Welcome

Welcome to the Country Doctor Revisited blog.  This blog is geared to health professions students who are on rural rotations. Based on the stories, poems and essays from the collection: The Country Doctor Revisited: A 21^st Century Reader (Kent State University Press, 2010), we will explore some of the issues unique to care in rural areas as well as some themes that are just part of health care no matter where you practice. Please be respectful of others when you respond to the blog entries. Do not include your preceptor/teacher’s name, the names of staff, the names of patients you see or the town where you are spending time. Such specifics will be removed from your blog entries. Be generic but share the heart of your experiences. We are all here to learn from each other.

Everyone Did Their Part, But

–Therese Zink

Late in the afternoon, the effects of my midafternoon cup of coffee were dwindling. I picked up the chart of a new patient with the chief complaint, “Needs a home health nurse.” He sounded like a good patient for Melissa, the nurse practitioner student who was working with me, to see and sort through the
concerns. In the meantime, I saw two other patients.

Melissa emerged from the exam room. “You better sit down for this one.”

“Be as concise as you can,” I said as calmly as I could.

The patient, eighty-seven years old, had not seen a doctor for twenty-five
years. Retired from farming, Mr. Gains and his wife lived alone in a farmhouse
outside of town. Their son worked the land, and their daughter ran the dry
cleaning store in town, just minutes away. The daughter said she cared for them
twenty-four hours a day, made their meals, bathed them, everything. It was
getting to be too much. Two days ago, her father quit walking and eating. Her
mother used a walker. They needed someone to come in and help.

Melissa and I entered the exam room. The daughter, a middle-aged bottle
blonde, who was generous with her makeup, rose from her chair. I introduced
myself and told her that Melissa had filled me in. “What’s your main concern?”
I asked.

“It’s getting to be too much. I need some help. I thought maybe a nurse once
a week,” she said as she moved toward the door.
Mr. Gains was frail, wearing a feed cap and overalls. When I addressed him,
he made eye contact but didn’t say much. We learned that he spent most of
the day in a reclining chair, that he was usually incontinent at night. He never
had much of an appetite. Both the daughter and son checked on the couple
throughout the day.

“Dad doesn’t have insurance, so my brother doesn’t want much done,” the
daughter said tapping her toe on the linoleum floor.

“But he’s over sixty-five. He should have Medicare,” I said.

“Neither of my parents have it.”

Strange, I thought, and asked the daughter to step out of the room while
Melissa and I did an exam. She was reluctant to do so, so I walked her down
the hall and reassured her that we would bring her in as soon as we were done.

“Please, they don’t have much money,” she told me.

I reiterated that we would do the best we could.

When I returned to the room, Melissa had helped Mr. Gains onto the exam
table, which was low to the floor, making it easier for elderly patients.
“Pretty unsteady on your feet, aren’t you Mr. Gains,” Melissa said.

“Do you hurt anywhere?” I asked.

Mr. Gains shook his head.

I asked the usual questions about vomiting, fever, chills, diarrhea. . . . Mr.

Gains denied all. Finally, I inquired, “Is anyone hurting you?”
Again, Mr. Gains shook his head. As we removed his flannel shirt, I noticed
a layer of brown oily scum around his neck and under his arms. His odor was
pungent, not like urine, but similar to that of overripe fruit. His T-shirt was
gray. His lungs were clear, and his heart rhythm was regular. No murmurs.
We removed his overalls; they were clean, as were his undershorts. The brown
scum was also accumulated at his beltline and in his groin. Melissa removed
his threadbare socks. Near his ankles were two quarter-sized bedsores.

(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

As health care professionals–nurses, doctors and social workers– we are mandated reporters of suspected abuse for adults in most states and for child abuse in all states. These are always difficult situations. This one was particularly complicated.  Read the rest of the story. When I talk to students about managing families who are living with abuse, I always remind them that as a physician it is not my job to decide who is right or wrong, but to link the family with support and the people who can make that decision.

 

Lost On Call

–Ann Neuser Lederer

was on call, and tense. Newly employed as a visiting nurse on the edges of
Appalachia, I had recently moved to this place
from a large rust belt city hundreds of miles to the north.
Our territory extended down to the river cliffs,
and outward through patchworks of farms.
I didn’t know it very well, especially in the dark.
It was a weeknight. I was tired from the day’s work.
The beeper jolted me awake.
I fumbled into my clothes, neatly folded nearby, awaiting.
I was called out to a place I had never been, on the edge of the county,
to a death of a patient I had never known.
It was the middle of the night. There were no lights anywhere.
I peered at the directions written on the paper.
Ever so slowly I made my way down the winding tree-lined lane.
It was one of those roads with steep drops on both sides and no shoulders.
Only the halo ahead, created by the headlights,
hinted which way the next curve might lead.
As I turned a bend, I spotted from the corner of my eye an odd red glow,
low to the ground, seemingly coming out of nowhere.
Slowly, I realized it was a pile of something smoldering.
I did not know anything about field fires then.
Wondering, tempted to imagine, I forced myself to attend to the task at hand.
I could not find the turn-in for the house. I must have passed it, so I backtracked, tried again, a little scared. A full moon rose over the bare tree limbs, soothing me with its steady presence. I followed a twisty road up a hill.

Far to the back of a farm, a trailer was parked. This was the place.
They sat, awaiting my knock.
They had no running water. The corpse had soiled himself,
maybe a good while before dying. They wanted him clean for the mortician.
They brought a bucket and I tried my best.
Fresh diaper, and shirt, buttoned to the neck. Hair brushed. Mouth closed.
Ready.
Now, the red glow in the dark field, the white moon above,
lighting the road up the hill are permanent reminders of potential surprises,
against the nights of dread.

(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Nurse Lederer was called to help in a setting quite different from one familiar to her. She was called outside her comfort zone to care for a patient who was poor and dying. As she describes the setting, I felt her fear and discomfort. Sometimes medicine calls us outside of our selves, to walk in the shoes of another, to see what it feels like to live in a world different from the one we know. You don’t need to go to another country to experience a different culture. We have reflected on this in other blog entries [December 19, 2011 and January 9, 2012].  It may be the same culture, but it might be a different sense of personhood—what it feels like to be old or disabled or have a mental illness. So far in your career, have any patient encounters given you the chance to experience life from another perspective? If so, tell us about it, preserve privacy please, no identifying information. What did you learn? How did it alter your view of the world?

Read other work by Ann Neuser Lederer.

Early Marriage: West Virginia

–Ann Floreen Niedringhaus

I
The other nurses called them brambles:
prickly creepers climbing up the rock face.
Stopping the car I gathered
blackberries to make an offering
for you—crystal jelly, all seeds
strained out through a dish towel.
Patients warned me later, “You better
watch for copperheads on those cliffs.”
You came home from hospital duty,
tired and distracted,
spread my ambrosia thickly and said,
I’d rather have Welch’s.

II
Driving to home visits, I took as a road
a dry creek bed overhung
with branches and vines.
It ended at a sagging porch,
the family processed a pig,
newly slaughtered, on the kitchen table.
Drawing me in near the carcass,
folks spoke their maladies: blind staggers,
drizzlin’ shits, a head gatherin’
that went away with white lightnin’.
And you walked home from your shift
in the emergency room
with your own stories: a man impaled
throw the chest with a telephone pole,
a woman with a neck goiter the size
of a cantaloupe; a child
whose smilin’ mighty Jesus
was spinal meningitis.
We talked in the dark before you fell asleep
feeling like Lewis and Clark.

III
Perched on the steepest hill in town,
our house was two stories high on the street,
four stories high in the back.
The gleaming Monongahela River
filled the winding valley bottom far below.
Years later my mother told us,
There was a hole in the bathroom wall.
I worried about rats.
We were surprised.
We couldn’t remember a hole.

(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Ann Floreen Niedringhaus, a registered nurse, holds a master’s degree in social work and was a public health nurse in a federal Maternal and Infant Care Program based in Morgantown, W.Va. She is retired, continues to write, and lives in Duluth with her husband.

Nurses, social workers and public health nurses are important members of the health care team in both urban and rural America. Given the focus on health care home, their roles are underlined. I think of home health as the eyes and ears of the clinicians who spend most of their days in the hospital or clinic.  Often a phone call to the public health nurse gives provides me with insights into how I can help a patient manage their health challenges. 

Read another poem by Ann.

A Modern Country Doc–playing the game

–Tom Bibey

The insurance companies love to play doctor. Take my noncompliant diabetic patient with a hemoglobin A1C that does not meet goal. (We explained this in an earlier blog post.) The first order of business, since I wish to stay in practice, is to send him to an endocrinologist. If possible, one should bolster the case by the choice of one from a medical center. A year later, the patient will still have the same numbers, unless he comes to Jesus and decides to change his life. The cost of the endocrinologist changed nothing but increased the bill to insurance, and my risk as a target for the blame is dramatically lowered due to the referral.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Here Dr. B is referring to our effort to meet certain treatment goals with patients. Some insurance companies reimburse physicians with extra money if a certain percentage of their patients reach the recommended goals. This is called Pay for Performance and sometimes referred to as P4P.

A large randomized controlled trial on diabetes–ACCORD– helped to outline the goals management of  patients with Type 2 diabetics. Here is an easy explanation.

The challenge is to motivate patients to change their behavior, often easier said than done. In earlier posts we’ve talked about Motivational Interviewing techniques to help patient weigh the pros and cons of continuing to do what they do. As you spend time in clinic, you’ll see different attempts to help patients quit smoking, lose weight, start exercising, be compliant with their medications. It is no easy task. However, I don’t want to leave you with a downer. When you do assist someone in making a behavior change, there is nothing like it—it can make your whole day or week for that matter.

A Modern Country Doc–The EMTALA end run and more

 –Tom Bibey

Over the ensuing decade, I did learn how to circumvent EMTALA (Emergency Medical Treatment and Active Labor Act). I call it “the EMTALA end run.” If by chance a doc has a patient who wound up in the wrong facility and can’t find anyone to accept a transfer, you do “the EMTALA end run”: tell the family to check the patient out AMA (Against Medical Advice—I try not to use abbreviations). Arrange for an ambulance to take the patient to a facility that has the specialist they need, such as neurology or cardiac surgery. Once there, the family can demand their loved one receive the specialized care not available at the first institution. This is an insider country doc trick, and it works every time. Oversight of medicines would be even more humorous, if not so sad.

One elderly patient came to see me and complained of being weak, nervous, and dizzy. Being the smart doc I was, I figured the three diuretics she was taking had something to do with it, so I changed her regimen to one that reflected current clinical rationale. In short order, she spun out of control, and became incoherent and combative. She was hospitalized for an intensive evaluation, only to find the resolution to the problem to be the urgent reinstitution of her old regimen. She returned to normal in a few days and again was weak, nervous, and dizzy. I knew the chart jockeys would come around in six weeks, and no one would understand, so I arranged a nephrology consult. (This guy was one of the smartest docs on our staff—the cats that get acid/base are always quick.) I’ll never forget the nephrologist’s thorough review of the entire medical record, and that poor woman doing her best to answer all those questions again. In the end, he told me it made no scientific sense, but he would continue her antiquated regimen. We all do our duty, I guess. I am still the patient’s doc; the patient is still weak, nervous, and dizzy; the nephrologist left town for a big-city practice where he can make some real money; and the chart jockeys still send letters. Some things never change, and all these government folks who believe they can morph these country people via legislation are naive as to medicine and human behavior.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

I love Dr. B’s cynicism and humor. What he says is often quite true. #1 Despite the high technology and money we spend on health care in the US, the system is broken. This is evidenced by the need for Dr. B’s EMTALA end run. It won’t take you much time on the wards or in the clinic to see what does not work about our health care system. This is one of the reasons we need energetic, young students interested in advocating for their patients and working for change.

#2 All the science doesn’t explain why some things work for certain patients and not for others. Sometimes they just do. Our scientific studies look for the average, but some patients are beyond the standard deviations of the norm. I don’t want to diss science, it helps me take better care of patients, but at times there is no rational explanation. This reality keeps one humble and also reminds me to see each patient as an individual.

A Modern Country Doc–alphabet soup

Inside the Mind of –Tom Bibey

COLA, CLIA,OSHA, HIPAA, EMTALA. I’ve heard the powers that be are going to start up the NBEMAA (National Bureau for the Elimination of Medical Abbreviations Agency) to question everyone’s integrity for use of nongovernment approved abbreviations. Now if they do, I guess I’m gonna call it a day. The hypocrisy would just be too much.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

 Modern medicine is an alphabet soup of acronyms. It can be quite overwhelming to the student. With the turn of the 21^st century we’ve added EMR or EHR –electronic health or medical records, HCH or MH—health care home or medical home, but MH can also mean mental health. You may encounter NCQA and JCAHO, both efforts to improve and monitor the quality of care in the US. The ACA, Affordable Care Act, which some folks call Obama care, the national health reform passed during President Obama’s first term and now under attack, also brought us ACOs—accountable care organizations, which are supposed to be different from the HMOs-health management organizations of the 1970s and 1980s. I know that was a run on sentence, but one acronym seems to give birth to others. You can probably add some others to this list. The bottom line is that medical care in the US is complex. All the efforts try to guarantee quality, affordable health care for the patient, but often seem like barriers between the doctor-patient relationship.

A Modern Country Doc–chart jockeys

–Tom Bibey

In the early 1980s, I made almost all my decisions in conjunction with my patient, together with the specialists we deemed appropriate in a given case. It wasn’t but a few years before modern medical “oversight” or “management” began to assert itself. This started first with government programs, soon followed by big business. Docs were forced to learn a new set of skills to overcome these obstacles to the delivery of care.

Early on, it was a benign process. Every once in a while I’d get a call from old Doc Smith who’d ask about a case. I knew him from State Medical Society meetings. Retired, he’d never made all that much when he was in practice, so I understood his need to supplement his income. I’d even taken over some of his patients, so Doc Smith knew me well. He wasn’t going to scoop me on much over the phone. I had the advantage of being the doc who saw the patient, and we both knew he wasn’t in a position to compete with that. Doc had to call every so often. I understood. He’d call and ask a few questions, and I’d tell him in doctor terms about where to go, and we’d laugh.

By the mideighties the minor nuisance grew to a downright disruption of patient care. I remember a fellow I had followed since I started my practice. I inherited him when a local doc retired. The patient was elderly and had multiple medical problems: several heart attacks, a pacemaker revised several times, bad kidneys, bad lungs, but he was a heck of a nice guy.

My first hospital admission for the patient was for an episode of syncope (they call it “falling out” around here) and the situation was complex, so an extensive workup was undertaken. Both carotid arteries had partial blockage, but the surgeon said that the literature showed that only the worst side of a 70 percent blockage warranted intervention. (Here is a country doc tip for you: if a surgeon doesn’t want to operate, I would take that advice very seriously.) I talked it over with the local cardiologist, we ran everything by the big boys at the Medical Center, and everyone agreed to a treatment plan. With some adjustments in medication, we sent the patient home. Surgery, at least at that time, was not indicated. A week later, he had an unanticipated TIA (near ministroke), which thankfully resolved. Due to the change in circumstances, the surgeons changed their minds and proceeded with surgery to correct his right carotid artery blockage.

The patient did well, and he went home satisfied with the outcome. For him, it was the end of that chapter of his story. For me it was the beginning. Six weeks later, I got a letter from one of the Medicare review boys, who determined the first admission to be unnecessary. I knew my patient could get stuck with the tab, so I began to compose a letter of explanation. Before I could complete it, I had a second letter on my desk from a different review bureaucrat (I call them chart jockeys). This jockey determined the second hospital stay was due to a premature discharge from the first admission. I have a fair amount of education, but I was confused. How can one be discharged too early from an unnecessary admission?

I found it a silly demonstration of the lack of medical sophistication on the part of the reviewers, but I did not anticipate the intense effort required to win this battle. However, I lost the war. Years later I noticed reviewer number one had his name on a government medical complex, and I assure you I will labor in obscurity until the end. I’ll consider myself lucky if I just stay out of trouble. I was the doc for my patient until the end, when he died of plain old, very old, age. Every so often we delighted in laughing at the incompetence of those chart jockeys.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. B talks about the chart jockeys. Today they come in many forms. If the clinic is part of a health system, the chart jockey may be the quality review folks who review patient charts for each clinician looking for patients who are lost to follow up or are out of compliance with recommended treatment. They can be helpful. Thanks to electronic health records (EMR or EHR), we can pull up lists of patients based on diagnosis codes (ICD-9, soon to be ICD-10). As a result, I can look at all of my diabetics and know who has been in the clinic in the last 6 months and what their lab values are.  With diabetics we aim to keep their HGBA1C under 8. (Glycosolated hemoglobin-the measure of sugar molecules on a red blood cell gives us an idea of how well a patient’s diabetes is under control over three months, the life of a red blood cell.) Then the nurse and I can figure out which patients we need to contact and ask them to come into the clinic. In the old days, we waited for patients to come to us. Today we make more efforts to reach out to patients, especially patients with chronic health problems. With diabetes we know that certain medications and checks actually keep patients healthier and prevent or delay kidney failure, loss of vision and amputations.

The chart jockeys can be a nuisance when I have to jump through hoops before I can order a treatment or medication–often call a prior authroization, especially if it is what I know I need to do for my patient. On your rotations you will hear lots of clinicians complain about the paperwork or phone calls that accompany this. It is all an effort to avoid unnecessary treatments, identify fraud and to manage cost. Often it consumes time and energy for staff that interferes with caring for patients.