Rural Doctoring

Case: A Plan for the End

An 81 year old man arrived in the Emergency Room with subacute onset of shortness of breath. He had a history of Parkinson's Disease and hypertension, neither of which had caused any significant decline in his quality of life although he had noticeable intention tremor when he felt tired.

He'd been hospitalized many years ago for what sounded like a soft tissue abscess that took a long time to heal. After the hospitalization, he and his wife consulted a lawyer for help drafting an Advance Directive:

The Impact of Diagnostic Errors

Bob Wachter has written a thought-provoking post on the hidden impact of diagnostic errors. The post discusses the current frenzy over preventing system-based errors (i.e. wrong drug, wrong side problems) which are made while providing patient care for an established diagnosis.  But what if the diagnosis is wrong?

It is the classic GIGO scenario: the result is only as good as the data inputs that created it.  As medical imaging becomes more sophisticated, genome mapping moves within reach, and competence in minimally-invasive surgical techniques increases, people naturally expect diagnostic accuracy to increase as well.  Why wouldn't it?

Los Angeles Times: Prescription Drug Diversion

Photo Credit: Iowa Department of Public Safety

The LA Times is running an article on the impact of prescription drug abuse on urban Los Angeles.. I suspect most of us have been burned on this issue and have adjusted our prescribing accordingly. In my case, I was torn between my desire to provide enlightened pain management and the evidence of diversion by the minority of patients to whom I prescribed schedule II drugs.

It became a case of a few bad apples, and those few spoiled the whole bushel. One of the major reasons I left primary care is because I was tired of the all the record-keeping and fact-checking I had to do for my schedule II patients, most of whom were appropriate in their medication use but all of whom needed monthly refills on a certain schedule, so if I was off by even a day it created a cascade of phone calls and drama for my clinic. A few things the LAT article did not address that I have observed in my rural community:

1. The title of the article asserts that "Prescriptions supplanting illegal substances as drugs of choice," but it should be noted that prescription drug abuse provides an entry point to illegal drug abuse. I had one patient who came to me for Vicodin after a car accident. Within a few months he was scoring OxyContin off the street, and before the year was out, he was shooting heroin.
2. In economically depressed rural areas, prescription drug abuse thrives because people rely on the money they get from selling their prescriptions. Last I heard, OxyContin was going for $1 per milligram, so a patient taking 40mg twice daily could sell half their monthly supply for $1,200 and still keep half for their own use. For this kind of money, even non-criminal retirees will divert their prescriptions to supplement their SSI income--I've met 70 year old grandmothers who have done so. Believe me, I'm not trying to justify this practice, but I've pushed a few families into economic collapse by restricting their access to schedule II prescriptions.
3. Prescription drug abuse accounts for a significant number of preventable deaths in small counties. For example, in the county in which I live, the successful suicide rate for 2005 was 18 times greater than the national average, and prescription drug abuse was implicated in the majority of those deaths. Furthermore, deaths from accidental overdoses in this county exceeded both state and national averages. People who die from drug-related suicide and overdose tend to be younger than those who die from non-drug related causes, so the effect of this trend over time is to rob a community of its youth.
4. The not-so-hidden cost of prescription drug abuse includes the hundreds of thousands of dollars of public money spent treating overdose patients who actually survive. I work at a very small hospital and we regularly have 4-6 overdose admissions per week. All of them get a head CT, IV fluids, and more than a few need a Narcan drip for a few days. I have no idea how much this is costing my community every year, but I can tell you this: we can't afford it.
5. A truly hidden cost of prescription drug abuse is its impact upon the primary care shortage. As I mentioned above, escaping the schedule II treadmill was a significant contributor to my decision to withdraw from primary care, and I know a number of other hospitalists who were similarly influenced. How many other doctors are making the same decision? Their numbers are hidden among the other, more measurable reasons for leaving primary care (better hours, higher earning), and in the desire not to appear unsympathetic to treating pain in general.

These are a few thoughts I had upon reading the LAT article, but I know they in no way fully unpack the consequences of prescription drug diversion. I'd love to know how the rest of you are dealing with this.

Sometimes, Doctoring Means Having to Say You're Sorry

I think this makes us all feel nervous, but I've supported the idea of acknowledging mistakes for a long time. You can't avoid mistakes without examining the ones you've already made.