Sept. 21, 1983, Dr. and Mrs. Robert Bowman cut the ribbon on his new medical office in Nowata, Oklahoma, joined by his nurse Billie Holland (left), Virginia Temple of the Nowata Chamber of Commerce (center), and Connie Majors, also on Bowman's staff (right).

[imgcontainer] [img:bowman-ribbon-cutting520.jpg] [source]Nowata Daily Star [/source] Sept. 21, 1983, Dr. and Mrs. Robert Bowman cut the ribbon on his new medical office in Nowata, Oklahoma, joined by his nurse Billie Holland (left), Virginia Temple of the Nowata Chamber of Commerce (center), and Connie Majors, also on Bowman’s staff (right). [/imgcontainer]

In 1983 I entered solo medical practice in Nowata, Oklahoma. At the time there were two social centers of town, the downtown area holding its own and Wal-Mart at the outskirts of town. As a new physician, I understood little about marketing, but when the medical staff members complained that my sign announcing the new practice had been up too long, I began to realize the power of location, location, location. My office back door faced Wal-Mart’s main parking lot entrance. I trimmed the sign a bit smaller and kept the remaining large print attached to my back door. Everyone leaving Wal-Mart headed back to town could spot my office.

Now, for the urban born and raised, this might seem an optimal marketing plan. However, my best marketing had already been done. I interviewed a few potential nurses but there was really only one choice. I literally went on bended knee to beg Billie Holland to join me and she agreed to a year, staying the four years I was there. My spot next to Wal-Mart may have helped introduce me to the community, but more people came to me because of Billie and her decades of experience as an office nurse. Only in the third and fourth year did I seem to stand on my own, perhaps.

In a rural practice, if you are a rookie, even a well trained rookie, people know it.
People came into my office trusting me because of Billie;  the rest was up to us. In current health care, people usually have to take what exists — and often that’s  anonymous, poorly coordinated, and uncertain. Billie kept people out of the office until they needed health care or she held out until they were about to get better anyway. Also, the people in Nowata tended not to come in or call unless they needed care. Now people all over the nation go to the doctor too soon, get worse early regardless of the care, see someone else soon, and get better mostly on their own. Meanwhile, the cost of care rises early and often.

In my first encounter with the banks of the area, I was turned down for a business loan. As a new physician about to boost the economy by a dozen jobs and several hundred thousand dollars of economic impact a year, it was distressing to be turned down  (of course, it took several years before I  understood what I was worth to the town). I was given the opportunity to pay double-digit home interest, about 2 percentage points more than the going rate, but I would learn that banks had survived here by being conservative — riding the ups and downs of agriculture and oil. My accountant revised my business plan to something that I could not accomplish, and the loans came from a town just across the county line in Kansas.

When you have been born, raised, educated, and trained all your life in Texas, it is a most distressing thing to travel only 20 minutes and cross a state line. My wife and I had rarely left Texas and when we did, it was after hours and hours of travel. Our transition to residency training at Waco was revealing. From our home in Houston, Waco seemed quite a distance, but I wanted to do Family Practice residency there. As we left the interview, my wife broke down at about Marlin, Texas, and blurted, “I don’t know anyone in Waco, Texas.” Waco remains one of our favorite places, and even now we scheme to get back.

[imgcontainer] [img:oklahomaw+nowata520.jpg] [source]Perry-Castañeda Library, University of Texas/Daily Yonder[/source] Nowata, Oklahoma, pop. 3971 in the 2000 Census. [/imgcontainer]

Waco was a major barrier crossed, and solo rural practice was the next step via some important bibliotherapy and spiritual revival from The Road Less Traveled (M. Scott Peck). Difficult choices do indeed turn out to be some of the most rewarding. The lessons learned in Nowata, Oklahoma, would launch a career dedicated to better access to health.  (Even now my wife and I break down in tears when we see the movie “Terms of Endearment,” and the highway sign says “leaving Texas”  — a scene not shot in Texas, by the way). Since Nowata, I’ve focussed on health access for rural East Tennessee, for rural Nebraska, and for the 65% of Americans left behind by the current designs for health and education.

So this Texas City boy, born and raised in a family medicine clinic by his nurse mom and his engineer father, learned to adapt rapidly to a small town, Oklahoma, and Walmart across the street. Our adaptation would have been painful without help. Wallace and Debbie Goodman, who ran one of the last independent rural daily newspapers, were our guides. Wallace faced the problem of balance between advertising for Wal-Mart and for Nowata’s main street stores. Knowing too much was also a challenge. When something bad happened in town, the Tulsa papers ran down small town America on the front page, but Wallace ran a more conservative back page review. My first efforts at journalism were columns for the Nowata Daily Star. I even took my first front-page photo of a fellow physician holding up twins he had delivered. Wallace kept this city boy from making too many rookie errors in my writing and in my small town efforts. He, the various city utility managers, the ministerial alliance, and many local government people were trusted folks with the best interest of the community at heart.
The mid-1980s was not a bad time to be in a rural town. For two years it was truly best of times. Recessions move in slowly but stay longer, and recession was not there yet. The Wal-Marts and the video games places brought about some new opportunities along with the challenge of change. The 1985 – 1987 years were lean with oil and agriculture problems and the competition for control of nearby Phillips Petroleum in Bartlesville. The only thing worse than being bypassed by a railroad or by a Wal-Mart (or by a power plant facility), was having the railroad line or the Wal-Mart die. When the Wal-Mart closed in Nowata, it even hit the Wall Street Journal. If the Wall Street Journal spent more time writing about the other topics mentioned in this article, perhaps there would still be a Walmart in Nowata.

[imgcontainer] [img:nowata-mural520.jpg] [source]John Farrell[/source] A mural in Nowata, Oklahoma, October 2006 [/imgcontainer]

Through Wallace I got to know various Wal-Mart assistants and managers – some great folks but incredibly stressed.  I had a chance to arrange some health care for Wal-Mart employees and their families. I suspect things are different 22 years later; however, at the time, one of the Wal-Mart Associate family members was dying of cancer. The Walmart health care folks did a particularly good job helping to arrange care. This was real care, not the saving-the-health-care-dollars that passes for health care now. I wrote Sam Walton and told him so. He sent back a signed letter of appreciation. (Of course I regret not being able to find this letter or the speeding ticket — just a warning, actually — I got from the state trooper who captured the Oklahoma City bomber. )

Rural practice in Nowata was efficient with the hospital and doctor’s offices next door. (My good friend Bob Boyer,  the first American Association of Family Practitioners Doctor of the Year,  tells a true story of setting a fracture in his office and delivering a baby in the hospital in Kingman, Kansas, with the elapsed time of just 11 minutes, or about the time a city doctor can park his Mercedes, walk through the parking lot, be transported upstairs, and finally get a cup of coffee. )

My last reminiscence involves a plan to integrate the Wal-Mart social center of town into health care and improve efficiency still more. There was an empty field between Wal-Mart and some public housing across the street from the hospital. An airline pilot was willing to fund some housing. The owner of the field was willing to sell. I approached the hospital leadership about a plan to build housing for the elderly across from the hospital. The plan died, mostly because I failed to introduce the project through the right community members. Looking back, I realize it would have been one of the first assisted living locations in the nation. The two annual health fairs that I organized and had hoped to continue died for the same reasons – the informal health care leaders of the town were not happy with being bypassed.

[imgcontainer left] [img:walmartNYTimesfamily243.jpg] [source]New York Times[/source] Nowata’s Wal-Mart closed in March 1995. Kay McKee, pictured with her children,  told the New York Times, “We’re stuck” without the store. [/imgcontainer]

Wal-Mart Corporate centralized operations with a Bartlesville Super Center, and the Nowata Walmart store closed, but there were many factors in the town’s decline from 13,000 people to fewer than 10,000 by 1990. Some of the major factors were already in place before I arrived. Highway 169 to Kansas City was bypassed by the interstate much farther east. This main road to Tulsa kept getting narrower and more dangerous with each new topping of asphalt. The power plant for the region went to nearby Oolagah and so did the property taxes and the ability to recruit the best teachers, including some who moved from Nowata.

For purposes of Medicare and insurance reimbursement, my practice coding was Area 99, meaning that  I was paid the least, even though I was working just where doctors are most needed. I also learned a valuable lesson about control of health care costs. When I raised my office charge from $18 to $20 per visit, the reaction was such that I was unlikely to raise rates soon. Rural areas have built in cost controls.

Of course the cost controls designed in New Jersey and Washington, DC, were not good ones for rural family physicians or towns like Nowata.  Rural areas were mired in regulation, attempting to gain physicians’ cooperation even though rural physicians had less and less support. Reimbursement increased slowly for primary care and rural areas relative to urban and hospital care. Inflation, liability insurance, and other overhead expenditures increased the costs of delivering care and decreased the potential for profit, or survival.  The end result has been fewer health care dollars going where health care is most needed.

[imgcontainer right] [img:nowata-finger-320.jpg] [source]Wade from Oklahoma[/source] On the side of Nowata’s Savoy Hotel, a hand points the way down to the old bath house. The SAvoy was being renovated in the 1990s, writes Wade, “but is apparently falling back into disrepair. Almost criminal, if you ask me.” [/imgcontainer]

Like Wal-Mart, Oklahoma kept centralizing its operations, with fewer state employees working in Nowata. My part time job teaching family practice residents in Bartlesville was cut and a year later this program was merged back to Tulsa. This trend of cutting those programs that are doing the most for those most in need has continued. People like Wallace and Debbie had to move on as well. Health care changed and in ways not likely to keep health care dollars and people in the town.

Wal-Mart did well because it understood the nation and its people (a much broader range of people) better than most. This is something that the nation’s leaders must do if they hope to run a nation as well as Walmart has been run.

Dr. Bowman is a professor of family medicine at A. T. Still School of Osteopathic Medicine Arizona. He can also find some silver lining to many clouds. Among the more normal types of medical students admitted to SOMA is at least one Wal-Mart Scholar, one sent on her way to health access by the early assistance of her community and a local Wal-Mart Store.

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