Monthly Archives: October 2011

Home Visit

As a medical student in North Carolina, Dr. Fleg did a home visit with his preceptor and received a gift for his heart.

 The Sisters

–Written in Love

by Anthony Fleg

My watch said it was time to go,

But my heart spoke otherwise,

Fortunately, I listened to the latter

And went with Dr. Stuart to see

The Sisters

Miss Minnie and Miss Viola

Hailing from Georgia,

With ten scores of wisdom between them,

They spoke first, without words

Perfuming the room as we entered.

They began to tell of their aches and pains,

Joking about whether Dr. Stuart or I would be their “catch” for the day

When asked about the key to their longevity,

Viola answered, “God has been good to us,”

While their relative with them offered, “It is because they were good to their momma.”

Which caused me to pause,

Trying to shut off that medicalized, left-brain-oriented way of hearing that afflicts many of us in medicine,

They spoke not on the recipe for reaching the holy feat of triple digits,

But instead on the way to appreciate each and every day whole-ly,

as something holy,

They teach that the goal is not to reach an old age

But instead is about how to be on your way there

They remind us that the goal is not to avoid death

But to fully embrace life

I am thankful,

I am refreshed,

Dr. Stuart and I leave smiling with our minds and hearts

If someone asks me why I am late

I’ll simply say, “My teachers had something I needed to hear.”

(used with permission and published in The Country Doctor Revisited, KSU, 2010)

Many patients have lots to teach us, especially older patients, who know their bodies and themselves pretty well. One of my favorite elderly patients, a retired farmer, cannot do much on the farm now that he’s reached 90, but he takes great pride in growing tomatoes. He’s given me many pointers and improved my green thumb. Despite the pressure of seeing lots of patients, Dr. Fleg reminds us that we need to take the time to listen and connect with patients on topics beyond their health and diseases. These kinds of connections nourish us and are the rewards that come from taking care of people. If we don’t take time to bask in these, we will get burned out and cynical. What are some of the treasures you’ve heard and witnessed on your rural rotation? What wisdom will you carry with you for a while? Urban patients have many treasures to share as well. Urban or rural, have you seen interactions between your teacher and a patient that remind you of Dr. Fleg’s. Sometimes you are working with teachers who are burned out. What opportunities to interact with patients have they missed?

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Mississippi Mayhem

Hinds County,MS 2001

–C.D. Bradley-Jennett

“Remember you’re just an observer”

The ID doctor with the long gray hair and tortoise shell rimmed glasses reminds me

I don’t need reminding.

I know this is her clinic

I know she is trying to help

I am just an observer here

I am just a resident

Just a witness

 

Jesse James is black

Really beautiful

Dark like mahogany

Cheek bones angled just so…like a model really

But he is dying

“Got that AIDS,” he says, matter-of-factly

He is 26

The medicines might’ve worked if he’d taken them right

Not “every now and then” as his mother divulges

 

Now he sits on the examining table, bones jutting out everywhere

“What hurts you” the doctor says

“Everything” he replies

“And I just keep runnin’ to the bathroom…

Won’t stop no matter what I do…”

 

“Jesse we need to think about hospice”

“Remember we talked about that…”

“I’m having a hard time remembering anything lately. Mrs.…I mean Dr. Lee…

just tell my mama…she remembers everything”

 

And she does…the positive test…pregnancy test…27 years ago…how they had to “remove her womb and everything else ” because she wouldn’t stop bleeding… ensuring Jesse would be an only child. 

She remembered everything…the first step, the first word, the first day of school…the first clue…that something just wasn’t right…

he was 19 and losing weight and kept getting rashes on his face that just looked funny and then pneumonia and almost dying like that in Jackson Memorial Hospital…

They drove 40 miles to get there…he needed to see the specialist.  She needed her baby to live. 

The other positive test…

”Yes, it was for sure”   “No. they couldn’t tell how long he had it”  “Maybe she should talk to him about it”

 

She had warned him about so much:

“Be careful crossing Fitzgerald road ‘less you get hit by a tractor or somethin’ “

“Don’t swim in Hinds county creek the waters too dirty ‘bound to get all kinds of germs…”

“Pleeeeze, don’t get that fast girl pregnant now…you know I don’t need a baby around here…with me working all day”

“Baby I know it’s the 20th century, but please don’t sass them white folks…Mississippi ain’t changed that much”

 

Hadn’t warned him about this.  This disease that would kill him.

He was disappearing right before her eyes.  

Shrinking…folding in upon himself. 

Graying…his skin and even patchy areas of his once thick and lush hair. 

She remembered everything, but she kept quiet.

And even after she lost her only child she found it hard to say it aloud.

Everyone knew what Dr. Lee’s clinic was for, but it was still a secret in this small Mississippi town where separate and unequal still reigned supreme.

And everyone said “Mrs. James, I’m so sorry about your loss”, and the deaconesses from the church baked cakes and the supervisor from her job made her famous deviled eggs and the pastor’s wife fried chicken and people whispered laughter…as was appropriate for a repass, and everyone was so polite…

But, I wanted to shout because Jesse was younger than me and quite possibly brighter than me…

and now he was dead and that was not OK with me…

And I wanted to scream…and I wanted to sound the alarm…and I wanted to rally…and I wanted to educate about how it’s done up North

…but mostly I wanted to scream…

but I was just an observer.

(used with permission and published in The Country Doctor Revisited, KSU, 2010)

Dr. Bradley-Jennett reflects on her experience in the rural south as a medical student. In small towns all over the US, everyone knows everybody’s business. Sometimes that business includes health problems with a stigma like AIDS (Dr. Bradley-Jennett’s patient), sexually passed infections, or an unplanned pregnancy. Even today depression, substance abuse or the need for Viagra can be embarrassing. Recently, I had a patient ask me to write out her husband’s prescription for Viagra so she could hand carry it to the pharmacy in another town. She didn’t want the local pharmacy assistant, who she’d known forever, to know that my patient and her husband needed it. Sometimes what is known is not discussed, like in Bradley-Jennett’s poem. As a result neighbors can have a passivity about what is: Mr. Jones is an alcoholic and he beats his wife. It’s a given, no one asks if she needs help, or they are tired of her denying that it happens. As a result the alarm and rallying never happens to change the status quo. What have you noticed on your rural rotation about small town nosiness and privacy/confidentiality?

Responding to the need for high quality emergency care in rural America

–Darrell Carter

Another cold blustery January night in northwestern Minnesota, and you hope everyone stays home and your hospital’s emergency department remains quiet. As the night charge nurse on duty, you are responsible for overseeing the care your night staff (one other RN and an LPN) gives to the twelve inpatients in your twenty-two bed Critical Access Hospital (CAH). These twelve patients include a mother and her hours-old newborn and an eighty-two-year-old female who is two days post-op after a hip pinning and who is exhibiting increased confusion and agitation. You hope to let your on-call doctor get some sleep since she was up much of last night delivering the baby in your nursery. The only other practicing physician in your community is gone for a much-deserved five-day break to Cancun.

 All has remained routine until 1:00 a.m. when the squawk from your ambulance paging radio disturbs your charting. The Basic Life Support ambulance is dispatched to a motor-vehicle-crash involving two vehicles and an unknown number of victims. At least two of the patients sound seriously injured. Reluctantly, you shift your role from more mundane tasks to organizing the team for the soon-to-be-busy emergency department.

 In the twenty-first century, seriously ill or injured patients benefit from a growing amount of advanced technology for diagnosis and treatment of their ailments or injuries. Highly trained specialists are now available to help manage a wide variety of complex conditions, and well-trained and highly skilled teams staff emergency departments. Unfortunately, this is true only in the larger population centers of the United States. Rural health care facilities do not have immediate access to this wide variety of specialists and frequently lack the more advanced equipment needed to diagnose or treat the seriously ill or injured patient. Rural providers frequently lack the organized team, knowledge, and skills to rapidly perform the life-saving procedures and treatments needed by the more seriously ill or injured patients. Extensive distances lengthen the time required to transport patients to specialized urban medical centers for life- or organ-saving procedures. It is little wonder that rural trauma victims have a higher mortality rate than their urban counterparts. In 2004 the Minnesota Statewide Trauma System reported that fewer than 30 percent of all motor vehicle crashes occurred in rural areas, but 70 percent of the fatal crashes are rural.

 There are many obstacles to our delivering the highest and most modern emergency and critical care to rural patients. However, the medical legal standards of care and the general public expect similar care to be delivered in both urban and rural communities. Disparity in the availability of advanced emergency care has adverse consequences. In rural areas, these include: higher rates of trauma deaths, increased burnout among providers, difficulty recruiting staff for existing health care facilities, and an increase in medical-legal risks for practitioners due to the inability to rapidly deliver emergency care or obtain easy consultation for some critically ill or injured patients.

 So what is the solution to this developing crisis in rural medicine? Some recommend more helicopters to rapidly transport the rural patients to urban centers. Others promote equipping rural communities with all the latest equipment, as well as hiring skilled specialists to respond to the infrequent events.  But is society willing to finance the cost of such solutions? Others claim living (and vacationing and driving) in the rural parts of our country is simply more dangerous, so if you elect to live in, or even venture into rural areas, then you need to accept the inherent risks.

(Excerpted from A Night in the Life of a Rural Emergency Care Team and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. Darrell Carter and his colleagues responded to this need by starting CALS—comprehensive advanced life support.  http://www.calsprogram.org/

This innovative program combines ACLS, PALS, ALSO and ATLS with a rural focus and a team response approach. In the 21st century, many rural areas are filled with innovative ways to respond to the desire of health care providers and patients to provide and receive high quality care.  What is happening in the community where you are rotating?   Please share some innovations on this blog.

Welcome to Elma

–Mitchell L. Cohen

Dr. Cohen, who practiced family medicine for five years in rural Washington, describes a typical day’s roster of patients to the third year medical student spending the month with him:

First on the schedule is a forty year old log truck driver coming in to get his physical for his license. I never knew how many log truck drivers were in this county until I started working here. Here’s a thirty two year old female with chest pain that’s probably either her asthma, anxiety, or both. She smokes way too much tobacco and marijuana. Then there’s a depressed patient with fairly newly diagnosed diabetes, high blood pressure, and elevated cholesterol. It’s so frustrating. He just doesn’t seem to care, but I know a lot of this is the depression. The next guy you’ve got to meet. He is eighty nine and coming in to talk about his gout. He’s a retired veterinarian and tells some pretty amazing stories. Just ask him about serving in Italy in World War II. A tough case of ADHD in a kid in foster care is next. We’ll do a skin biopsy on the next guy. His dad is one of my patients in the nursing home. Really sad; rapidly advancing dementia.  He’s having a tough time watching his father go through so much. 

Then it’s lunch time. Do you like Mexican food? Good. For lunch we’ll walk on over to this great Mexican place on the next block. The owners and most of the employees come here for their medical care too. I highly recommend the spinach enchilada.

In the afternoon we’ll start with a pregnant patient of mine. I delivered her last baby. I also take care of her parents and grandparents. We have quite a few third and fourth generation families in the practice. My partner holds the record for a five generation family, but then the great-great grandparent died and it went back to four generations. This guy here always comes in to get his ear wax cleaned out. Ahh, fascinating stuff there! Here’s a guy in his mid-forties with low back pain and, and, oh by the way, he’s seventy pounds overweight, smokes, and uses walking to his mailbox as his form of exercise. These visits are painful for both of us. Anyway, dispersed among all of those there are a few well child visits, other pregnancy appointments, some of these might be Spanish speakers. How’s your Spanish? I spent two years of my CME time learning Spanish. I am passable, unless it gets complicated, then I use a phone translator—but as you’ll learn, the visit fee hardly pays the cost. Then of course, more high blood pressure and diabetes, and the rest we’ll figure out when we take a look on the other side of the door.  Looks like about twenty-two patients total—pretty typical day.

Remember, you’re here to learn about rural medicine. Get to know the patients. Let them tell you about their families and what they do for a living. You’ll see that so much of what they tell you relates to their medical illnesses in ways that you haven’t ever considered. This is one of the intangible benefits of family medicine and it is best brought out in rural areas. It doesn’t appear in any proficiency scores or quality measures, but the continuity of care we provide for generations of families allows us to tailor modern medicine to fit their needs. This is the art of medicine. 

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

Today we talk about the value of evidence-based medicine, knowing the best practice for your patient’s disease and situation. Research and science have their place in caring, but so does the art. Dr. Cohen describes the art as letting the patients tell you about their families, what they do for a living and about their lives and then comes the art—you adjust the science to make it work for them and their unique situations.  I am thinking of one of my new diabetic patients. If I want to get quality credit for my diabetes management I need to have the BP well controlled, the Hemoglobin A1C under 8, the LDL under 100, and the patient needs to take an ACE/ARB (like lisinopril) and aspirin. If I addressed all that with him during our first visit he would have been drinking out of a fire-hose—not fun for anyone. So little by little we examine the various issues and negotiate what he can and cannot do.

What has surprised you about the patients you have encountered on your rotation? Where have art and science intersected? How has your teacher/preceptor’s knowledge of the patient over a number of years informed the diagnosis and treatment?

Dual relationships

–Godfrey Onime

The yellow-, red-, and green-striped gift bag containing the present lay on my office desk among the stacks of charts and assorted papers. Curious as to the sender, I looked at the card that came with it. “Oh no, not again.” It was from my patient Ms. Emalee, next on my schedule. Among her myriad medical problems—diabetes, hypertension, obstructive sleep apnea—was intractable knees and back pain for which she used narcotics chronically. On her current visit I’d planed to perform a random drug test, to ensure she was actually taking the medications and that she did not use illicit drugs. But now the gift, although this was far from her first—she often brought fruits, baked goods and other presents for everyone in my clinic. After she learned I got married and hinted she was looking for “something special” for me, I’d entreated her not to worry. She had looked at me as if I were from a different planet and then declared I was “like family now,” adding “you better believe you getting something from me, don’t matter you snucked off ‘n’ got married without telling no one.” Now I wondered: What if her test results indicated a problem? Would her act of kindness make it difficult for me to do my job, such as refusing to prescribe further narcotics or even discharging her from my practice?

 The question of boundaries with their patients is one issue that small-town doctors face. Often for lack of convenient alternatives, country doctors not only have to take their friends on as patients, but their patients quickly establish themselves as friends. It seems to challenge the reader to consider that in small towns, where privacy is shunned and familiarity with neighbors prized, maybe physicians’ closeness with their patients is exactly what they need to render care with true understanding and deep compassion.  

 When I entered Ms. Emalee’s room, she looked up at me expectantly and asked if I liked her present. I told her I had not opened it. Sensing her disappointment, I quickly added that I was waiting to get home, before opening it with my wife. The explanation seemed to satisfy her. “Smart man,” she said, “I’m sure she’d love it.” Ms. Emalee’s knees and back still hurt, but her pain medications were helping. No, she did not have significant side effects from the medications, such as constipation or drowsiness. I also asked if she ever sold her pain pills, but that seemed to annoy her. “You keep asking me that foolish question every time I comes here and I keeps telling you no, I does not sells my medicines. Don’t you even trust me?”

I apologized, but reminded her it was the law and my job to ask. At the conclusion of the visit, I told her I’d like a sample of her urine for a random drug test. “Whatever you say, doc,” was her sarcastic reply. Then she informed me they were having a birthday party for her mother—who was also my patient (as were her two sons, a daughter, a sister, and brother-in-law). Her mother was turning eighty. Her family would be greatly honored if my wife and I could come. Not sure how to respond, I promised to get back with her.

(Excerpted from Who We Are—Synopsis, The Country Doctor Revisited)

Boundaries between physicians and patients are usually different in rural areas than in larger metropolitan areas. Students are often caught in a double bind when they learn in medical school that physicians cannot be friends with their patients, but see in rural areas they usually are. As Dr. Onime states, “Patients often quickly establish themselves as friends… and that closeness may be what is needed to render care with true understanding and deep compassion.”  What do you see as the benefit and downside of “dual-relationships” –friend and doctor to the same person?  How do the professionals on your rural rotation negotiate this? Physicians often feel like they live in a fish bowl, especially in small towns where everyone knows everybody’s business. How do your preceptors draw the boundaries? Some professionals relish being the heart of the town and others prefer much more privacy. Imagine yourself as a small town practitioner, what would you do?