Family & Rural Medicine with Toney Graham, III, M.D.

Family medicine physicians provide more care for America's underserved and rural populations than any other medical specialty. In this episode of Advance with MUSC Health, Toney Graham, III, M.D., talks about how he can now provide more essential support for both the health and well-being of people in rural South Carolina because MUSC Health is expanding into even more rural areas of the state. Graham is an internal medicine specialist with a focus on family medicine at MUSC Health Primary Care Ron McNair Boulevard, which is part of the new MUSC Health Black River Medical Center in Cades, SC.

“These are the type things that we have to take into consideration in the rural community and understanding — just the myriad of differences with regards to socioeconomic circumstances and how this impacts people's abilities to be able to access medical care as well as other things that are going to impact their health. From quality of food, understanding the importance of health and exercise and all the things that a lot of us may take for granted that that have had the opportunity to either spend time outside of a rural community or have the resources to be able to attain these things.”
— Toney Graham, III, M.D.

Topics Covered in This Show

• Graham first became interested in medicine growing up in rural South Carolina and watching his father, who was also a physician, take care of people in his community. He wanted to become an integral part of the health and well-being of the community where he grew up.
• He discussed the importance of having a family care physician and how continuity of care benefits him and his patients.
• Graham also discussed the role he plays when a new diagnosis arises and the process a family care physician takes to provide either referrals or other orders to support a family’s needs.
• Graham discussed how important it is to meet the patients where they are.
• He explains the impact social determinants of health can have in underserved communities. Specifically, access and how hard it is for patients to travel to receive the care they need.
• The most important part of meeting patients where they are is to have “cultural competency” and an understanding of different backgrounds and walks of life.
• Since the pandemic there have been a lot more conversations around mental health and he has made it a priority to check in with his patients about how they are feeling. It has been really important to manage your mental health because it can affect your overall health.
• Graham discussed the new MUSC Health Black River Medical Center and how it will bring more resources to the community. The hospital will be equipped with more technology to assess the needs of the rural patients and provide better services to rural communities.

Read the Show Transcript

Erin Spain: [00:00:04] Welcome to Advance with MUSC health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Family care physicians have been called the foundation of healthcare in America. About one in five of all doctor's visits are made to family physicians, and they provide more care for America's underserved and rural populations than any other medical specialty. Dr. Toney Graham the third is an internal medicine specialist with a focus on family medicine at MUSC Health Primary Care Ron McNair Boulevard, which is part of the new MUSC Health Black River Medical Center. He's here to explain how family physicians can provide essential support for both the health and well-being of your family. Welcome to the show.

Dr. Toney Graham: [00:00:58] Thank you for having me.

Erin Spain: [00:00:59] What was it about family medicine that drew you into this specific field?

Dr. Toney Graham: [00:01:03] Getting into family medicine starts simply with watching my dad do the job for 30 plus years. From 1979 until the time I was able to go off to medical school. About the time I was eight years old is when I decided I definitely wanted to be a medical doctor. There's a neighbor that lived approximately two or three miles down the road. He was working with his horses, thumb basically hanging off and came to our household about 8 p.m. it was a Wednesday night. I'll never forget it. My dad's office was literally not even half a mile away from our home on the same premises. I literally helped him stitch the gentleman's finger back on in the middle of the evening. And at that point I was sold. I knew this is exactly what I wanted to do. And, you know, along the way, I thought about different specialties. And it always kind of pointed me back in the direction of family medicine and specifically here in the rural community in which I grew up.

Erin Spain: [00:01:59] In some cases, you're treating little infants all the way to grandparents, all in the same family. Tell me about that continuity of care. How does that benefit you as a physician and the family?

Dr. Toney Graham: [00:02:11] Well, first thing is, you know, there's an implied trust. One of the things that I say to my patients when they come into established care is there's an unwritten contract that's understood between you and I when you come in, and that is that you've given me your trust to look out for your best interests. And when it's in a family, it disseminates from grandparent to parent to nephew to niece to uncle to aunt. And you almost have an established relationship to start with, even on the initial visit. And then it allows communication walls to not be there. It allows communication to be easier. And some of the things that people would probably be more hesitant to tell the person on in other instances. In these instances, I'm often able to get that information out of them more easily. And of course, the more information we are able to get, the better I'm able to take care of the patients.

Erin Spain: [00:03:06] When a new health issue arises from a broken bone to maybe a more serious diagnosis such as cancer. Tell me about the role that you play.

Dr. Toney Graham: [00:03:15] So with regards to being a primary care provider, whether it's general internal medicine, family, medicine, pediatrics, it doesn't matter which one, you really should be the hub of communication for that patient. When they develop a new problem, it's up to you to assess and figure out whether they need to go on to see a specialist, whether it's something that you can take care of in house, and then be a good warden of all the information that the patient receives. Because oftentimes they're going to come back to me to get clarification on things that they may not have understood when they went to a specialist or when they got a test done or say they got their wellness testing at work and then they got a printout. And for me, it may be simple in layman's terms, and to them it still looks like Mandarin Chinese. So they end up coming in with the stack of papers and, you know, literally it takes a small amount of time to sit down to clarify all of that for them. And that's probably the main role you play with regards to new diagnoses, is just setting the course for treatment and making sure that they're on the right path. And then if there's any specialists, any other things that are needed to make sure that they have the best outcome, it's up to you to make those referrals and those connections so that they have the best outcome possible.

Erin Spain: [00:04:28] You know. You mentioned you're almost like an interpreter in some ways of medical information they may be getting from other sources. And to play this role, you have to have some cultural competency or maybe some consideration about the backgrounds of the individuals that you are serving. Tell me about that and how that plays into how you communicate with your patients.

Dr. Toney Graham: [00:04:49] So a funny thing, my patients will tell you that what I say to them is, OK, I'm going to start out and I'm going to talk in doctor English and then I'm going to transfer to the regular-people English, OK. And they always will laugh when I say that and I say it somewhat just to make them comfortable. But I mean it because, you know, you take a term this is, you know, for any doctor, we take something like costochondritis and we hear it and we know that it means nothing but, you know, just inflammation of your chest wall. You can do pushups, lifting weights, and pushing boxes. But the average person here thinks they're dying and it's up to you to make sure they understand that wait. Listen, I'm going to shoot a 15 letter word at you and it is not a death sentence just because it's a large foreign word. And just to break it down and make sure they understand why it's not that and how it's completely and easily handled and why it should not be a worry for them. And that's you know, and that's the biggest thing there. Everyone has different educational levels here. Again, I grew up right here in Lake City, a small community outside Lake City called Hogeye you know, the average educational level here is I think it has risen from the time I was a kid. When I was a kid, I think it was sixth grade. Now it's, you know, around 9..10th grade. That being said, medical education, that's a far cry from that. And so understanding that even a person that has a high school education or college education, when they're being inundated with so much information left and right, whether it's on the Internet, whether it's from commercials, infomercials, you've got to be willing to just take the time and sit down and help them understand, you know, how that information pertains to them and what's going on with them at the time and get them to be settled with what's happening, even if it is something dire. Get them to understand that, hey, look, we have a plan of attack. We know how we're going to address this. And, you know, it requires you just establishing trust.

Erin Spain: [00:06:45] I mean, you are truly an expert on your community. You grew up there and this is a more rural area of the state. Just explain for people listening about some of the social determinants of health that we see in rural areas that maybe we don't see in other parts of South Carolina, like more affluent suburbs.

Dr. Toney Graham: [00:07:02] Well, you know, it's honestly, the overall access to resources is completely different. And that's the beauty of what having MUSC come into the community means for this rural community. And hopefully, as MUSC continues on its mission to integrate the rest of rural South Carolina into academic medicine, the same thing for them is just to increase access to these resources that's needed for people that have that laundry list of disease processes. And they come in with that, you know, travel bag full of medications that allow them to be able to get access to discounted medications, allow for them to be able to do telehealth visits with specialists that they would not otherwise be able to see just because the overall price of travel is just way too much for them to go forward in general with, they have to travel because back in the day when I was coming up, you know, some visits was a trip to the peninsula. And, you know, for most people that trip is a bill or, you know, making sure they had dinner for that evening. So these are the type things that we have to take into consideration in the rural community and understanding just the myriad of differences with regards to socioeconomic circumstances and how this impacts people's abilities to be able to access medical care as well as other things that are going to impact their health from quality of food, understanding the importance of health and exercise and all the things that a lot of us may take for granted that that have had the opportunity to either spend time outside of a rural community or have the resources to be able to attain these things.

Erin Spain: [00:08:48] One of those examples of a resource from MUSC Health is the new Black River Medical Center that's just opening in Cades. Tell me about what you're hoping this new facility is going to bring to the community.

Dr. Toney Graham: [00:09:01] I can't tell you how much it means to myself. Many of the members of the community. One of my patients literally was in tears in examining room number eight yesterday morning. Talking about that, she remembers when my dad came back here in 1979. There were still remnants of segregation in the community. There was hoopla even about an African-American doctor hanging on his own roof to begin a medical practice and integrate into the hospital. It had been in existence for roughly 20 years. And now their doctor's son is such an integral part of the hospital that my dad and I we would my grandparents' home is literally which is my mom's parent's is literally next door to the hospital and I would tell my dad when I was a teenager between being a teenager and undergrad that it was absurd that we had two separate hospitals that were so small and that it only made sense that we combined resources and you would hear other people and conversations that were in the medical community say things like that, and they see something like that come to fruition and the things that it is going to produce with regards to cutting edge medical care, top of the line emergency services, radiologic evaluations, including 3D mammograms, easy access to endoscopy, including colonoscopies. Believe it or not, 22 years in the 21st century and Williamsburg County, this is the first time it's had an MRI in the entire county.

Erin Spain: [00:10:43] You're even brainstorming ways to make this more accessible for your patients, such as providing transportation services for patients to the new hospital. You know, how important do you think it is for health institutions to support the communities that they're based in by offering these additional services?

Dr. Toney Graham: [00:11:00] Again, it can all be there, but if they can't get to it makes no sense. And again, we're talking about people that have some of the most limited resources. When gas shoots up to almost $5 a gallon, we're talking about a trip five miles down the road, ten miles roundtrip. And maybe I'd rather feed my two kids tonight. That's not a choice that should have to be made. And obviously, the model won't be perfect to start with, but allowing the process to take place and presenting people with the option to be able to have some type of transportation and integrate it into what goes on daily, it's going to mean the most for people to get access. And not to mention what it's going to mean for economic development. While I realize this is mainly about medical care, you know, I'd be remiss to not mention how excellent health care all around impacts a community and helps with its overall growth and what that means from an economic standpoint. And if you're thinking about things from a well-rounded standpoint, you begin to pay attention to these things and understand these things. And of course, you only want to feed into it and help improve it, so it'll help bolster the community in its own growth.

Erin Spain: [00:12:20] It's obvious that you care a lot about your patients and their well-being, and that can also include their mental health. Just tell me about some of the other ways that you sort of wraparound care is mental health care something else that you take into consideration?

Dr. Toney Graham: [00:12:35] Absolutely. So in the rural community, the perspective on mental health is a little different. It's almost taboo to a certain extent, not as bad as it was when I was younger, but it's almost taboo to a certain extent to even mention that you feel depressed or that you have doubts about how you are feeling about life. And you know, again, one of my sayings I say to my patients, and if you ever meet one of them, they'll tell you, he says this, it's great that I order all these tests and I go through all these numbers with you. And make no mistake, I'm going to try to make sure your cholesterol is perfect, your blood pressure's perfect. But if all of that's in line and you're not OK up here in your head and here in your heart, then it doesn't mean a whole lot. It's all for nothing. I need you to understand that I don't stand in judgment of you when you come to me and tell me you're not OK. I need you to express that to me and let us sit down and work it out. Let's figure out what we can do to help you feel OK. Or at least start going in the right direction and get you other services counseling as well as medication if needed, in order to help people get into a good place from a mental standpoint.

Erin Spain: [00:13:48] Is there anything else that you want to add?

Dr. Toney Graham: [00:13:50] You know, I'd just like to reiterate just the importance of integration of academic medicine in our rural communities. I've had the pleasure of growing up here watching the impact that a few doctors and a few people that are willing to go above and beyond can have on the community, and then going out to be educated outside of the community in Nashville, doing work in Chicago, doing medical volunteer work with my father in Haiti, and going on and being trained in in eastern Carolina ECU, where we worked with a lot of the rural area and how academic medicine can really impact areas like that. And I saw it as a mirror of what could be if we had the same thing here. And so it's not just with overall elation that I welcome MUSC and the idea that they're doing this here, but that it's going throughout the state, given that South Carolina is so much a rural community.

Erin Spain: [00:14:56] Before I let you go, I want to ask you the question we ask everyone who comes on the podcast. And what do you do to optimize your health and live well?

Dr. Toney Graham: [00:15:06] I exercise. I like to lift a lot of heavy weight. That's, you know, a time of clarity for me. I'm just kind of letting out some frustrations and whatnot. I try to keep a fairly healthy diet and just try to stay active, whether it's running around with my kids. Sometimes it's about getting out, running the three or five miles, just taking a walk with my wife. Anything to just keep the motor running and keep the mind, you know, as clear as possible.

Erin Spain: [00:15:35] Well, Dr. Toney Graham, the third. Thank you so much for coming on the show. It was just a pleasure to talk with you.

Dr. Toney Graham: [00:15:41] Awesome. Thank you for having me.

Erin Spain: [00:15:47] For more information on this podcast, check out advance.muschealth.org.