Rural Doctoring

Case: Forest vs. Trees

I was a fourth-year medical student by the time I finally rotated through anesthesiology.  Students who suspected they might be interested in entering this specialty scheduled their rotations early in the third year, but crunchy family practice types like me let it slide until fourth year, when you have a bit of medicine under your belt and can kick back and have some fun on a procedure-rich rotation.  Yet there are primary-care teaching moments on every rotation, even ones which take place largely in the operating room rather than the clinic.  Here's one example:

Why I Left Primary Care, Part 4

In the earlier posts in this series I discussed my reasons for choosing a primary care specialty, the problems I encountered while practicing primary care, and considered some factors which might draw me back into the field.  In the final post in this series, I've pulled together a few tips for young doctors considering a primary care career.

Why I Left Primary Care, Part 3

I've been writing this post series in an effort to unpack my mixed feelings about leaving primary care to become a full-time hospitalist.  Part One described the original Dream of Family Practice which inspired me to enter primary care in the first place.  Part Two described how reality fell short of the dream.  In this post I want to examine how I feel about my decision and revise the dream to propose specific changes that might lead me--and other doctors in similar situations--to return to primary care.

Why I Left Primary Care, Part 2

In the first post of this series I described the Dream of Family Practice:  the idealized notion of a career as a family doctor, delivering babies and seeing patients through the life span.  The DoFP was such a strong motivating concept, I ended up  training for rural practice despite my school's strong urban/tertiary care orientation and my mother's strong objections--she didn't want me to move away from the city where she lives.  Yet the DoFP was stronger than all of these influences, and within a few years I was in Rural starting my first job.  This post describes how the reality diverged from the dream.

Why I Left Primary Care, Part 1: The Dream of Family Practice

I stopped seeing patients for primary care late in 2007, after having struggled to balance hospitalist, OB call and clinic responsibilities for almost three years.  Now I am a full-time hospitalist and I also contribute to the prenatal care and call-sharing for my clinic's perinatal program.  It's been about a year since I made the big change and I often find myself thinking about my past and future in primary care, so I've decided to discuss the topic in a short series of posts.  Today I want to talk about what I like to call the Dream of Family Practice, an ideal of clinical medicine which inspired me to enter family medicine oh so many years ago, and which served as a clinical framework for my entry into a primary care specialty.

The End of Old-School Family Practice

Via the Healthcare Entrepreneur, today I learned Dr. Steve Harrison is closing his practice in King City, CA. (Image credit.)

King City is a very small agricultural town in central California. I've never been there but the residents in my program used to take care of King City's patients when their own rural hospital, Mee Memorial, couldn't provide needed services. The people of King City and surrounding environs don't have many options for obtaining health care except for a publicly-funded FQHC and Dr. Harrison's private practice.

The Stack of Damnation

That's what I used to call the pile of clinic charts that used to follow me around.  Here's an example of a moderate pile:

What's in these piles?

• Requests to refill chronic meds (levothyroxine, atenolol, etc.)
• Requests for early refills on Vicodin, Percocet, Xanax, etc.
• 4-6 applications for state disability
• 3-4 authorizations for durable medical equipment
• 6+ preauthorization demands for speciality referrals and special studies such as CT scans, etc.
• 1 or 2 requests for a letter of support for a patient's SDI appeal
• 1 or 2 jury duty excuses that need a doctor's signature
• 2-3 requests to be referred to chiropractors, orthopedic surgeons, dermatologists, etc., from patients I haven't seen in over 12 months
• Uncountable numbers of home health agency reports which must be signed and returned immediately. Some of these are on patients I have never seen.
• At least 8 telephone messages from patients with questions about medications, test results, etc.

These piles represent about 2 hours worth of work, only 30 minutes of which will be reimbursable time (at my old job)--and a major reason why I gave up primary care. Does the Medical Home model address the sinking feeling we feel when faced with the Stack of Damnation? I don't think so.

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.

Pondering Change: Healthcare Shortages in My Town

So far, 2008 has been a roller-coaster ride for the medical community in my neck of the woods. Some of the major events:

1. Three primary-care internists closed their practices at the beginning of the year. Their mostly geriatric patients are still in the process of finding new doctors.
2. A local prenatal care provider also closed her office. She practiced with two midwives, and between the three of them, delivered 25-30 babies every month. The majority of her clients have transferred their care to my clinic, where we have five prenatal care providers but are only used to 12-15 births per month. Now we are facing 35-40 babies per month through the summer months.
3. A family doctor who specialized in pain management also closed his practice. His pain patients, many of whom receive primary care at other offices but rarely saw their PCPs, are now re-establishing pain management contracts with these PCPs. Because the pain specialist practiced--shall we say--beyond the comfort level of the rest of the medical community here, the influx of his former patients has been causing a lot of distress among the rest of us.
4. Two hospitalists have resigned from my group, making it impossible for us to provide 24/7 coverage for our community hospital. Solutions are being proposed, but none of them look promising

Remember when you were a medical student and you thought your job was going to be showing up at the clinic or hospital and seeing patients? You thought the only sacrifices you were going to make were long hours, sleepless nights, and exposure to bodily fluids. Right? Wrong! The biggest sacrifice I've made recently is the investment in time/anxiety/energy/earning potential towards solving the shortages above, especially #2 and #4. I've spent more time attending meetings, rewriting contracts, generating call schedules, and preparing payroll than I have staying current with CME this year. Didn't get paid a dime for all that work, and I'm certainly no smarter.

I'll take bodily fluids any day. More anon.