Monthly Archives: July 2012

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?  

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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.