The Country Doctor Revisited

A Twenty-First Century Reader

Therese Zink

• Publisher: The Kent State University Press
• Year: 2014
• ISBN:
  9781631010842
• Topic: Medizin
• Subtopic: Familien- & Hausarztpraxis

An anthology that addresses the changing nature of rural medicine in the United States

"These authors courageously document the emotional and literally physical vulnerabilities they experience while delivering care in rural communities. …This book exquisitely illustrates the complexity of 'dual relationships' and boundary issues in rural practice."— Family Medicine

Over the past thirty years, rural health care in the United States has changed dramatically. The stereotypical white-haired doctor with his black bag of instruments and his predominantly white, small-town clientele has imploded: the global age has reached rural America. Independently owned clinics have given way to a massive system of hospitals; new technology now brings specialists right to the patient's bedside; and an increasingly diverse clientele has sparked the need for doctors and nurses with an equally diverse assortment of skills.

The Country Doctor Revisited is a fascinating collection of essays, poems, and short stories written by rural health care professionals on the experiences of doctors and nurses practicing medicine in rural environments, such as farms, reservations, and migrant camps. The pieces explore the benefits and burdens of new technology, the dilemmas in making ethically sound decisions, and the trials of caring for patients in a broken system. Alternately compelling, thought provoking, and moving, they speak of the diversity of rural health care providers, the range of patients served in rural communities, the variety of settings that comprise the rural United States, and the resources and challenges health care providers and patients face today.

Who We Are

Who We Are—Synopsis

GODFREY ONIME

The yellow-, red-, and green-striped gift bag containing the present lay on my office desk among the stacks of charts and assorted papers. Curious as to the sender, I looked at the card that came with it. “Oh no, not again.” It was from my patient Ms. Emalee, next on my schedule. Among her myriad medical problems—diabetes, hypertension, obstructive sleep apnea—was intractable knees and back pain for which she used narcotics chronically. On her current visit I’d planed to perform a random drug test, to ensure she was actually taking the medications and that she did not use illicit drugs. But now the gift, although this was far from her first—she often brought fruits, baked goods and other presents for everyone in my clinic. After she learned I got married and hinted she was looking for “something special” for me, I’d entreated her not to worry. She had looked at me as if I were from a different planet and then declared I was “like family now,” adding “you better believe you getting something from me, don’t matter you snucked off ‘n’ got married without telling no one.” Now I wondered: What if her test results indicated a problem? Would her act of kindness make it difficult for me to do my job, such as refusing to prescribe further narcotics or even discharging her from my practice?

The question of boundaries with their patients is one issue that small-town doctors face. Often for lack of convenient alternatives, country doctors not only have to take their friends on as patients, but their patients quickly establish themselves as friends. Given that the conventional medical ethics frowns on doctors treating friends or relatives, Dr. Kullnat grapples with this dilemma as it applies to rural medicine. In “Boundaries” she asks if a doctor could both be friends with their patients and be objective in caring for them. Dr. Farah’s “LIFEprayerDEATH,” manages to blur the boundary even further. It seems to challenge the reader to consider that in small towns, where privacy is shunned and familiarity with neighbors prized, maybe physicians’ closeness with their patients is exactly what they need to render care with true understanding and deep compassion. This theme is further explored in Arne Vainio’s “Mashkikiwinini: Thanking Sylvester for His Unconditional Smile” when the author cares for a patient with end-stage cancer and wrestles with the difficulty of accessing up-to-date diagnostics and treatments in a rural setting. Another essay, David McCray’s “Three Days Changed My Grandfather’s Life,” seems to erase the boundary, when the author is confronted with a grandfather he adores and respects.

When I entered Ms. Emalee’s room, she looked up at me expectantly and asked if I liked her present. I told her I had not opened it. Sensing her disappointment, I quickly added that I was waiting to get home, before opening it with my wife. The explanation seemed to satisfy her. “Smart man,” she said, “I’m sure she’d love it.” Ms. Emalee’s knees and back still hurt, but her pain medications were helping. No, she did not have significant side effects from the medications, such as constipation or drowsiness. I also asked if she ever sold her pain pills, but that seemed to annoy her. “You keep asking me that foolish question every time I comes here and I keeps telling you no, I does not sells my medicines. Don’t you even trust me?” I apologized, but reminded her it was the law and my job to ask. At the conclusion of the visit, I told her I’d like a sample of her urine for a random drug test. “Whatever you say, doc,” was her sarcastic reply. Then she informed me they were having a birthday party for her mother—who was also my patient (as were her two sons, a daughter, a sister, and brother-in-law). Her mother was turning eighty. Her family would be greatly honored if my wife and I could come. Not sure how to respond, I promised to get back with her.

My early notions of the country doctor come from Norman Rockwell’s 1954 painting “Doctor and Boy Looking at Thermometer” in which a kindly doctor making a house call sits on an unmade bed. The patient, a prepubescent boy, kneeling in bed, rests his head on the doctor’s right shoulder as he peers with the doctor at the reading on the thermometer—an unmistakable indication of the bond between doctor and patient. Most people would agree that the idea that this image represents has been lost to today’s fast-paced and complex world of medicine, where, as one patient complained of his previous doctor, a physician using an electronic medical record system may pay more attention to the computer than to making eye contact with patients. But besides technology, modern medicine is besieged with countless other intricacies that threaten the cosmopolitan as well as the country doctor—not the least of which are the effects of such acronyms as HMO and RVU and phrases like “risk management” and “pay for performance” discussed by Deborah Lee Luskin as she takes the reader through the struggle she and her husband had in their rural clinic. This is painfully obvious in Patricia J. Harman’s “Teen Pregnancy,” in which she, the nurse midwife, must explain to a pregnant sixteen-year-old that she and her family-physician husband no longer do deliveries because of the malpractice cost, which jumped from $70,000 to $130,000 per year. “You can buy a pretty good house in Jefferson County for that amount, a house every year, that’s what it amounts to,” she explains.

Thankfully, many physicians serving rural communities still manage to incorporate—if not hang on to—their Norman Rockwell image of the country doctor. In the process, they offer their patients expedient and excellent care, while learning a thing or two about themselves. Indeed, the reader cannot help being amused and intrigued by the experience of Dr. Gibes when he found himself clutching a steak knife while making a house call to an Amish family.

The landscape of today’s rural medicine has changed in another significant respect: the faces of the doctors themselves. In Rockwell’s “Doctor and Boy Looking at Thermometer,” the physician is a white male. Today, that country doctor could just as easily be a woman—or even an Asian, African, or Hispanic, a far cry from the Rockwell painting. While these immigrants help to allay the manpower crunch in rural areas, the local people have to learn to understand them. But the physicians also face pressure of their own: that of fitting in. My own essay for this collection, “When Hostility Melted for the Funny Accent,” examines my struggle to comprehend the people and the concept of family in my small, southern American town. Dr. Verghese, in his characteristic rich and elaborate style, even goes as far as exploring the challenges of alien doctors and their families independent of caring for patients. He and his Indian colleagues and families essentially formed their own subculture. In my mind, this adds to the richness of the place, just as a city like New York is no doubt enhanced by the endless ethnic and cultural diversity: Jews, Italians, Jamaicans, Indians, Chinese, gays, and lesbians. Diversity, I think, is the most rapid and sure road to development. I can attest that almost every foreign doctor in my local community felt comfortable enough settling in the area because they found someone like them here.

Other works in this section (Ann Floreen Niedringhaus and Richard Berlin) invoke the frustrations and joys of today’s rural medicine. Another particularly stirring poem by Cinnamon Bradley calls for country doctors to be not just witnesses but participants in the living and dying of their patients. It invokes a place where “Everyone knew what Dr. Lee’s clinic was for, but it was still a secret in this small Mississippi town,” and where “people whispered laughter … as was appropriate.” But Dr. Bradley “wanted to scream” for the country doctor to be different.

Was Dr. Kullnat’s “Boundaries” a form of screaming too, a shout to the medical profession that one set of ethics does not suffice for all locales of medical practice, that technological and loan repayment requirements do not apply to all doctors equally? Perhaps these are some of the areas that need further work. I am also amazed at the number of cancellations and no-shows to my clinic, ostensibly for transportation needs. Are there ways of correcting these, or should there be provisions and assistance for the rural doctors to return to the days of Norman Rockwell, when house visits were a welcomed part of the profession?

The day that I received the present from Ms. Emalee, my wife and I unwrapped it once I was home. We erupted into laughter as soon as we saw it: the statuette of a bald African woman standing tall in a regal outfit. “I love it,” my wife declared. “Tell her I just love it and thanks.” She put it among our assorted collections on a shelf in the living room.

Ms. Emalee’s urine drug screen showed she was using her narcotic medications and that she was not using illicit drugs. I called to tell her this, as she liked to be informed of all the results of her tests as soon as they become available. I also thanked her for the present. She reminded me about her mother’s upcoming birthday party and the family’s hope that I could attend. I remembered how we narrowly lost her mother at the hospital only months before, how I allowed Ms. Emalee’s tears to stain my shirt when she feared the lump in her own breast may be cancer, how two years ago I prayed with the family at her brother’s funeral, who was also my patient. Like many families, this one had seen its share of pain, and I felt honored being there for them. Now was their time to celebrate; I decided it was only proper I be a part of it.

That, in my mind, is what makes a complete country doctor—the image, I believe, that all the preceding essays help to illuminate.

LIFEprayerDEATH

KATHLEEN FARAH

“I prayed for you”

she said.

“I prayed every day you would have a healthy baby.”

I did.

She sat across the aisle from me at church you know,

Exchanged greetings of peace and watched my pregnant belly grow.

We prayed.

Tall in my white coat I stood before her in shivering snowflake gown.

My eyes and hands observed the tumor her right arm birthed had grown.

I sighed.

Too few weeks later I kneel beside her in her home hospice bed.

“I pray for you”

I silently said.

Words and tears are blocked by “professional boundaries” in my head.

I silently cried.

“I pray you have a peaceful death.”

She did.

Boundaries

MEGAN WILLS KULLNAT

Some say that a delirious patient is unaware of the situation around him. That may be true. But as I peered into my patient’s face, I saw clarity in his venerable eyes. And terror. Smiling down at him reassuringly, I began to organize admission orders and formulate a plan for his care.

Out of the corner of my eye, I noticed an emergency department nurse crouched by his bedside, gripping his hand. Despite the cacophony of beeping monitors and intrusive voices, my attention was drawn to the compassion in her grasp, the concern in her furrowed brow. Immediately impressed by her bedside manner, I paused with my paperwork to watch her. Moments later, a tear trailed from her lower lash to her trembling lip. I had rarely seen such empathy at the university. My thoughts were interrupted by another staff person bellowing for morphine. The nurse mumbled something in response. When nobody reacted, she repeated more clearly, “He’s allergic to morphine.” Surprised, everyone turned to her. “I know,” she sighed, “because he’s my grandfather.”

In the first few years of medical school, “dual relationships” are briefly addressed in ethics class. When it comes to patient relationships, physicians-in-training are advised to avoid treating family members or close friends. In fact, numerous medical associations advise that “professional objectivity may be compromised.…As a general rule it should be avoided.” This had seemed common sense to me, prior to spending a five-week rotation in a rural community as required by my medical school curriculum. However, upon arriving at this small rural community, I took an immediate interest in dual relationships: they were everywhere I looked. Yet look as I might, I struggled to find how these ethical guidelines were applicable to such a community.

Can dual relationships be avoided in a small town? Should they even be avoided? During twenty-minute personal interviews, I queried nine physicians and nine patients in Tillamook. The former group included general practitioners, obstetrician/ gynecologists, surgeons, and Emergency Department physicians. The patients were a diverse group, including nurses, a lawyer, an insurance agent, a barber, and a banker. I sat with the city commissioner in the courthouse, the CEO/president of the hospital in his office, with a judge in the courtroom. What I found both surprised and intrigued me.

No one was familiar with the term dual relationships, nor with the aforementioned guidelines. Many reacted with shock, and most stated without hesitation, “That’s not possible in a small town.” In fact, only one of the patients denied having a dual relationship with his physician. This individual maintained that he preferred distance from his physician because he was concerned that they would begin discussing medicine outside the office. He did not identify other potential downfalls of a dual relationship. Of note, this patient was relatively new to town and acknowledged that he often felt like “the new guy” with other town residents.

The remaining patients professed a deep and mutually respectful relationship with their physician. In some cases, their physician had cared for their parents, and even grandparents, before them. Rather than feeling uncomfortable disclosing information issues because they knew their doctor outside the office, they were more at ease discussing sensitive issues because of their friendship. One noted, “Guys don’t talk about emotional issues … but our friendship makes it easier. … I don’t look forward to the day [my doctor] retires.” When asked if he withholds any potentially embarrassing information, he stated, “If I am to fully utilize him as a doc, I can’t withhold anything. I’m not the first person in his office. It may be very personal to me, but he’s heard it a hundred times. He doesn’t internalize it, so why should I?”

Similarly, another patient declared, “We put on a different hat when we’re doing business.” Also having benefited from a dual relationship, he finds that he can be more honest and candid with his physician because of their friendship. “I respect him too much to not be truthful.” This patient, like many others, recognized that the advantages and disadvantages of dual relationships are closely linked. A disadvantage is that one loses anonymity and privacy. An advantage is that one is constantly reminded to improve one’s health: “If I haven’t followed up on something and I see my doc at a poker game, he’ll bug me to come in and get checked!” This patient also emphasized that a friendship makes his physician feel more approachable and that, indeed, “The best doctors are warm, humane, and open.”

Other patients echo the importance of a physici...