Hurricane Helene wrought historic devastation when it hit western North Carolina last September. Nearly 100 people were killed in the region and thousands were left injured, traumatized or homeless.
Hundreds of volunteers arrived within hours and began assisting with everything from food delivery to housing to medical care. Their presence was a godsend. But for many of the area’s medical professionals, the crisis underscored their own advantage: They knew the place, the people, the culture.
“A lot of questions I don’t have to ask my patients, because I know already,” said family medicine physician Tim Bleckley, who returned to his hometown of Franklin after residency to take over the practice of a retiring doctor.
Rural Americans are more likely to suffer from, and die prematurely of, a number of chronic conditions, including cancer, heart disease and diabetes. Effective management of such diseases is bolstered by long-term doctor-patient relationships, and studies show that cultural awareness provides a firm foundation for these relationships.
Cultural awareness is, essentially, having an understanding of and being sensitive to a community’s customs and rhythms. For health care providers, it’s having a sense of what your patients arrive with when they enter your office.
Bryan Hodge is chief academic officer for the Mountain Area Health Education Center. He’s tasked with convincing young health care professionals of the virtues of practicing medicine in a rural community. Hodge said in the storm’s aftermath, he felt “so much pride and inspiration for the way in which people showed up.”
He also witnessed “the value of knowledge of the fabric of a community.” Those attuned to its rhythms were uniquely well-placed. It reinforced Hodge’s conviction that “the more local the care can be, the better.”
A ‘Comfort Zone’
Health care administrators in Appalachia are striving to meet two objectives at once: addressing a critical shortage of providers by nurturing homegrown talent.
Case in point: Tim Bleckley.
Bleckley was born with a heart defect and underwent surgery at a month old. While initially pediatric cardiology was his ambition, he changed his mind while in residency. He wanted to go home to Franklin, but knew the town was too small to sustain such a practice. So he chose family medicine instead.
His patients, he believes, are in a “comfort zone” when they visit him. They like that he’s aware of what they experience, how they operate, “the things that matter to them.”
“Primary care is very personal in terms of understanding where people come from, and understanding what their lives are like,” he said. “People are very comfortable with the fact that I’m a hometown boy who’s come home, and they feel very at ease coming to see me.”
He’s been able to translate that cultural awareness into change, one step at a time. He knew that his patients — like so many mountain folks — have a tendency to take the advice of their doctor without question. He wanted them to take more ownership of their care, to know why they’re taking a particular medication, when it should be taken and potential side effects. He uses the teach-back method to have them describe what they’ve been told about medications their cardiologist or nephrologist prescribed.
“I want them to feel confident they know what they’re doing.”
Rivers Woodward had a similar career trajectory.
When Woodward was a junior in high school, his sister was stricken with an illness for which traditional means of medicine proved inadequate. The family turned to Patch Adams — a physician with an alternative approach to medicine (and the subject of an eponymous motion picture starring Robin Williams) — and she made a remarkable recovery.
This experience inspired Woodward to pursue a career in health care, to help reinvent the way it’s delivered. Further, he wanted to realize that ambition in a rural community.
Like Bleckley, Woodward was raised in Franklin, in rural Macon County. Today, he’s a family medicine physician at Blue Ridge Health, a federally qualified health center in the town of Lake Lure, in the same mountain region in which he was raised.
Studies show that those who were raised in a rural community or trained in one are more likely to practice in a rural region. Both are true of Woodward. While in medical school at the University of North Carolina, he was selected for the Rural and Underserved Scholars Program, a collaboration of the University of North Carolina and the Mountain Area Health Education Center.
“Things move at a different pace” in a rural community, Woodward says. His sense of that serves him well. His cultural awareness provides a foundation from which he offers empathetic care, which, he says, entails “listening with curiosity because I actually want to know someone’s experiences.” It requires listening without judgment.
Regardless of where you come from, rural cultural awareness can be learned with time and patience, assuming you’re receptive to it. But for many, it requires a reset.
“The more insular your upbringing,” Woodward says, “whether that’s in New York City or in Macon County, the more difficult it is to tap into cultural humility with people who may not look like or speak like or think like you.”
Woodward’s upbringing was an unconventional one; learning was experiential. His family took extended trips through Latin America, traveling by bus, staying with local families.
At times, he felt tensions in his relationship with his hometown: that he was somewhat “other.” He says his practice of rural medicine, listening with curiosity, has allowed him “to heal that tension.”
Designing a New Model
In reflecting on his community in the weeks since the storm, Woodward references a paper written for the Episcopal Relief and Development agency on the emotional stages of a community that’s experienced a natural disaster.
“There’s a peak immediately afterwards that’s fueled by adrenaline and cortisol,” he explains, “survival mode, basically.” Next is “this feeling of the community coming together and supporting each other, which we saw.
“But then after that, there’s this long downhill slide into disillusionment, before the upward slope of rebuilding.”
There’s much work to be done in Western North Carolina. Its health care needs, like those of most of rural America, are urgent; solutions require systemic change.
Bryan Hodge recalls so many people being overwhelmed by the attention they were extended in the aftermath of the storm. They were accustomed to going without. This underscored for him the critical need for an overhaul of rural health care. And it underscored the heightened importance of cultural awareness to inform that overhaul.
Woodward was recently named Blue Ridge Health’s associate chief medical officer. One of his primary responsibilities is to help design new systems of care for its rural clinics.
“My hope is to leverage all of the resources we have within a really large organization to make sure that we’re meeting people where they’re at, regardless of their location and their condition,” he says.
This could mean, for example, recognizing what a huge issue transportation is in rural communities and taking better advantage of telehealth, or providing more home visits.
Tim Bleckley’s immediate community was spared from major damage in the storm. But a number of his patients live in communities that weren’t. The morning after, he was on the road, checking in on those he couldn’t contact.
“These are people I know,” Bleckley says. “They’re not numbers.”
He plans to continue to practice medicine in his hometown, using his cultural knowledge of the place to improve care, one patient at a time.
“I never regret or feel like I should have done this differently. Not at all.”
