Subscribe to The Podcast by KevinMD. Catch up on old episodes!

We welcome Ryan McCarthy, an internal medicine physician, to delve into the multifaceted challenges of providing primary care in Appalachia. Ryan shares his firsthand experiences from Martinsburg, West Virginia, a region grappling with the invisible effects of lifelong trauma, poverty, and addiction. We explore how socioeconomic factors shape patient health, the evolving role of primary care in mental health, and the profound impact of the opioid crisis in his community.

Ryan McCarthy is an internal medicine physician.

He discusses the KevinMD article, “A doctor struggles to provide mental health care in Appalachia.”

Our presenting sponsor is Nuance, a Microsoft company.

Together, Microsoft and Nuance are leveraging their rich digital technology and advanced AI capabilities to tackle some of health care’s biggest challenges. AI-driven technology promises to revolutionize patient and provider experiences with clinical documentation that writes itself.

The Nuance Dragon Ambient eXperience, or DAX for short, is a voice-enabled solution that automatically captures patient encounters securely and accurately at the point of care. DAX Copilot combines proven conversational and ambient AI with the most advanced generative AI in a mobile application that integrates directly with your existing workflows.

Physicians who use DAX have reported a 50 percent decrease in documentation time and a 70 percent reduction in feelings of burnout, and 85 percent of patients say their physician is more personable and conversational.

Discover AI-powered clinical documentation that writes itself. Visit https://nuance.com/daxinaction to see a 12-minute DAX Copilot demo.

VISIT SPONSOR → https://nuance.com/daxinaction

SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://kevinmd.com/recommended

GET CME FOR THIS EPISODE → https://earnc.me/hKNgFF

Powered by CMEfy.

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Ryan McCarthy. He is an internal medicine physician. Today’s KevinMD article is titled “A doctor struggles to provide mental health care in Appalachia.” Ryan, welcome back to the show.

Ryan McCarthy: Thanks Kevin, it’s good to be back.

Kevin Pho: So Ryan’s been on before. Go to KevinMD.com/podcast and you can search his name to hear his story. But today let’s get right into your most recent article. Tell us about it.

Ryan McCarthy: Yeah, the most recent piece that I’ve written for KevinMD is really a reflection on the reality of what it’s like to be a primary care internal medicine doctor in West Virginia, and I think Appalachia writ large. After these years of providing primary care and specifically mental health care, I find that I am better at it, but at the same time the challenges are astronomical, they are getting harder and harder, and so I feel like I’m failing more and more because my patients are more and more complex.

Kevin Pho: So give us a picture about some of the challenges this specific region presents to you as a primary care doctor.

Ryan McCarthy: Sure, absolutely. So as a native West Virginian, I’m unique in that I practice medicine in my hometown of Martinsburg, West Virginia. And so about an hour and a half east of me are large medical regions, Baltimore, Washington, where there are a surplus, plenty of providers for all sorts of medical specialty services. Out here in West Virginia though, we lack lots of things, all sorts of specialists. I tell my patients I could use five or six of every medical specialist available.

Specifically for mental health care though, my perspective starts with the lack of access to care. My patients, many of whom have experienced trauma in their lives, depression, substance abuse, all of the things that are ubiquitous in mental health care, it’s really the lack of access to those services where my patients, they turn to me. And that’s very important, because as a primary care doctor they can come in for anything, and they do. And so they bring these really complicated mental health care needs to my doorstep, where I’m not exactly the best person always to help.

Kevin Pho: Well, what would be an example of that? And you don’t have to talk about a specific patient, but talk about a hypothetical patient, about what they would come to you with when it comes to behavioral health issues.

Ryan McCarthy: Sure, absolutely. I mean, just from my clinic this morning, a patient comes in and they are on medicine for depression, but that’s in addition to a chronic pain syndrome. Many folks in Appalachia over the last several decades have either been involved with prescription pain medicine or street drug use, and so a lot of my patients are taking, whether it’s methadone or some other medication like that, that’s in the background to where we begin treatment.

And so if you then add depression, now we’re talking about those kinds of medicines. If they have panic symptoms, I have to think and debate about what other medicines might be involved. And that lack of access that I mentioned before, a lot of my patients would really benefit from a really good relationship with a counselor. Not always easy, not always possible, financial barriers. So then they’re bringing that to me, and I find I do a lot of in-office counseling, a lot of hands-on, really emotional based talk therapy, in addition to prescribing medicines.

And then we can even talk about patients that have even further complex needs, because a lot of my patients, let’s say they’ve achieved sobriety from a previous addiction, whatever that might be, they’re now trying to get their life together, and some of these folks have a very legitimate history of the need for stimulant medicine because they might have attention deficit disorder. And so you can just imagine what that pot feels like when we’ve got old pain medicine, current antidepressant therapy, do I add a stimulant to that, because that could be very essential to them keeping their job or getting a job. So these are really complex medical treatments that I don’t know that the best place is the primary care internal medicine office, but it’s definitely where I’m doing it.

Kevin Pho: So on this podcast and on my site we talk a lot about the behavioral health shortage, and that’s nationwide. Just to give us some sense about the particular West Virginia area, how long would it take if you had to refer someone to a behavioral health specialist? And it could be a psychiatrist or counselor. Just give us a sense of what kind of delay we’re talking about here.

Ryan McCarthy: Yeah, we’re talking about a delay that would easily be multiple months under the best case scenario. If a local psychiatry or mental health group told me eight months, wouldn’t surprise me. And that’s often why I have to start cobbling together my own best fit, makeshift, ad hoc solution. At this point I feel like I have some skills to get things started, and the people I have here are great, we just don’t have enough, and the need is overwhelming.

And in my part of West Virginia we have an incredible influx of people from the metropolitan areas of Baltimore and Washington, and that’s a great quote-unquote problem to have. I mean, the rest of West Virginia is losing population, so I’m thrilled that people are coming to this community, but we are just so overwhelmed because we can’t meet that need.

And when you think about the mix that I have, I have some urban problems creeping out here, and then I have all of the rural challenges from Appalachia, and they really mix here in this region where I live and work, in the Shenandoah Valley. And so we are just really, really underserved. There are plenty of patients who I want to send to a psychiatrist, I don’t even attempt it, because I know there’s no realistic person I can get them into.

Kevin Pho: So let’s go a little bit more granular. What’s it like to live in the West Virginia Appalachia region, and how can that environment sometimes lead to the behavioral health issues that you’re seeing?

Ryan McCarthy: Yeah, it’s a great question. Living in West Virginia, the really wonderful and beautiful parts, and many the reasons that people like myself still live here and love living here, is small towns, close-knit community, beautiful green space, fresh air. I kid you not, this morning on my drive into my hospital I saw two bald eagles and a 10-point buck. I have wildlife in my backyard. And that green space and fresh air and neighbors that I know, if my car were stopped on the side of the road as I was coming in here, several people would have stopped to ask me if I was OK. That’s the kind of community that I live in.

Now, that said, this is a culture and a place that over the last century we have been the victims of extraction industry, from timber to coal, to industries that have really physically hurt the citizens of West Virginia in many ways, and disrupted our geography and our culture. And so I think the particular challenges here are the result of that. We are very much a part of America that has not yet got to a high-tech future.

And so that would be injuries, isolation, brain drain. That’s when families are estranged because young people had to leave, so that’s loneliness that feeds into the depression of older people who are aging in place and their family members have had to go somewhere. So that sets up, I think, depression in the older generation.

There’s a middle-aged group of people of West Virginia who, I have lots of patients who have physically been hurt on the job by employers that really squeezed a lot of labor out of them, and so they have physical pain that they’re dealing with, physical disabilities that then lead to loss of personal identity and lost income. And all of those things really become the canvas over the last 20 years onto which OxyContin and all of that, that is really well described at this point. Those are some of the local mental health challenges that are unique to West Virginia and Appalachia.

Kevin Pho: How difficult is it for someone to find a primary care physician like yourself?

Ryan McCarthy: It’s extremely hard, and I have to say no every day to patients who say, what about my neighbor, what about my sister. I have to say no. I think the last time I looked we were booking appointments into 2025, and many doctors’ offices here are just like me. So our best hope is to recruit and grow additional doctors, because it’s really unsustainable at the moment.

Kevin Pho: Now, what’s your day like? Because you mentioned sometimes you have to engage in this talk therapy to handle some of these behavioral health issues, and I can only imagine that probably doesn’t fit into a typical 15-minute office visit. So how do you manage that time, as well as the demand of people who need primary care? How do you manage your day?

Ryan McCarthy: Boy oh boy, that’s a great question. I manage my day by going to bed early and then getting up early, and I engage the EMR on my phone to assess my hospital patients even before the sun comes up. I really try to be as efficient as I can with seeing patients in the office and doing the extra charting and what have you. It’s exhausting, I go home really, really tired.

I give patients more time for follow-up visits. Most office visits for complex patients in my office are half an hour, and we do that so that we can get the whole spectrum of time to talk about their mental health needs. And in that space that also becomes a therapeutic place to extend the visit by adding, have you gotten a mammogram, you’re here, what about a flu shot, getting to all of those things.

So it’s hard. Some days I feel like I’m not good at it, other days I feel like I can tap dance most of the day, but it is really exhausting, Kevin. I find that I go home, and my kids have heard me say that I’m mentally trashed at the end of the day. It’s true, because I want to come in here and serve my patients, but there are some days that I look back and I’ve given out two and a half to three hours of talk therapy, kind of layered over top all the internal medicine, and my brain is just done.

Kevin Pho: So it doesn’t sound like a very long-term tenable situation for you. How realistically sustainable is a schedule and a demand like that?

Ryan McCarthy: I don’t think it’s sustainable really at all. And I’ve been reflecting about that a lot lately. And so one of the things that I’m involved with here at my hospital is we’re starting an internal medicine residency program, because we realize that we have to grow our own, that we can’t recruit enough, that we have to just kind of start building the base and really thinking about the long term in that way, to bolster what we have, our frontline primary care workers.

So I think that’s the real answer to your question, is we’re just going to start at the beginning and just train internal medicine doctors here, because we’ve tried everything else to try to get folks into our region, but we think that this is really going to be what it takes.

Kevin Pho: So a solution like that probably is more longer term, in order to create a program and spend three years training an internal medicine physician. Anything on the short term that can help you and your fellow primary care clinicians deal with a schedule like that and behavioral health demands of your patients?

Ryan McCarthy: I think in the short term, here in my office I have great staff and excellent teamwork in the office, delegating other tasks, and that kind of day-to-day teamwork really makes a difference.

And a lot of our office and nursing staff, our nurses have a lot of contact with patients and end up providing a very therapeutic component to office visits here, so let’s not undersell the importance of that. And our patients mention that oftentimes, when they come in especially if somebody’s upset, we give them time to sit, and they may end up speaking to somebody else in addition to me, one of our really caring nursing staff. And so utilizing our team members here in the office as best we can has really made a difference.

And part of that is recognizing that all of us take home a lot of trauma from doing this. And so really recognizing that we’re all affected by that, our team outlook has changed on that. And so I think we really try to take care of each other better in the office, in a way that we didn’t at the beginning of my career, because we’re all affected by this workload and burden.

Kevin Pho: Talk in a little bit more detail when you say that you take home the trauma, and you and your staff members band together to help with that. So what exactly are you doing? Because that sounds like a pretty big concern to me.

Ryan McCarthy: Yeah, it’s definitely a big concern to me as well. And I think openly communicating to each other, I think every staff member in my office has seen me shed tears. And so just being open and honest about, hey, this patient has gone through something terrible and I’ve learned about it and it’s really heavy on my heart. I don’t hide that anymore, I do acknowledge that. So I think starting with my own humanity, I don’t feel like Superman anymore.

And then, some social things, especially at lunchtime, we really joke and cut up with each other, that makes a difference more than anything. I think when I hear laughing in my office amongst the staff, that tells me that we’re taking care of each other’s mental health needs.

Kevin Pho: Now, how about from a policy and administration standpoint? You have a platform here on the podcast, and I know KevinMD. Any messages that you want to share with your administrators or politicians from a more macro level that could help improve things?

Ryan McCarthy: I think the recognition that primary care access really makes a big difference. Every time I read a health care article that talks about a high-tech gadget or artificial intelligence something, or a robot or some gizmo, I balance that against what I know, that if a child can get into a pediatrician’s office in a timely manner, if somebody can get into their family medicine doctor or their primary care internal medicine or their OB/GYN provider in a timely manner, those low-tech, person-to-person access of care, the value of this is really what makes a difference.

And I think sometimes we lose sight of that by thinking that we need to add technology or gizmos or gadgets or AI or something, when most health care needs are known, they’re low-tech, and they’re served by one person listening, examining, and then making a plan with another human being.

I would like for all legislators and leaders to understand that. And I always stop and ask them, what would you like us to do for your grandmother? How would you like us to treat your husband? And when we look at it from that point of view, we stop and say, I really want that person to be able to get in front of a caring, compassionate, and competent doctor in a timely manner.

Kevin Pho: And my final question, Ryan, let’s end off with some of your take-home messages that you would like to leave with the KevinMD audience.

Ryan McCarthy: I think my take-home message is, despite the difficulty of providing mental health care here in West Virginia, I’m very hopeful for the future in the long term. The infusion of young people that I have seen come into health care after the COVID-19 pandemic, it’s going to take a while to bring our youngest colleagues on, but they are a new and a different generation, and I love their energy, their vibe. And the young folks in health care are really interested in caring for one another, they believe in social justice, and they are bringing something that we need. So those of us that are far enough along, it’s incumbent upon us to educate and mentor our young health care colleagues, because they clearly are the future that we need.

Kevin Pho: Ryan, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Ryan McCarthy: Thanks.