“Two blocks into my paper route and I can’t peddle my bike,” Joe complains. He tells us the pain started when he was playing Hacky Sack. He rotates his hip out and balances on his left foot, his right knee protrudes from his denim shorts like a doorknob. Ankle-high red tennis shoes squeak on the linoleum floor. I marvel at his flexibility considering all the pain he describes.
“Sometimes my knee locks up and I have to massage it to release it,” Joe says and demonstrates. “Twenty Ibuprofen in two hours doesn’t touch it!” His blonde ponytail flips from one shoulder to the other.
Joe and Doug, the patient and the medical student, are in their early twenties. Both are tall; their clothes hang on them like a dress shirt drapes a hanger. Doug listens intently, making notes on his clipboard from his post on the exam room stool. Near the end of a nine-month rural rotation during his third year of medical school, he has seen patients at the local hospital, clinic, and nursing home and learned about the community’s health issues. He’s rented a trailer home in the town’s trailer park. As faculty in the Rural Physician Associate Program at the medical school, I am here for one of six visits to assess his progress, observing his interactions with patients and doctors, the professor monitoring the student.
Doug methodically uncovers the how, when, why, where, and what about Joe’s pain, what makes it better and what makes it worse. Shifting his focus between his notes and Joe, he pauses and runs his long fingers through his short brown hair. I hold my tongue during the pregnant silences and Doug always comes through with the appropriate next question. I quietly applaud him. So far, Doug has documented Joe’s history of present illness, past medical history, and family history and is working through social history. As Doug concludes the interview and prepares to conduct the physical exam, I decide to interrupt and ask Joe where he lives.
“In my van,” he responds.
At this, Doug’s gaze locks with mine and he settles back on his stool, crosses his legs and begins a new line of questioning, probing where Joe gets money for food and cigarettes.
Reprinted from The Country Doctor Revistied (KSU, 2010) with permission.
Doug had done a good job of understanding Joe’s problem–the PQRST of pain, but he and I broadened our understanding of Joe’s situation when we asked about where he lived. Homelessness is an issue in rural areas. Because it is often more hidden than in urban areas, we forget that it is a problem. Rural homelessness, like urban homelessness, is the result of poverty and a lack of affordable housing. In 2005, research shows that the odds of being poor are between 1.2 to 2.3 times higher for people in nonmetropolitan areas, than in metropolitan areas. (National Coalition on Homelessness) The current mortgage crisis hit rural areas across the US. The challenges in rural areas are magnified because resources are more limited.
As you spend time on rural rotations, think about poverty and ask who and what organizations create the safety net in the community.