People have long discussed the divide between urban and rural America, especially when it comes to health care. Nowhere is this seen more than in pediatric care. In fact it is growing worse. Many times doctors are hours away and only available part time. Why is this such an issue? What can be done to solve it? Is the issue getting better or worse?
I had a chance to learn more in this interview with Dr. Lori Langdon, a noted pediatric doctor, faculty advisor for the Pediatrics Club, the Med/Peds Club, and the CMDA. She is the vice-chair of the Harnett County Board of Health, and serves on the Harnett Health Foundation. She has addressed this issue in her soon to be released book, Doctors Work In Air Conditioning.My book is written in an autobiographical style and with a purpose. My goal is to shed light on healthcare disparities for pediatric patients living in rural areas. You will learn of my own childhood through stories of our hog and tobacco farm, driving a tractor at the tender age of seven, and learning to walk on eggshells to not trigger violent tantrums from my abusive father. You will meet my nurturing mother and my two siblings and begin to understand how my childhood shaped who I am today. The reader will get to follow along through all the rigorous training to become a physician. From my almost 30 years of being a practicing pediatrician in a rural area, you will learn firsthand of some of the unexpected challenges and wild medical stories that happened.
When I was five years old, in the middle of a tobacco field on a blistering July day in Eastern North Carolina, I asked my father if girls could become doctors. He said yes. I asked him if doctors were guaranteed to always get to work in air conditioning. He said yes again, and I decided that a doctor was exactly what I wanted to be.
I have been writing stories about my childhood since I was a teenager. Having the chance to finally put them all together has been cathartic. There is a certain redemptive quality to naming all the good and all the bad parts of one's life and retrospectively seeing how everything worked out for a reason.
The biggest challenge so far has been that one family member objected to speaking the truth about my childhood. I was even told the following quote exactly, "Family secrets should stay in the family." I was shocked by that sentiment after all these years. Certainly, I continued with this journey and hope that family member will be able to see the redemptive arc through the book regarding my father. Even more than that, I pray that even one other person could see that everything did work out for me after that challenging childhood. I hope other women or children or anyone who has suffered could find some hope in my story. My adversity was certainly not severe compared to so many, but I think it is always encouraging to read a good overcoming adversity story.
I'm satisfied that I included enough specific stories that actually occurred that the reader will be able to get the full picture of my life and my concerns about rural pediatrics. There was one study from October 7, 2024, published in Health Affairs, that I wished I had included that noted that 80% of Emergency Departments are not prepared either with equipment or training or both to handle life threatening pediatric emergencies. One of my "Langdon Laws" has always been that a genuine pediatric emergency deserves a genuine pediatric emergency department. It is important that parents know that.
My biggest surprise with writing the book was how vivid many of these stories still are in my memories.
The book is packed with advice, and I hope it can help pre-med majors, medical students, residents, and even attendings. For women specifically, I do talk about the challenges of pregnancy, breast feeding, balancing work and family. For women interested in becoming a physician, I would offer this advice. Medicine is certainly a demanding occupation. While you can achieve it, there is a price to pay. Remember that while I believe in you and you can accomplish anything, what no one can do is accomplish EVERYTHING. There are two different sections in the book on mom guilt. That is some very real stuff! The reader will meet the absolute hero of my story, my husband Mark. He was the one who maintained a well-oiled machine in our home of six children and made it possible for me to work so much. I had all sorts of random guilt hang ups. They were silly at times. For example, I felt okay using a boxed cake mix to make a birthday cake for my child, but felt it was important to make home made icing, or I felt I had failed my child. I have no idea where that came from!
For parents looking for a pediatrician, I would recommend the first step is to verify that they are board certified. You can go to the website for the American Board of Pediatrics and check this. I would recommend that this pediatrician recommends vaccines, so that their waiting room will be safe for your newborn. Then check the website of the practice and make sure the group is solid. After you pick the group, then you are down to personality preferences.
We know now through studies that there are several predictive factors for which medical students will decide to pursue rural medicine. One of them is that the student is from a rural area. Certainly, that was my case. I wanted to be close to my family, which prompted the move back to the same rural area.
There are multiple and complex reasons for the differences in quality between rural and urban areas. It can be difficult to recruit qualified physicians to rural areas. Those physicians want to have good schools for their children or good job opportunities for their spouse. I believe one of the hardest issues is that in rural areas, the pediatricians are the only ones still doing it all. They see patients all day in the office, may have to run to the hospital to resuscitate a newborn or admit a child from the emergency department to the hospital. Adult medicine figured out years ago to split the responsibilities of inpatient and outpatient services. Adult medicine typically has inpatient hospitalists that work shift work and outpatient doctors who work regular office hours and never the twain shall meet.
This is particularly challenging for pediatricians because we are paid at much lower rates than doctors for adults. When I was young, this did not bother me as much as it does now. Now that I have retirement at least in my sights, it is frustrating that I do not have typical physician level wealth. It's not anywhere close! We also deal with many more after hour phone advice calls than the average adult physician. Every single one of those calls has some level of liability for us if we make a recommendation that does not work out or the parents do not agree with. Parents can be very harsh and demanding at times. Dealing with child abuse cases in poor counties with poorly resourced social services can be completely heartbreaking and soul crushing. Many adult subspecialists have clinic hours in rural towns, but this does not happen for pediatrics. Our families must travel out of town. Rural counties have higher Medicaid populations and having a high Medicaid population for your practice is notoriously risky from a business standpoint. Often rural practices have parents that have lower socioeconomic levels as well as educational levels.
In fact, instead of availability improving, it is getting worse in many rural communities across the US. Many hospitals have closed to labor and delivery/newborn nursery because they cannot find the doctors to staff them.
Some solutions to this could include increasing Med/Peds residency slots to train providers that could be both internal medicine and pediatrics board certified and become hospitalists for both. As far as covering the pediatric side of labor and delivery as well as the newborn nursery, groups of neonatal nurse practitioners could be contracted, and these groups could be remotely supervised by a neonatologist. This would both increase the level of quality and free up the local pediatrician from attending the deliveries. There are already programs in existence and expanding to help residents choose rural areas to assist with loan repayment.
The lack of trust from some parents can be discouraging. As an entire society, this seems to be increasing. On a personal level, I have seen more vaccine hesitant parents in the last five to six years than ever before. It breaks my heart. We have been taught to remain non-defensive and engaging and empathetic and I really try. What I wish I could say is that I have seen children die of vaccine-preventable illnesses and that I do not think the parents understand how deadly measles can be or how contagious. I do not think they understand how terrible Hib (haemophilus influenza b) was before the vaccine with the number we saw of meningitis cases and epiglottitis cases. They do not realize that pertussis is surging as we speak. These young parents have never had friends who were permanently paralyzed by polio. I cannot comprehend that these loving parents care about reducing risk by using a car seat and bike helmets but do not realize how important vaccines are to their children's health and safety. I want to tell them how much I love this little baby in front of me in the exam room and that I would do anything to protect them. Maybe I could show them my retirement fund and that would convince them I have NEVER received kickbacks. There is no giant conspiracy here folks, just science and a bunch of pediatricians who are underpaid and overworked and genuinely love your children. I would challenge anyone to be careful about internet "research" because that is never the same as actual scientific inquiry. The internet would have you believe there is great controversy around vaccines, but in the world of epidemiology, virology, microbiology, infectious diseases, immunology, there is no controversy whatsoever.
The way I deal with stresses at work such as parents who argue or are rude is I usually rethink the entire scenario several times to see if I could have done anything differently. Then I tell the whole story to my husband. I never have to worry about his breaching confidentiality, because I think he's not even listening sometimes. Ha ha. We did figure out years ago that sometimes I just need to vent, and he can fix a lot of my problems but not all of them. Then after an overthinking and venting session, I try to put that bad encounter in a box and not re-open it. It is sad that I could see 25 delightful patients in a day and the one sour encounter is the one that sticks.
Two and a half years ago, I became the Chair of Pediatrics at an osteopathic medicine school, even though I am an MD. I adore the students and love to have them over to the farm to feed them. They are beautiful, smart, and stressed out and I feel like a hug and a hot meal can fix them. I'm at a transitioning point currently and will most likely decrease some of my clinic time in the next few years. Pediatrics is not a physically easy job sometimes with the chasing them around the room to look in their ears and twisting over sideways. I would love to help tackle the upcoming workforce issue in Pediatrics and continue to expose healthcare disparities.
When I was five years old, in the middle of a tobacco field on a blistering July day in Eastern North Carolina, I asked my father if girls could become doctors. He said yes. I asked him if doctors were guaranteed to always get to work in air conditioning. He said yes again, and I decided that a doctor was exactly what I wanted to be.
I have been writing stories about my childhood since I was a teenager. Having the chance to finally put them all together has been cathartic. There is a certain redemptive quality to naming all the good and all the bad parts of one's life and retrospectively seeing how everything worked out for a reason.
The biggest challenge so far has been that one family member objected to speaking the truth about my childhood. I was even told the following quote exactly, "Family secrets should stay in the family." I was shocked by that sentiment after all these years. Certainly, I continued with this journey and hope that family member will be able to see the redemptive arc through the book regarding my father. Even more than that, I pray that even one other person could see that everything did work out for me after that challenging childhood. I hope other women or children or anyone who has suffered could find some hope in my story. My adversity was certainly not severe compared to so many, but I think it is always encouraging to read a good overcoming adversity story.
I'm satisfied that I included enough specific stories that actually occurred that the reader will be able to get the full picture of my life and my concerns about rural pediatrics. There was one study from October 7, 2024, published in Health Affairs, that I wished I had included that noted that 80% of Emergency Departments are not prepared either with equipment or training or both to handle life threatening pediatric emergencies. One of my "Langdon Laws" has always been that a genuine pediatric emergency deserves a genuine pediatric emergency department. It is important that parents know that.
My biggest surprise with writing the book was how vivid many of these stories still are in my memories.
The book is packed with advice, and I hope it can help pre-med majors, medical students, residents, and even attendings. For women specifically, I do talk about the challenges of pregnancy, breast feeding, balancing work and family. For women interested in becoming a physician, I would offer this advice. Medicine is certainly a demanding occupation. While you can achieve it, there is a price to pay. Remember that while I believe in you and you can accomplish anything, what no one can do is accomplish EVERYTHING. There are two different sections in the book on mom guilt. That is some very real stuff! The reader will meet the absolute hero of my story, my husband Mark. He was the one who maintained a well-oiled machine in our home of six children and made it possible for me to work so much. I had all sorts of random guilt hang ups. They were silly at times. For example, I felt okay using a boxed cake mix to make a birthday cake for my child, but felt it was important to make home made icing, or I felt I had failed my child. I have no idea where that came from!
For parents looking for a pediatrician, I would recommend the first step is to verify that they are board certified. You can go to the website for the American Board of Pediatrics and check this. I would recommend that this pediatrician recommends vaccines, so that their waiting room will be safe for your newborn. Then check the website of the practice and make sure the group is solid. After you pick the group, then you are down to personality preferences.
We know now through studies that there are several predictive factors for which medical students will decide to pursue rural medicine. One of them is that the student is from a rural area. Certainly, that was my case. I wanted to be close to my family, which prompted the move back to the same rural area.
There are multiple and complex reasons for the differences in quality between rural and urban areas. It can be difficult to recruit qualified physicians to rural areas. Those physicians want to have good schools for their children or good job opportunities for their spouse. I believe one of the hardest issues is that in rural areas, the pediatricians are the only ones still doing it all. They see patients all day in the office, may have to run to the hospital to resuscitate a newborn or admit a child from the emergency department to the hospital. Adult medicine figured out years ago to split the responsibilities of inpatient and outpatient services. Adult medicine typically has inpatient hospitalists that work shift work and outpatient doctors who work regular office hours and never the twain shall meet.
This is particularly challenging for pediatricians because we are paid at much lower rates than doctors for adults. When I was young, this did not bother me as much as it does now. Now that I have retirement at least in my sights, it is frustrating that I do not have typical physician level wealth. It's not anywhere close! We also deal with many more after hour phone advice calls than the average adult physician. Every single one of those calls has some level of liability for us if we make a recommendation that does not work out or the parents do not agree with. Parents can be very harsh and demanding at times. Dealing with child abuse cases in poor counties with poorly resourced social services can be completely heartbreaking and soul crushing. Many adult subspecialists have clinic hours in rural towns, but this does not happen for pediatrics. Our families must travel out of town. Rural counties have higher Medicaid populations and having a high Medicaid population for your practice is notoriously risky from a business standpoint. Often rural practices have parents that have lower socioeconomic levels as well as educational levels.
In fact, instead of availability improving, it is getting worse in many rural communities across the US. Many hospitals have closed to labor and delivery/newborn nursery because they cannot find the doctors to staff them.
Some solutions to this could include increasing Med/Peds residency slots to train providers that could be both internal medicine and pediatrics board certified and become hospitalists for both. As far as covering the pediatric side of labor and delivery as well as the newborn nursery, groups of neonatal nurse practitioners could be contracted, and these groups could be remotely supervised by a neonatologist. This would both increase the level of quality and free up the local pediatrician from attending the deliveries. There are already programs in existence and expanding to help residents choose rural areas to assist with loan repayment.
The lack of trust from some parents can be discouraging. As an entire society, this seems to be increasing. On a personal level, I have seen more vaccine hesitant parents in the last five to six years than ever before. It breaks my heart. We have been taught to remain non-defensive and engaging and empathetic and I really try. What I wish I could say is that I have seen children die of vaccine-preventable illnesses and that I do not think the parents understand how deadly measles can be or how contagious. I do not think they understand how terrible Hib (haemophilus influenza b) was before the vaccine with the number we saw of meningitis cases and epiglottitis cases. They do not realize that pertussis is surging as we speak. These young parents have never had friends who were permanently paralyzed by polio. I cannot comprehend that these loving parents care about reducing risk by using a car seat and bike helmets but do not realize how important vaccines are to their children's health and safety. I want to tell them how much I love this little baby in front of me in the exam room and that I would do anything to protect them. Maybe I could show them my retirement fund and that would convince them I have NEVER received kickbacks. There is no giant conspiracy here folks, just science and a bunch of pediatricians who are underpaid and overworked and genuinely love your children. I would challenge anyone to be careful about internet "research" because that is never the same as actual scientific inquiry. The internet would have you believe there is great controversy around vaccines, but in the world of epidemiology, virology, microbiology, infectious diseases, immunology, there is no controversy whatsoever.
The way I deal with stresses at work such as parents who argue or are rude is I usually rethink the entire scenario several times to see if I could have done anything differently. Then I tell the whole story to my husband. I never have to worry about his breaching confidentiality, because I think he's not even listening sometimes. Ha ha. We did figure out years ago that sometimes I just need to vent, and he can fix a lot of my problems but not all of them. Then after an overthinking and venting session, I try to put that bad encounter in a box and not re-open it. It is sad that I could see 25 delightful patients in a day and the one sour encounter is the one that sticks.
Two and a half years ago, I became the Chair of Pediatrics at an osteopathic medicine school, even though I am an MD. I adore the students and love to have them over to the farm to feed them. They are beautiful, smart, and stressed out and I feel like a hug and a hot meal can fix them. I'm at a transitioning point currently and will most likely decrease some of my clinic time in the next few years. Pediatrics is not a physically easy job sometimes with the chasing them around the room to look in their ears and twisting over sideways. I would love to help tackle the upcoming workforce issue in Pediatrics and continue to expose healthcare disparities.
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