David City, Neb. -- Dr. Gerald Luckey starts before dawn each day and works past dusk, caring for patients whose needs can range from colonoscopies to calluses.
He is a primary care doctor, called the frontline of U.S. health care. The ranks of these providers are growing thin, especially in rural communities like David City.
As the number of elderly Americans increases and health care reform gives more people access to care, the shortage of these physicians – including family medicine doctors, internists, pediatricians and gynecologists – will grow. By 2020, the shortage is expected to reach nearly 45,000, according to the Association of American Medical Colleges.
New medical school graduates often are lured by the promise of higher pay and shorter hours in specialty practice. Doctors like Luckey, though, say the opportunity to treat a variety of conditions and to become part of a community is worth the trade-off.
Following Luckey, 67, through what he calls a typical day makes it clear what's essential in primary care: broad and deep medical knowledge … and a good pair of tennis shoes.
Try to keep up.
6:19 a.m.: Luckey is picking weeds in front of his two-story house with his stethoscope in hand. Earlier, over a slice of toast and coffee, Luckey dialed into the Healthland Network with his iPad to check the vital signs of hospitalized patients. “It helps me get a head start to the day,” he said.
6:29 a.m.: Luckey pops open his garage and hops on his bike for a quick ride to work.
6:36 a.m.: A mile and a half later, Luckey arrives at the Butler County Health Care Center, where he has served the people of rural Nebraska for more than three decades. Inside, we find Luckey with a cup of coffee, having traded his loafers for tennis shoes, his slacks for scrubs and his tie for a white coat.
6:53 a.m.: Luckey heads into the procedure room. On the docket: two colonoscopies and an upper GI endoscopy. He hangs up his white coat as the nurses sedate the patient. Using a video-game like controller to view the woman's intestines, he notes diverticulums in the colon – a weakness in the muscle wall. “She just needs to eat more old-fashioned oatmeal,” he says.
7:28 a.m.: Luckey scrubs out, and I scurry after him as he heads to the doctors' lounge to dictate into a landline phone. His voice is soft, and I catch about every fourth word. Colonoscopy.Period.Diverticulum.Period. You can tell he does approximately 175 colonoscopies a year.
In a town of fewer than 3,000 people, it's not surprising that Luckey's next patient taught his nurse's son to drive a stick shift in high school and pulled her car out of a ditch last winter. That patient is John Dehner, and today is his 81st birthday.
8:16 a.m.: The AM radio plays softly as Luckey performs an upper GI endoscopy on Dehner. A dose of “bubble buster” to clear away saliva reveals an abnormal, corkscrew-like swallow. With the help of his team, Luckey nips a piece of esophagus to test for possible Barrett's esophagus. They'll know the results by tomorrow. Luckey heads down the hall and informs Dehner's wife of 50-plus years that everything went well. “Now, let's get John some birthday cake,” he jokes.
9:09 a.m.: Teresa Pokorny of Bellwood has a family history of colon cancer. That's why she's here for a colonoscopy before age 50. Luckey puts her at ease, asking how the crops are growing. As he's finishing up, Luckey discovers and removes a polyp. They'll test it for cancer, but he's confident it's benign.
10:07 a.m.: Luckey stops for his fourth or fifth cup of coffee (he's not sure) after changing back into his button-down-shirt and tie. He winds his way over to the clinic side of the building and confers with a nurse. A man called worrying about blood in his urine. Another was concerned that insurance won't cover a brand-name prescription. A pregnant woman asks if she can have dental X-rays at eight weeks along.
10:27 a.m.: Luckey opens the door to one of three exam rooms and is greeted by Albin and Gladys Shultz. Luckey doesn't mind the two-for-one appointments. “You get more accurate information,” he said.
Gladys mentions that calluses on her feet have been bothering her. A good pedicure might have been in order, but instead Luckey trims her calluses on the spot.
Hanging on the wall is a plaque in the shape of the State of Nebraska. “2003 Nebraska Family Physician of the Year.” Luckey also received the 2012 J.G. Elliott Award from his alma mater, the University of Nebraska Medical Center, for being an “outstanding physician, leader, educator and innovator in rural medicine practice.” None of his colleagues was on hand to witness the honor. “He didn't tell us until the Monday after,” says Dr. Mark Carlson.
Luckey has served as a mentor to many UNMC medical students and health professionals. “The students are able to do more here,” he said.
Unlike many office-based family physicians, Luckey and his students do hospital rounds, perform surgeries every Wednesday, dabble in obstetrics and gynecology and rotate being on call for the emergency room every fifth day. Luckey does nursing home rounds on his day off. “It allows us to maintain our skill set,” he said. “But we could use more help in the area of mental health and psych.”
11:05 a.m.: A patient with a persistent cough and a crushed vertebra is back.
Luckey sympathizes as he knows she likes to garden. After reviewing X-rays, he demonstrates flexion exercises for her backpain and prescribes an inhaler for the cough.
12:02 p.m.: Luckey helps himself to oven-fried chicken and cranberry salad as he joins a confidential credentialing meeting. I'm happy to have a few minutes to sit down.
12:46 p.m.: Luckey is sipping a Diet Mountain Dew at his workstation outside the clinic exam rooms. He walks us by the mailroom, where we get a look at his overflowing inbox. He's part of a physician's group whose members exchange charts for review. He's also affiliated with several physicians hoping to set up a rural Accountable Care Organization or Health Care Co-op. He spends weekend nights on these projects.
The appointments continue well into the afternoon. Knee problems. Hip problems. Heart problems. Blood pressure problems. Bed sores. Dry mouth. Dry skin. Diabetes. (No more “Mexi-fried nachos” from Amigos for that guy). Back pain. Chest pain. Plain old pain.
One woman brings in all 10 of her prescription bottles. This is why Luckey favors the medical home concept, where one physician coordinates all the care. The idea is to keep patient costs down by serving as a one-stop shop. “If we send people away (for their health care), that's bad for the local economy,” he said. “We want to keep them home, and patients appreciate having their health care delivered in their hometown.”
3:10 p.m.: A line has formed, and Luckey is bombarded as he emerges from an exam room: “What would you call this type of ulcer?” Ischemic; “PT or OT?” (Physical therapy or occupational therapy?) PT; “Can you read this EKG?” Yes.
While Luckey is with another patient, Physician Assistant Leah Hays says, “If I could take someone to the fountain of youth, it wouldn't be my mom or dad, it'd be Luckey. He's the best family medicine doctor in the state.”
Luckey -- a Columbus, Neb., native -- relishes small-town life. “Ninety-five percent of the things I like to do are quick and handy,” he said. He fills up his gas tank once a month.
He tells the story of the time when his knees were younger and he was nearly finished with a long run on a gravel road on a hot day. He had maybe 100 yards to go. Just then, a farmer tore off after him. “Doc, whaddya think of these blood pressure readings?” Did he stop? “Oh yeah, I stopped and talked to him.”
4:07 p.m.: A patient with a marginally low thyroid level is feeling “pepless.” Luckey also checks her feet for psoriasis, places her shoes back on and tells her he always wanted to be a shoe salesman.
4:32 p.m.: Luckey drains fluid from a patient's swollen knee. “We can do mine while we're at it,” Luckey jokes.
For the clinic staff, 5 o'clock signals quitting time. Luckey still has hours of work ahead. He needs to check on three patients he admitted to the hospital, fill a dozen or so prescriptions and finish documentation on all the day's patient visits.
About 8 p.m., he heads home for dinner with his wife, but he's back at the clinic by 9:30 to sign off on more than 35 messages.
11:45 p.m.: He's home for the night. In less than 7 hours, he'll pedal back to the clinic to do it all over again.
“It occurs to me that this schedule is not what many people desire,” he said. “It just happens to be what I enjoy.”