Settling Disparities in Care and Getting Back to Treating the Whole Patient

What is happening to the blissful joy of country living? While it remains for those who can afford it, for others it seems to be slipping away. As I reported last week, finding a family doctor or adequate health care services is at a crisis point in rural America. As I noted, according to the Centers for Disease Control and Prevention, research shows that people who live in rural areas are more likely than urban residents, due to a lack of proper care, to die prematurely from all five of the leading causes of death — heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke. They have less access to supermarkets and healthy foods.

A recent report by the nonprofit organization ChangeLab Solutions reminds us that we can also add access to clean water and reliable wastewater systems to the list of those things affecting health outcomes in rural communities. Needing to travel 40 miles to get water for drinking, cooking and bathing and experiencing constant problems with sewage backups are among the challenges many rural communities face due to rising water costs, aging infrastructure and depleted water supplies, notes the ChangeLab Solutions report.

As a result, it should not be surprising that a recently published study from the University of Houston reveals that those living in the country say they don’t consider themselves more satisfied with their lives than people who lived in urban areas. In fact, “rural U.S. residents didn’t feel like their lives were more meaningful, and they also tended to be more anxious (and) depressed,” says the report, which is based on the analysis of data from two studies of Americans, the Midlife in the United States and the Health and Retirement Study.

Among the reasons suggested for this widespread dissatisfaction is the current shortage of mental health professionals, as well as a surge in rural hospital closures since 2010. Nearly 85% of all rural counties have a mental health professional shortage, says the report.

“Given the far-reaching consequences of rural health disparities for individuals, families and communities, there is a pressing need to identify the psychological, social and structural mechanisms responsible for disparities and the ways in which to intervene upon those mechanisms to improve the health of rural Americans,” says Olivia Atherton, an assistant professor of psychology at the University of Houston.

Can a turn back toward family medicine improve America’s mental health? According to a recent Washington Post report, a growing number of health care providers are convinced that, by integrating behavioral health and primary care, they can improve the continuity of treatment. “Primary care providers are at the forefront of the nation’s deepening behavioral health crisis,” writes the Post’s Akilah Johnson. “When patients walk into a doctor’s office, they bring all their needs with them. Asthma. Anxiety. Diabetes. Depression. Sniffles. Stress.”

“We artificially separate ‘this is a mental health issue’ and ‘this is a physical health issue,'” Lisa Barkley, a doctor and director of the family medicine residency program at Charles R. Drew University of Medicine and Science, explains. “But really, people are just coming in for their issues.”

“Although behavioral and physical health are deeply intertwined, the two forms of care are often siloed in a poorly coordinated system,” notes the Post report. “Patients often fall through the cracks of the disjointed system when they are referred to an outside specialist.” The report notes that federal government has awarded 24 medical schools and hospitals “a total of $60 million to train the next generation of primary care physicians — family medicine doctors, pediatricians, internists — to address behavioral health needs.”

The barriers to receiving such care can range from a shortage of trained providers, high out-of-pocket costs, and gaps in insurance coverage. Then, there is the stigma and shame often associated with receiving mental health treatment.

“Primary care physicians — or providers — are the front line. They know the patients. They know the families. They know when someone is struggling,” says Sarah Abdelsayed, a family medicine and addiction medicine physician at the University of Buffalo. “Some people might not be comfortable going to a therapist’s office. They might not be comfortable hearing the word (therapy).”

“We’ve grown comfortable with colleagues having diabetes, having serious things like cancer, but if they say they have a behavioral or substance use issue,” that same grace often is not extended, says Millard Collins, a family medicine physician and professor and chairman of the family and community medicine department at Meharry Medical College in Nashville. “For me as a family physician, at least 65% of what we deal with is influenced by behavioral health and mental health,” he says.

In reading all this, I could not help but think back to what started this exploration — the allegory of the good old country doctor and their accrued wisdom and dedication. Of how in the rural areas they serve, even today, what they do for the health of communities they serve transcends the simple practice of medicine.

While not a country doctor, renowned British neurologist and bestselling author Oliver Sacks once expressed this sentiment well: “In examining disease, we gain wisdom about anatomy and physiology and biology,” he said. “In examining the person with disease, we gain wisdom about life.”

Dr. Hans Duvefelt is a family medicine doctor in the small town of Van Buren, Maine. Writing in his blog A Country Doctor Writes, he described the subject of being a doctor this way:

“A good doctor gives medicine in response to the condition of the situation … This is not a matter of adhering to one absolute method. It is rather like a good general who fights his battles well by observing his enemies closely and responding to their changes. His methods are not determined beforehand. He observes the moment and is in accord with what is right.”

It is reassuring to know such doctors are still out there. I just wish there were a heck of a lot more of them.