Rural Health Care - who's out there?

20% of Americans or approximately 60 million people live in rural America. Those who live in rural communities are older, poorer and have more chronic diseases than the typical city dweller. The problem: few doctors choose to practice in rural America. And the doctors who are out there are getting older themselves and are close to retirement.

Medical schools, with few exceptions, are located in urban areas. What, you may ask, about medical students who we recruit from rural areas? Are they more likely to go back?

Take a typical 18-year old female raised on a farm in Nebraska. She goes to college in a city, stays for medical school in a city and then marries an aerospace engineer. Is she likely to go back to her home town? Hmm... probably not. On a positive note, studies do report that those from rural areas are more likely to return there... but not enough of them do.

Who are the doctors out in rural areas now? They are mostly family doctors. Family physicians are the only specialty that's evenly distributed across all settings - inner city, large rural and frontier, isolated rural. Other specialties (as seen in the graph below) cluster themselves in cities, where they can actually sustain a practice. BUT, we've had fewer people entering family medicine over the 10 years (exception of this year) and, as such, the rural doctor pipeline is drying up.

Figure: Physicians per 100,000 people

To ensure the health of rural Americans, we need to have more doctors practicing in rural areas. From studies, we know the type of doctors who are likely to end up in rural areas:

• doctors in family medicine (not pediatricians or general internal medicine doctors... and definitely not sub-specialists)
  
• doctors with rural origins
• doctors who are married when they graduate medical school
• male doctors (not being sexist - this is a statistically proven fact)
• doctors who have rural experiences during medical school and/or residency
  

So what do we need to do? We need to support more residency and medical school experiences in rural communities. Possibilities include rural elective opportunities, expanding rural residency training programs or rural training tracks.

We also need to talk about rural medicine as an exciting opportunity! In rural settings, family doctors get to do everything - from deliveries to surgeries to colonoscopies... a family doctor gets to call all the shots (unless the patient's condition is really serious). A family doctor gets to practice his or her full scope of training.

Doctors, especially family physicians, are needed now in rural areas! Otherwise, in a generation's time, we may not have rural communities and rural America!

Overmedicated and confused

"I take three blues at half past eight
to slow my exhalation rate.
On alternate nights at nine p.m.
I swallow pinkies. Four of them.
The reds, which make my eyebrows strong,
I eat like popcorn all day long.
The speckled browns are what I keep
beside my bed to make me sleep.
This long flat one is what I take
if I should die before I wake."
-Dr. Seuss

It may be in a children's picture book but this often reflects the truth. When I was on my geriatrics rotation, it was quite common to see patients on 15-20 different types of medications. In fact, it was rare to see patients who weren't on any.

The problem lies in the fact that often patients forget or refuse to take their medications. When a patient has 15 similar looking bottles, with similar looking pills and miniscular writing differentiating between the pills, this isn't surprising. Heck, I know that when I have to take one pill once a day for 2 weeks, I'll forget on at least 1 or 2 of those days. Not to mention when someone has some level of dementia and is somewhat sight impaired.

This doesn't even take into account that the directions that we write on the bottles (when the patient actually figures out how to read them) are just as confusing as not reading them. Take for example: "take three pills three times a day for 7 days." Does that mean I take 3 pills in the morning, 3 at noon and 3 before bed? Or 1 pill in the morning, 1 pill at noon and 1 pill at bedtime? Or should I space them out to exactly 8 hours apart?

With all this confusion, we've started developing pill organizers and blister packs. Either the patient, a loved one or the pharmacy will organize meds into AM, noon, PM and night time meds. However, studies have shown no difference in compliance levels from using pill organizers.

Ultimately, I believe that thinking of new ways to organize meds or remind patients is not the solution. The ultimate solution is that we need to re-evaluate each medication that each patient takes and try to focus on compliance with the most important of the meds. Does a 95 year old female need to be on a statin? Should a 30 year old male be taking calcium supplements? Maybe or maybe not. But as primary care doctors, it is our imperative to dive in deep and look at whether each and every medication is necessary - to stop specialists from piling on the meds for their unique specialty and to take a step back and look at the bigger picture.

Last week in my dermatology rotation, an attending physician was explaining to a patient's mother the treatment regimen for atopic dermatitis that he wanted to put her son on over an interpreter phone. The patient was to use triamcinolone when there was rash except on the face, tacrolimus on weekends only when there was no rash and hydrocortisone on the face with or without the rash. The poor resident typing the prescription had to ask the attending twice to clarify the correct directions. Now, what are the chances that the mother (a) understood what the doctor was telling her in a different language and/or (b) would be able to find someone to read the directions in English to her?

As physicians we must take a patient-centered approach to prescribing medications. What does the patient want? What is the patient willing to do? And before we get frustrated when a patient returns 2 months later "noncompliant" to our treatment regimen, we must also take a step back and reflect if we were the patients, whether we would be able to be "compliant" ourselves. This reflection will help us become more compassionate and more effective physicians.