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.

Final entry

In the last year we’ve highlighted many of the poems and stories in The Country Doctor Revisited. We’ve examined the joys of rural practice — the beauty of the wide open spaces, the close relationships with staff and patients, the benefits of less red tape. We’ve considered the challenges  modern health care poses in rural settings — how to provide the latest high tech care, how to install electronic health records with limited dollars, how to welcome more ethnically diverse populations and serve them in culturally competent ways. We’ve learned that big city problems are also problems in small towns — alcohol abuse, domestic violence, suicide and violent shootings. In rural areas the resources are more limited, so health care professionals are often more innovative.  Please review these pages and share them with your colleagues who are exploring rural practice as a career.

Check out the web site. http://thecountrydoctorrevisited.com/

Look at the contributors and their new work.

Consider starting a book discussion group to learn more about rural health and access the discussion questions on the web site.

Above all celebrate the importance of having a well trained rural workforce to care for the 20% of the US population who live rural.

Blog: Rural Mississippi—Aftermath of Hurricane Katrina

–Shailendra Prasad

August 2005. I planned on flying back to New Orleans after a conference in Arizona. My wife and son had accompanied me. We watched Katrina grow like a weird reality show—a petulant child gaining weight, becoming unruly. There was talk about this being bigger than Ivan from the year before, even bigger than Camille from 1969. “No,” my friends and patients in Mississippi told me, “nothing gets bigger than Camille.”

Our flights home were canceled. Then we learned our neighborhood was under mandatory evacuation. Evacuation was not foreign to us. We’d participated in four drills during our seven years in Mississippi. “Hurricane parties,” we called them. We’d lock the shutters on the house, secure the garage door, and remove the yard implements that could become missiles in the sixty plus mile-per-hour winds. Then along with our two satchels filled with a change of clothes, our son’s favorite toys, and copies of our important documents we would drive to a safe home, a friend whose home was not in the path of the storm. We’d spend the night playing cards, talking, and waiting out the squall. Usually we could go home the following morning.

We hoped this, too, would pass and called a friend who had a spare key to our house.

“Sounds like a bad one,” our friend said.

“Can you get our hurricane satchels? There are two of them, in the closet in the master bedroom.”

“Sure. I’ll lock up the house too. Anything else?”

“Yeah, put the birdfeeders in the garage. The birdbath too.”

“Of course. Be safe. I’ll be in touch.”

That night in Phoenix I watched the television. Reporters talked about the rain and wind in surrounding areas. Counties in both Mississippi and Louisiana were evacuated. I called every number in my cell phone. No answer at the hospital, the clinic. My practice partner did not respond at his home phone or cell. I could not reach our neighbors or local friends.

Our county, Pearl River, and our town, Picayune, were orange on the weather map. The Internet news pages said nothing more. I could not eat dinner. I continued to make calls. I phoned my dozen sickest patients whose numbers I kept just in case they needed me. No one answered. I worried about my three-year old patient waiting for a renal transplant at Tulane. He’d just gotten a match.

What would happen now? No answer. And there was complicated Mr. Shirley who I just referred to the neurologic unit in Birmingham, Alabama. Would he get there for his appointment? When was that appointment? No answer. Then there was my dialysis patient. Where would she go? No answer. Feeling restless and helpless I walked down to the business center and opened this blog:

Pearl River County Katrina Survivors

This is my attempt to help in the aftermath of Katrina. I work in the Picayune area and have very dear friends in the area. The only precondition to this blog is this—respect your fellow bloggers.

Please blog away to add on to the information on Picayune/Pearl River County,Mississippi.

posted by sprasad @ 8/30/2005 07:54:00PM

By midnight there were thirty posts. I am looking for . . . I am trying to reach. . . does anyone have any information on . . .

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

Dr. Prasad felt an obligation to his patients during Hurricane Katrina. Medicine is rarely something you can walk away from when you leave the hospital or office. Often you carry patients with you – think about them, worry about them, pray for them. In a small town you often see  patients as you run errands at the hardware or grocery stores. This raises the issue about how one sets boundaries. How one cares for his/herself.

Talk with your preceptors and other staff in you clinical setting and see how they manage these challenges. 

Trends in Medicine

–Tom Bibey

We’ve been around long enough to see the trends come and go. I’ve seen Aldactone fall in and out of favor three times now as the latest “hip” drug. When I see some young fellow tout the latest study on the merits of the drug as some new thing, I ache from his lack of wisdom.

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

 Dr. Bibey, who has some gray hair, gives us perspective on the changing knowledge of medicine. We have embraced Evidence Based Medicine (EBM), but the evidence changes. We once encouraged menopausal women to take hormones to protect their hearts, then learned that was not helpful. We encouraged anti-oxidants, then learned that did not make a difference. Talk with your preceptor and explore the other trends that have come and gone as our knowledge and science has grown.

Modern rural

–Tom Bibey

And yet before you misunderstand, let me reassure. We are modern. We use the same medicines as our city counterparts, and we are only a helicopter flight away from the latest technology, not that it solves all of our problems. We take the same competency tests as our colleagues, and I’ll bet we do just as well or better. (Maybe my old professors did a little better, but they got to write the questions.) We have access to the same information too. My computer is just as fast as the ones over in Raleigh.

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

Dr. Bibey addresses with humor the impression that rural means backward. It is easy to judge the choices another provider made when you aren’t in the trenches with him/her.  In other entries, we’ve examined the innovative efforts to adapt to the quickly changing world of modern medicine that have originated in some rural practices. Examine your setting. Who are the innovators? What are the qualities they have that keep them thinking and moving forward? Is it curiosity? Is it the desire to serve their patients well? Is it the need to keep learning and stay engaged?  

The changing face of rural America

–Therese Zink

Rural counties, especially those located adjacent to metropolitan areas have seen population growth. Challenges arrive along with these new Americans: How do two or three different cultures live together? How does a small clinic with limited resources accommodate different languages and different understandings about health and healing? The diabetic diet looks different from a Mexican diet where beans and rice are staples and different from the farmer who wants his meat and potatoes. Some workers arrive without family, leaving their wives and children back home for the season or several years. Problems such as alcohol abuse, sex trafficking, and violence often accompany this disconnected lifestyle.

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

How do we meet the needs of patients that extend beyond the clinic.  These are often called the social determinants of health. These play an important role in keeping people healthy and helping them achieve health.  Health care professionals need a team to address these issues and that team includes public health, social workers, as wells a policy makers and community advocates.  Pay attention in you community.  Is your preceptor aware of the other factors affecting a patient’s situation?  An alcohol problem? Housing problems? No money for food? Family problems?

Sometimes new Americans or immigrants have a more difficult situation because supports do not yet exist to help them and language barriers make it hard to communicate. If you community has immigrants, how are they welcomed into the health care setting?  Interpreters? Signage? Specific patient education? Multi-lingual providers? Art on the clinic walls?

If you were in charge what would you do differently?

Cattleman

–Michael R. Rosmann

Kent raised the manure-splattered tailgate of the livestock trailer to let his cows enter the chute into the Farmers Livestock Auction stockyards. This was the last truckload of his 130 cows that were scheduled to be sold at today’s auction. Most of the red and white cows hurriedly tramped down the sloped chute to reach the more solid footing of the concrete alleyway leading to their pens. There they would wait for prospective buyers to inspect them. Kent was familiar with each animal as she passed and knew all their ear tag numbers and names.

He remembered how he helped Sally give birth to twins in April 2003. Sally’s first calf was coming with one front leg turned backward. Despite Sally’s contractions, Kent pushed the calf ’s head and chest back into her uterus and reached inside to pull up the errant leg. After grasping both front feet, he quickly pulled the wet calf into the outside world. The second calf was less fortunate, for Kent discovered that its umbilical cord had become twisted earlier during its detained emergence.

Wincing from the hollow feeling in his stomach, Kent watched as Belle scrambled down the chute, and he remembered that she had produced the high-selling bull in his annual production sale twice in the past five years. “I’ll miss you.” Then Molly came to the trailer doorway and briefly locked onto his gaze as she gingerly placed one hoof ahead of the other into the chute. They had an eleven-year relationship. “Sorry, old girl.”

When all the cattle were unloaded and chased into their holding pens by the sale hands, Kent visited the auction office to tell the clerks that he had delivered all his cows. With a Styrofoam cup of steaming coffee quivering in his thick hand, Kent headed to the holding pens in the adjoining shed to take a last look at his pets.

. . .

A heavyset neighboring farmer in coveralls lumbered to catch up with Kent
and protested, “Kent, why is that cow bellerin’?”

Kent stopped in his tracks, turned, and responded, “She’s wondering what
she did wrong that she should have to be sold.”
The hefty man momentarily paused and put a hand on Kent’s shoulder. “Yeah,
it’s too bad,” he murmured.

Shivering, Kent struggled to maintain his composure. He remembered the
words of his psychologist whom he had consulted last week for his depression.
“Why don’t you keep a few cows for yourself; they’ll help you maintain your
self-respect.”

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

Part of loving rural is the relationship with animals and nature. I have my own relationships with a miniature donkey who has inspired many stories due to his onwry personality, a horse Indy who is a terrific riding partner. An experienced rider told me the relationship with a horse is 60-40. I am the sixty. Sometimes he’s right about the way home or recognizes the hole in the trail I miss. Then there are the cats, precious for the mousing abilities and their willingness to hang out in the garden with me when I weed.

In this selection Kent has to sell his cows due to financial hardship. Dr. Rosmann explores the challenges of depression and access to mental health services in rural areas. Ask questions about the mental health services in your area. Where do patients go for psychiatric help and how long is the wait? Where can patients go for counseling services, for substance abuse assessment and treatment? Often rural providers manage more complex mental health issues because consultants are few and the wait is long.

National Rural Mental Health Association has a journal and other resources.

Local Medical Doctors: State-of-the-Art Healers

–Gwen Wagstrom Halaas

In an emergency room in Cambridge, Massachusetts, at Harvard Medical School, I first heard the acronym “LMD.” As a medical student, this was one more acronym to add to my brain, already swimming with acronyms and millions of bits of information. I soon realized that LMD was the house staff’s term of derision for the local doctors whose patients they were presenting. This was news to me, that other doctors would not respect their peers. Maybe I was naive, coming from Minnesota where we are “all above average.” This realization dulled the shiny image of the medical mecca that I had the privilege of experiencing.

Moving back to Minneapolis, I managed to escape this attitude for a while, training in a hospital where the family of family doctors was the valued source of patients and referrals. This attitude resurfaced as my peers joined practices in small communities in Minnesota, and I would hear them complain about how they were treated by the urban consultants.

On my rural rotation in Homer, Alaska, I was first introduced to the amazing level of care rendered in a rural setting. While on call one evening in the hospital, a man with chest pain arrived in the emergency room. He was quickly evaluated, treated with streptokinase, stabilized, and put on a Lear jet to Anchorage.

This was months before anyone in the big city of Minneapolis was considering thrombolysis for acute MIs (heart attacks). I bragged about this experience and others on my return to the city. They looked at me like I must be hallucinating.

In my professional journey, I first started my own family practice on the skyway downtown—a very old-fashioned general practice in a fancy setting in St. Paul. From there I traveled through combinations of practice, teaching and managing the business of health care until I found myself directing a program that taught medical students the basics of medicine by immersing them in rural community practices. Again face to face with LMDs, I marveled at the innovative ways they cared for families and communities. These “hick” towns have helicopters, digital X-rays, telemedicine, electronic health records, robot consultants, medication vending machines, and approaches to care that are on the cutting edge. Their state-of-the-art facilities are patient-centered healing environments.

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

It always surprises me that this term of derision is still alive today. You’d think that our dependence on each other for referrals and consults would have fostered more respect. But 30 years later, I still hear students talk about some of the same derogatory comments I heard about primary care in the 1980s.

It takes a lots of smarts to know a little about the wide range of health care issues patients face today. It also requires a lot of wisdom to know your limits and when to ask for help. Some personalities may be better suited to the wide swath of general knowledge and others may do better with deep and narrow. Pay attention to what you hear and remember, putting down someone else certainly helps one feel better about his or herself.

 

Disconnected US health care–Part 2

The Dressing Change – Part 2

–Tara Frerks

As I worked, I listened as Mr. Friedrikson repeated some of the particulars of their story. It was clear that he was angrier than his wife, maybe feeling some guilt. He clearly had taken the lead in trying to secure help.

I washed off the remaining betadine and dried blood, then patted the patient’s hand dry, careful not to hurt her. “Want to take a look before I wrap your hand?” I asked.

Mrs. Friedrikson emphatically shook her head.

Using supplies from their bag, I carefully placed Telfa (no-stick gauze) over the healing lacerations, then wound gauze around the fingers and thumb, wrapping the thumb separately and keeping the fingers visible to just below the nails. I’d watched many dressing changes, but this was the first I’d done on my own. I gained confidence as I worked.

Two hours after entering the clinic, I sent the couple on their way. They left with a neatly applied dressing and two hours of telling their story. Now more confident in my wound care, I realized that today I’d made a valuable contribution to Dr. Brown and the clinic team. As a medical student I had the luxury of spending time with patients, listening and talking and hearing every detail of their nightmare in a way that Dr. Brown could not. Now, my challenge over the next years of training is to learn how to demonstrate the same humanistic care in a more compact interval. And maybe with advocacy on my part, I might see a saner health care insurance system during my career.

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

We’ve talked before on these pages about the student’s luxury of time, what a gift that is for the patient and the clinic. Pay attention to what you can learn because of the time you have to spend with patients. You’ll gain not only techniques and skills, but a wealth of information about health and healing and  the resiliency of the human body and spirit.

 

Disconnected US health care

The Dressing Change

–Tara Frerks
I shook hands with Mr. Friedrikson and touched Mrs. Friedrikson on her thin shoulder to avoid the bulky dressing on her right hand.
“I need my dressing changed,” she said in a grandmotherly voice. She cradled her right hand in her lap and shielded it with her other hand and arm.
Mr. Friedrikson, a few strands of gray hair combed across his bald head, sat on the edge of his chair, tapping his left foot on the linoleum floor. “Do you know that you are the fifteenth contact we’ve made trying to find someone to help us?” He thrust a paper bag filled with dressing supplies into my hands.
I placed the bag on the counter and then settled onto a stool to listen. I enjoyed the independence and array of experiences I’d encountered in this small Minnesota community. I asked one open-ended question, “What can we do foryou?” and the Friedrikson’s story came pouring out.
A few months ago, they had retired to a house on one of the nearby lakes. They were new to this town and clinic. Helping her husband of forty plus years with a kitchen project, Mrs. Friedrikson had been trying to steady a two by four he was sawing. Her hand slipped and the blade of the circular saw sliced deep into the flesh and bones of her right hand. With blood soaking an old towel, they drove to the town’s emergency room. The ER physician deemed that the injury was too complex for the local surgeon to repair. An air-ambulance transported her to a trauma center for microsurgery. “We were discharged home last week, and they told us to get checked up here within the week,” Mr. Friedrikson said.
“We couldn’t find any clinic that would see us. Finally, we just went to the local emergency room this weekend. I have to tell you, the surgeon who changed the dressing was kind of nasty.”
“Now Herbert,” Mrs. Friedrikson said. “He was probably very busy.”
I controlled my smile, I’d worked with that surgeon.

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

It doesn’t take much experience to see that our health care system is broken. Patients work hard to locate what they need and even with persistence, their needs often go unmet. This week we learn whether or not the Supreme Court declares the Affordable Care Act’s (ACA) mandate that patients purchase insurance unconstitutional. While the ACA has many problems, it was an attempt to address the fragmentation of the US health care system which spends exorbitant amounts of money and has little to show for the effort. Granted, many of the medical miracles achieved by technology are tremendous, but too many citizens don’t get the basic care they need.

Pay attention in your setting to what works and does not work about patients’ access health care. Whether or not the ACA’s mandate is declared unconstitutional or not, much needs fixing in the current US health care system.

A Psychiatrist Waits for His Ten O’clock Patient and Imagines He Is Han Shan

 

–Richard M. Berlin

Daughter gone,

hair gone, my father

dead for half my life.

Patients I saved from suicide

lived until old age,

died from cancer instead!

Twenty years of hospital work.

Twenty years pruning apple trees

on the west flank of Cold Mountain.

Once they were sticks.

Now the branches bow with ripe fruit.

A faint wind stirs them.

I’ll share a bushel with the crows,

another with the worms!

 

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

Dr. Berlin, a psychiatirst and poet whose poems we've shared in other blog entries, reflects on life's rhythms and transience mimicking the Chinese poet Han Shan. Han Shan referred to himself as Cold Mountain. Dr. Berlin lives on Cold Moutain. Han Shan was a cynic and a hermit who liked to poke fun at the self-importance of the other monks. Enjoy this brief reflection on all we try to do and hope to do as healers/physicians and what it all amounts too.