ANNIVERSARY Countdown (Count-Up?)

Today is Friday, March 7th, 2014. We were married 986 days ago, on June 25th, 2011.

Thursday, May 16, 2013

Adequate, convenient care

It is clear that H and I are morphing into a new species given our backgrounds. Well, maybe it isn't so new come to think of it, as many people before us have left urban lives to choose rural communities. There are push factors to be sure, but each day in this house makes us more aware of the pull factors.

Of course, the picture isn't always rosy. There is poverty to be sure. There can be a sense of isolation that is the other side of the coin from blessed privacy and solitude. And there is the state of medical care, which is not news.

  • Only about ten percent of physicians practice in rural America despite the fact that nearly one-fourth of the population lives in these areas.
  • Rural residents tend to be poorer. On the average, per capita income is $7,417 lower than in urban areas, and rural Americans are more likely to live below the poverty level... Nearly 24% of rural children live in poverty
  • There are 2,157 Health Professional Shortage Areas (HPSA’s) in rural and frontier areas of all states and US territories compared to 910 in urban areas. 
  • Twenty percent of nonmetropolitan counties lack mental health services versus five percent of metropolitan counties. In 1999, 87 percent of the 1,669 Mental Health Professional Shortage Areas in the United States were in non-metropolitan counties and home to over 30 million people
  • Medicare payments to rural hospitals and physicians are dramatically less than those to their urban counterparts for equivalent services. This correlates closely with the fact that more than 470 rural hospitals have closed in the past 25 years. --Statistics from National Rural Health Association

I spoke with an old friend yesterday who once lived in Vermont when he was 20 something and able to build his own house. Now, though he is reluctant to stay in Seattle, and not interested in spending his life in New York where he grew up a few blocks from where I grew up, he says that he wouldn't return to Vermont because he isn't up to the physical requirements and he and his partner have a host of chronic medical problems that would make healthcare an issue.  It certainly isn't the first time I have heard this story.

A year or so ago, I got a call from someone at the state Democratic organization, asking me to write an editorial about the Republican "lies" about the planned universal health care plan in the State. We got to talking and I mentioned a friend who had stayed in his job long after he began to hate it, because he is HIV positive, and he has health insurance which he would be hard pressed to get elsewhere if he left that job. He is effectively imprisoned at work. She was "disappointed" to know that he lives in New York, and we couldn't use him as an example, though there are no doubt many others in Vermont who could tell the same story.

Over the weekend, H and I went walking in the woods behind the house with our friends.  They left immediately to get home and shower. We did the same, stripping off clothes in the laundry room and showering off potential ticks. H found three on the floor under the clothes. I found one hours later embedded in the center of my back. H took it off with a tweezers and alcohol and an antibiotic cream, but three days later, it is a black spot in a place I can't reach. Looking at it last night, a friend advised that I go to the doc. My doc is 4 hours away in Boston. "Well then, the emergency room." That is a minimum 4 hour wait with people who are far sicker. There is the "urgent care facility downtown". Sounded like a great idea. Not sure they would take our health insurance, but....

It took the better part of a half hour to find them in the yellow pages on the web under "Convenient Care."  One might hope for "skilled" care, but in this situation, convenient would do as long as they had a sharp blade, some antibiotic cream and a prescription pad.  I called.

"The doctor is still in Kuwait."   Kuwait?  OK... But there is no other doctor? "He extended his time. He was supposed to be there for 3 months, but he is staying 6 months. He has been there since November. There was a 'nurse prac' until April, but she had to go back to North Carolina. So (let's-call-her) Debbie is here two days a week. If you get here tomorrow at 8:30, she will take the first twelve people who are here. She starts at 9 but I would suggest you get here at 8:30 if you want to be seen.  She is here two days but she works elsewhere the rest of the week." Ahem.... Convenient. No. Skilled? Well that remains to be seen.

A tick bite is annoying, not much more. Lyme disease is much more. But this is a small threat considering the nature of illness in this country. From chronic care for the explosion of "lifestyle" diseases of obesity and our sedentary lives, like diabetes and asthma, to acute injuries of blue collar people working with big machines that can amputate limbs in a heart beat, the system is increasingly overburdened and under-equipped. Back in the mists of the distant past, when I was writing for the New England Business Journal, I wrote a paean to the care of the top-tier hospitals--Fletcher Allen in Burlington and Dartmouth in Lebanon, NH--where most people go. They have built elaborate telemedicine programs to deliver care to rural underserved areas. They have all the radiological bells and whistles of urban hospitals, though care for diseases  like asthma is no longer provided by their circuit-riding docs in places like the third largest city in Vermont. In the article, I discussed the local smaller hospitals as well, but I am wondering about the reality, as the nature of medical care delivery is more than an abstraction, reported in newsprint that will be tossed out with the trash.

Rural medicine is broken, but so is urban care. I spent 14 hours in an emergency room with a burst appendix awaiting surgery while triage put me lower on the need scale than those with gun shot wounds or car crashes - and this in the ultimate teaching hospital in an urban place.

The reports in the media are endless; the debate in political circles is mind-numbing pablum or a reflection of the desire for the media-minute.

And then one day you are trying to get care. H had heart palpitations a year or so ago. I had whooping cough that went undiagnosed as I exposed people around me. And now this tiny little bug has made me look again at the care that is available.

Oh yes, and one more thing...the local hospital has disbanded its rehabilitation program saying there is adequate care in the nursing homes and other facilities which happen to be a 4 hour round trip drive away.

Adequate? For whom?

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