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Tuesday Mar 24, 2015

House Calls: What to Do When Your Patients Are Snowed In

Medical schools and residency programs tend to be in larger cities, in part to provide inpatient training and to ensure there is enough volume to train physicians appropriately. Fortunately, there are programs that focus on rural outpatient education and place students and residents in rural settings for rotations or for continuity throughout their training, but even these learning opportunities are still within proximity of an academic center.

My nurse, Crissy Dean, L.P.N., (right) hikes through the snow with me to reach a homebound patient. Heavy snows in February and March made it impossible for some of my patients to come to me this winter.

Thus, many of us never practice in isolated rural settings during our training. This is my first year out of residency and my first in a truly rural setting -- Appalachia in Clay County, W.Va. I expected patients to have transportation challenges, I anticipated there would be socioeconomic barriers to care, and -- as is the case in many locations -- I was sure I would see fluctuations in the volume of patients coming in for treatment because of adverse weather.

What I didn’t expect was to not see many of my patients for two consecutive months -- regardless of how sick they were -- because they could not leave their homes in the winter.

Some of my elderly patients told me months ago that they need 90-day supplies of their medications during the winter, but they prefer 30-day supplies (which are easier on their budgets) during the rest of the year. That should have clued me in that they were not coming to town, much less to see me, during the winter.

I assumed they didn’t like to come out in the cold, didn’t want to risk falling in an icy parking lot, would rather stay home and were planning ahead. What I didn’t realize until about two weeks ago was that these people were not just being cautious; they knew they were going to be stuck at home from the first snow until spring.

We had significant snow fall from Feb. 15 (President’s Day) until two weeks ago when it started to rain and eventually stayed above freezing for a few days. Within two days of the weather turning warmer, I was the busiest I’ve been since starting my new job. I also recall being rather busy the week before Thanksgiving, in part because these conscientious patients were planning ahead and making their appointments as late in the fall as they felt comfortable doing. Now, here they all were again after the first thaw.

And some were quite sick. I saw patients with heart failure, subacute strokes, heart attacks, diabetic complications, skin infections, depression and pregnancies. They knew they needed to see a doctor; they just hadn’t been able to get out. Quite a few of my patients have to travel an hour or more to get to my office. Some live in the mountains and couldn’t get down the road safely, and others live in areas with flooded roads. Some don’t drive and depend on family who live far away to drive them, so there were multiple layers of bad weather limitations.

I was snowed in at my house only one day. Sometimes I was late, but I managed to get to work. Some days I didn’t see many patients and wondered if it had been worth driving through such terrible conditions to see so few patients. But each day that the weather was horrible I sent at least one person to the hospital. And there also were those determined patients who put the chains on their Jeeps and made it to their routine visit, so I wanted to be there for them, too.

The most important job I had on those snowy days was taking care of patients over the phone. Wives and daughters calling with concerning reports about loved ones who I would attempt to triage and decide who could wait and who could not. And those who could not I often decided to go to myself. My volume in the office was low, so I would put on my boots and head out to some hollow hoping to find the right house. I don’t have good cell phone service outside of town, so I depend on old-school pen and paper directions.

Reaching people's homes often involved a fair amount of hiking because if they couldn’t get out, I couldn’t drive all the way to them either. But at least I’m healthy enough to walk, and my nurse is in good shape and was willing to go along to get bloodwork, give intramuscular medications, etc. Home health is a huge help in these rural areas, but home health workers are often travelling from neighboring cities and cancel if the roads are bad, so some of these patients had no health care for weeks.

These home visits were the most rewarding work I have done thus far in my short career. By going out, I was able to keep most people home -- which is where they all want to be -- when some of them were close to needing to be hospitalized. The patients who didn’t call for help and waited until the weather broke didn’t fare as well, and one is still in the hospital.

Next time, I’ll be much more prepared when winter hits. I may even develop a list of high-risk patients to call and check on, offer home visits to, or whatever is needed. I have never viewed my job as a physician as one limited to a brick-and-mortar structure with exam rooms. It is more than that. But patients aren’t used to doctors doing home visits, and most would never think to even ask.

My goal during the next year is to change that perception within my patient population. I want to be their doctor, not just "the doctor in town." My goals are their goals: to have better quality of life and not go to the hospital because of a lack of access to care for any reason.

Kimberly Becher, M.D. graduated from Marshall University's family medicine residency in 2014 and practices at a rural federally qualified health center in Clay County, W.V.

Posted at 05:05PM Mar 24, 2015 by Kimberly Becher, M.D.

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