Stateless Patients

A 30 y/o woman presented to a rural clinic for prenatal follow up: G2P1 at 25 weeks. As I used the ultrasound to check dates, look for anomalies, and measure amnionic fluid, I thought of the patient’s lack of sufficient identification in this country to allow her access to complex OB care. Instead, a volunteer internist was doing her ultrasound. The baby appeared healthy, but I later noted that she had not gained weight for several visits and that she was on prednisone. She had started having joint pains when she first got pregnant, was diagnosed with rheumatoid arthritis, started on steroids, and the labs that she could afford were sent off.

Through translators, the patient reported oral ulcers that were now healed, but no rash. Exam confirmed persistent pain and limited range of motion in the elbows, knees, wrists, MCP and PIP joints. Anemia down to a hemoglobin of 5 had improved to 8.5 with iron and steroids, but the WBC was still low at 2.7. She had negative rheumatoid factor, positive ANA and dsDNA, and negative anti-Smith. The creatinine was normal and urine protein was 3+. She met criteria for lupus.

I explained to the patient how a lupus diagnosis put her and her baby at risk, and the medications had risks as well. I increased the prednisone and asked her to come back in a week, hoping I could get some advice via email as to what to do. Thankfully, rheumatology friends overseas emailed back. We then developed a plan including medications that we could obtain and that were considered relatively safe during pregnancy, hoping to reduce the steroids at some point.

Three weeks after I first saw her, the patient had gained some weight and her joints were nearly normal, though she still had proteinuria. I outlined an ongoing plan for the staff as I left and prayed for her and the baby.

One wonders when helping people who are outside the “system” and its resources for whatever reason, at home or abroad: am I doing the right thing? Am I practicing beyond my scope if no one else will see them? How can I get better at doing this when medical progress seems to require more and more sub-specialization? And how can I protect these people’s privacy and security and still advocate for improved access to care?

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How to Get Doctors to Small Towns?

The State of Missouri, using what has remained in State governance all of these years, the licensing of doctors, to make a very unusual ruling: allowing doctors without any residency training whatsoever to practice medicine (see article). This with the goal of providing medical care in rural areas.

This decision is short sighted and fraught with difficulties. It will serve to degrade quality and standards in the health care field. And yet it does illustrate the difficulty that the rural areas have in obtaining adequate health professionals in this country. And indirectly the failure of the medical education system to ensure the supply of doctors to rural America. This despite millions of dollars of loan repayments, various pilot projects, general guilt-tripping of students to goad them into primary care specialties, etc. Some fundamental changes must occur to reverse this trend and it is the responsibility of those in medical education and their f

und sources to ensure that this happens.

“Begin with the end in mind,” as Stephen Covey would say. What do we need to see? Doctors in rural areas need to be different than primary care in the city, where a multitude of specialists line up to compete for every possible disorder, especially every possible procedure. In fact, different rural areas need different things from their doctors: some may have a well-established OB practice and need primary care doc who can work in the ER. Some have ER docs and need some people who can do OB and ICU. Many need docs who can do psychiatry, since there is very little mental health support in much of rural America.

The current training system does not produce what the rural communities need. Residency has become more and more focused on producing sub-specialists. Primary care residencies such as Family Practice and Internal Medicine have become so heavy with top-down direction, that there is very little room for the innovation necessary to address the needs we are talking about. Endless streams of directions come from the central planners such as the Institute of Medicine, and the ACGME, ensuring that any possible change is nearly impossible.

In desperation, the State of Missouri has decided: this field in which training is done is too restrictive, and we are punching a hole in a fence. Maybe at least we will get some doctors out to our rural patients by doing this. I disagree with the specific decision, but I can certainly see the reasons for it. And if the organizations such as the IOM, ACGME, Medicare (holding the purse strings and thus basically guiding a lot of this), the American Board of Medical Examiners, and the specialty organizations tie the hands of the trainees and the trainers, then the states and the doctors and whoever can, will have to also help break down some of these fences, though hopefully in more strategic locations.

Some examples of things to try:

1. Pick out more procedures for the primary care to do that strategically expands the capability of the medical care provided in the rural setting: colonoscopy and echocardiogram interpretation are low hanging fruit, that could be incorporated into primary care training.

2. Form more residencies in rural medicine. Perhaps tailored to the specific community in need, and at the community level. In the age of the internet, a resident could train in the community he or she is to work in, with needed supplements of education and experience in larger centers and through teleconference.

3. Fusion of specialities: why make a “family practice” doctor and an “OB” doctor? Why not credential someone in those areas or subsections of areas that they need to do their job in their town? Board certification is a way of ensuring quality, but when it becomes impractical and stands in the way of patient care, it may be time to replace the process or the particular board, or both.