How Will Health Care
Reform Change the Way
We Practice Medicine?
Most [doctors] are in practices with ve or fewer other physicians.
ey keep their records on paper in longhand. When they need to
consult a colleague, they reach for the telephone. ey bill for each
visit. ey have little idea about how their skills compare to those
of fellow practitioners, nor do most know what their patients really
think about the care they give.
David Brown, Washington Post, May 4, 2010
In 1978 I was a second-year medical student at the Louisiana State University
School of Medicine in Shreveport. e medical school had been started nine
years earlier with the goal of increasing the number of primary care physicians
in the northwest part of Louisiana. Each Wednesday afternoon we shadowed a
local doctor. I spent the year with Dr. Edward Butler, a family practitioner in
Haynesville, Louisiana, a rural community of 2,500 people in north-central
Louisiana, ve miles south of the Arkansas border.
e rst time I went to Dr. Butler’s clinic, he was sitting in his wood-paneled
oce, his boots propped up on his desk, enjoying a plug of tobacco. Two stued
148 ◾ Understanding Health Care Reform
ducks extended from the wall behind his head, and his desk was covered with
huge piles of medical journals. He had graduated at the top of his class from the
LSU School of Medicine in New Orleans and had scored in the ninety-ninth
percentile on the family practice boards, and he devoured each of those journals
that sat on his desk. Dr. Butler returned to Haynesville after medical school
following in the footsteps of his grandfather, who had been an army surgeon
during the Civil War.
e Butler clinic was a long A-frame building nestled in the pine trees indig-
enous to north-central Louisiana. ere was a waiting room at one end and
a small emergency care area at the opposite end. A surgeon from Eldorado,
Arkansas, came to town once a week to perform elective cases at the local hos-
pital. Patients needing emergency surgery were transported to one of the large
private hospitals in Shreveport if they had insurance or to a charity hospital
in Shreveport or Monroe, Louisiana, if they didn’t have insurance. Dr. Butler
shared call with a partner. On some weekends and nights, a surgical or medi-
cal resident from LSU-Shreveport would cover the hospital to give Dr. Butler
a night o. While some patients had private insurance or Medicare, many of
his patients had no insurance, and it was not uncommon for patients to pay for
their care with fresh game or produce.
Haynesville has changed little since 1978. e population is largely the
same size, most people who are employed work in the oil and gas or the pulp
wood industries, and nearly a quarter of all families live below the poverty line.
Haynesville is located in Claiborne Parish. e doctors who practice in the par-
ish all have close links to the community. Of the seven primary care physi-
cians who serve the population of 20,000, three are direct descendants of former
Claiborne Parish doctors. As a result. Claiborne Parish is the best-staed rural
parish in Louisiana due in large part to the relationship between the doctors and
Sam Abshire grew up in Abbeville, Louisiana, a tiny hamlet in South
Louisiana. He exudes condence and has that ideal mixture of compassion and
concern that patients expect and admire. His passions in life are his family, his
medical practice, and duck hunting. He joined the Butler Clinic when he n-
ished training, and it is now called the Butler-Abshire Clinic. Sam’s practice
is much like Dr. Butler’s was thirty-some years ago. About 20 percent of his
patients have Medicaid, and about 30 percent have Medicare. “In a good year,
15 percent of our patients have no insurance, and in a bad year, it’s 22 percent,”
Sam told me. Patients without insurance pay a fee based on a sliding scale, or
sometimes their care is simply written o. Sam told me that this past spring he
received “so much produce that we could have lled a truck.” A surgeon still
visits the clinic two days a week because many patients are unable to travel to
Shreveport because of costs or lack of transportation.