When I was in rural solo practice, I was caring for a lady with a stroke
that made it difficult for her to communicate. She had no family, was not
good at eating, and her one pleasure in life was smoking. She continued to
have blood pressure control problems, a likely reason for her overall poor
health. Loneliness was the other.

The nursing home was not a great place, but it was adequate. The funding
from the state was so bad that the owner provided many of the personal
services or used her children to do so, even so she was barely able to make
ends meet. At that point it cost $17,000 per bed to meet all of the
regulations for construction of a nursing home, back in the 1980s, not
including the salaries and ongoing expenses. Medicaid paid only about $900
a month.

Each time my patient had a new neurological event, I could order speech
therapy for her. This meant that 3 or more times a week she could have an
individual come in to work directly with her one on one. After the second
event, I began to notice a pattern. When she had speech therapy, she was
around people more even when not in therapy. She got to smoke more because
she had someone more attentive. She also gained weight. Eventually the
approvals would run out and she could no longer get the speech therapy. A
third "event" may or may not have been as severe and she may or may not
have fully needed speech therapy, but I ordered it and she got it. After
this there was a final event and she was gone. The medications of the time
may not have helped, but they did not hurt.

The lessons were there to learn although the processing took some time
later: Involvement, medications, therapy, communication ability, mobility,
some ability to control life circumstances however small

Similar situation with a cardiologist (source: pathologist at the center) .
She was in a famous heart center, got a grant, and was studying amyloid
heart disease. After diagnosis, most live only a few months. Using old
drugs (thalidomide) with serious but tolerable side effects, her patients
made it to 17 months. She left the center and the work was farmed out to 5
cardiologists and their individual staffs. Under their care, there was no
benefit for the therapy, and it was terminated. In review, her staff appear
to have made the difference. Recognizing the serious side effects of the
medicine (burning extremities) and that aspirin and other efforts could
help, they worked diligently with patients to make sure that they
understood what to expect and how to cope.

Another setting is cancer in lower income populations, with much the same
problem and the same poor result. Much of this comes from pediatric cancer
research where over 80% of children receive close scrutiny in protocols,
not so in adult cancer treatment where few are studied. The difficulties in
pediatric cancer treatment do tend to involve treatment irregularities.
Much can be traced to failure of basic problem solving skills on the part
of physician, staff, patient, and family.

In the collaborative care model, it is just Gordon Moore MD and his
experienced RN, 2 computers, software, 24-7 cell phone access, and a few
hundred square feet of office. He was able to take all types of patients to
above average outcomes, but not the 80 - 90% levels in the best clinics.
Eventually they stratified patients into abilities. Those with good problem
solving were given less attention and different focus. Those with less
problem solving skills got special attention, the kind that any well
structured family can provide, but many cannot access. His outcome measures
are now with the best. He takes all types of patients and bills at the
usual rates, but has one difficulty. When he takes too many government
patients, the model cannot be sustained. An even mix - yes, too many - no
Perhaps the most fun model for medicine, and clearly one of the best and
most efficient. Only for physicians with understanding, good communication
skills, and good boundaries. If you like to talk with patients, you will go
broke in this model.

The total care environment in any location is rarely appreciated, the lack
of understanding of this impact invalidates many studies. Biomedical
studies rarely have psychosocial controls. People clearly make as much or
more difference in some instances, but how many is not known. However the
task of medicine is to select optimal responses with minimal risks. To do
so requires a much broader range of study, more dimensions, and more
understanding researchers and governments.

Robert C. Bowman, M.D.
[log in to unmask]
www.ruralmedicaleducation.org

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