dr. Buch. “Without the mobile unit being able to come to these communities, some patients may have to drive 30 minutes and even up to an hour to find the quality and comprehensive health services–and many families are without reliable transportation,” she adds.
Dr. Buch and the other clinicians at FamilyCare provide a wide range of services including primary care, pediatrics, women’s health and gynecology, birth services, nutrition and diabetes education, behavioral health, social services, dental care, and chronic care management. A nearby partner clinic offers x-ray and laboratory services.
But Dr. Buch’s first love is still nutrition: “I want to be a source of inspiration for people and show them that healthy food can be both satisfying and economical.” She envisions a program where she could help patients make better choices in the grocery store as well as provide meal plans. Dr. Buch hopes to make personalized dietary recommendations based on a patient’s goals, medical comorbidities, and food preferences.
FamilyCare accepts most insurances—including PEIA, United Healthcare, Cigna, Aetna, UMR, and the Health Plan, as well as Medicaid and Medicare. A sliding fee scale is available to patients who do not have insurance.
Mobile Medicine with a Pediatric Focus
While Dr. Buch spends most of her time working with school-aged children 3 and up, she often cares for school faculty and staff. On occasion, she’ll even see family members.
“Another barrier to good health is education, which I hope to improve by establishing some programs within the school,” reports Dr. Buch. “By starting with a healthy childhood, we hope for a healthy adulthood.”
A large percentage of patients in Kanawha County fall below the Federal poverty line where affordable health care isn’t the only concern. Children of impoverished families tend to have more health problems, some of which may not manifest for decades. Childhood is the best time to intervene.
Both PAs and DMS PAs are especially qualified to treat underserved populations
“Many PA schools try to accept students from underserved locations and place them in such locations during training. These are areas that typically lack a large physician population,” says Dr. Buch.
In these underserved areas, PAs cut down wait times, especially in subspecialty care. DMS-trained PAs are especially well-suited for primary care roles given their additional medical training and experience. These doctorally-prepared Physician Associates were already used to providing high-quality care before becoming doctors.
Will We Even Have a Healthcare System After COVID-19?
“We are in a rocky place with healthcare right now. For many, this has been the most stressful 2 years of their medical career. Hospitals are swamped, wait times at EDs and urgent cares are astronomical, and virtually everyone is short-staffed and lacking supplies,” remarks Dr. Buch. “Patients that need urgent or emergent care are afraid to go to hospitals because of the wait times and fear of contracting COVID, while the ED is full of patients waiting for COVID testing.”
The strain of the COVID-19 pandemic has pit clinicians against administrators. Healthcare providers want to do what’s best for their patients but are too often compelled to follow asinine mandates from third-party payers and to make concessions in government-sponsored care. Dr. Buch comments that many clinicians feel unheard and unappreciated. Traveling nurses and other professionals can help alleviate shortages but are often paid 2-3 times average wages which leaves longtime staff feeling overworked and underpaid. The national labor shortage has also left care providers in unsafe conditions where there aren’t enough staff to provide adequate care. This can lead to burnout. Doctors, nurses, and PAs are leaving medicine at an astounding rate which weakens an already ailing system.
“I think we as clinicians need to remember that everyone is stressed out and frustrated right now. We need to try to be present for our patients, and bridge the gap to make those connections to improve understanding and quality of care,” comments Dr. Buch. “The pandemic has also taught us to take care of ourselves because we can’t take care of others if we’re exhausted and burned out.”