March 1991
Michigan Land Trustees Newsletter
Health Care in a Rural Setting
by Lou Cervone, RN, MSN
It started about two years ago in my final year of graduate school.
“We have an opening in a small community in southwest Michigan
for clinical experience,” they solicited. “Not for
me,” I thought. I had already conceived my idea of a useful and
practical clinical setting, where it would be, and the type of
population it would serve. Perhaps a clinic on the north side of town
with innovative physicians and a large underprivileged population. Or
perhaps an office outside of the well—established satellite
hospital where I had worked for most of my adult life. Or maybe the
employee health department or health maintenance program at the larger
institution where I had been employed for nearly 11 years-—such
an exceptional opportunity to put to use those hundreds of hours of
health screenings to counsel persons accordingly. At any rate, I sought
something financially secure and well renowned.
After many attempts to secure such sites and none of them resulting in
the anticipated and expected outcome I had hoped, I remembered the
invitation placed before me so many months before. With time running
out, I begrudgingly set out for the 40 mile drive from my home in the
city to the small community in southwest Michigan. I interviewed with
the physician and established a practicum site for my final year in
Michigan State’s Family Clinical Nurse Specialist program. It was
only one year. I could handle the drive one or two days a week for
eight months. Then I could secure that wonderful position I had so
often dreamed of in my home town.
So it began, working with a quiet and unassuming physician who was
unlike any other I’d ever seen before. This guy actually took the
time to listen to his patients. Turnover was not his idea of success.
Meeting his patients needs seemed to be more the focus for him. Of
course, this often meant that by 4:15 in the afternoon appointments
were backed up an hour or so, but every patient was seen and given the
time and respect that they deserved. Why schedule so heavily then, I
thought. It seems that most of the persons’ calling for
appointments have pressing concerns and need to be seen that day. So
all patients were seen-some in the office, some in their homes-until
the phones were quiet.
The physician began to teach me about the philosophy of family practice
medicine, which complimented the nursing model of practice I had
operated from for many years. Patients and families are the ultimate
decision-makers; we as health care providers are only the facilitators
in such a process. I had always practiced from a model which supported
the premise that health was the state of harmony between the being and
his or her environment. Nursing simply facilitated this balance.
Advanced nursing practice would further expand this process and
integrate components of medicine as needed. The philosophy of medicine,
which he proposed, was one void of paternalism and judgment. It was one
I felt I could work with. His approach was one that I believed was
beneficial to facilitating harmony between the person and their
environment.
And so it went, week after week, month after month, giving me the same
time he-gave his patients. I began to understand that primary health
care in the rural community took commitment, endurance, and time. It
was not a high tech, revenue generating system, but rather a simple
means of offering necessary health care to a population often neglected
and forgotten: the quiet, small-town folk, the 60-plus hour per week
minimum wage earner, the farmer and his family unable to get health
needs attended to during the busy times of the year. Most of these
folks have little or no insurance. If they have coverage at all it most
often did not cover office calls-even when an illness was present. I
discovered that health care was a great expense for most folks in the
small community in southwest Michigan.
I began to learn from my patients what type of treatment they desired
and needed. Although an antibiotic was often in order for the relief of
pharyngitis, bronchitis, or otitis media (ear infection) in a child,
often times just as crucial was attending to the exhaustion of the
mother or the despair of a recent widower or widow. Many times, I am
now convinced, physical aliments are manifestations of the many
stressors affecting the lives of hard-working country folk.
Now, two years later, I continue to be taught by these gracious people;
not only about them and their way of life, but also about myself and my
own responses. I have since left my position in the BIG health care
institute in the city and the life in the fast lane with the glory,
status, and the unattainable power that that particular way of life
promised me for so long. I work with the people that come to see me.
Some for an ear ache or rash. Some to talk about the adjustment
necessary after a particular trauma in their lives.
In each case, I have the freedom and support to practice nursing and
medicine in collaboration with my mentor physician in a way that I hope
brings self-respect and insight to the patient with whom I work.
I won’t comment on the statistics that show the bleak economic
outlook for rural communities, nor on the available information that
proves the health care disadvantages facing the rural population. My
only hope is that the high technology and the super-efficiency mode
that seem to be sweeping health care systems across the country will
not eliminate the small town family practice. For years in this small
practice of ours the patients have asked: “Will you be staying?
Most of the doctors leave so soon.” This I’m sure is true
because of the lack of economic incentives and the demands of solo
practice competing with the lure of more efficiency and more money. I
have yet to see an increased efficiency system that has improved the
quality of patient care. Regardless, yes, we are here to stay and are
committed to serving the population of this community.
Our efficiency ratings won’t win awards, but in small- and
sometimes insignificant ways-we meet the needs of much of our
population. I am grateful to have this opportunity to work in a
situation that reinforces my basic beliefs about people and life. I
hope that I continue to learn from the rural community and that
circumstances continue to allow us to provide health care for the
family that promotes harmony within and symphonic interaction between
each individual and his or her environment.
(Editor’s note: Ms. Cervone practices at Decatur Family Practice in Decatur, Michigan.)
Book Review by Michael Phillips
Medical Nemesis: the Expropriation of Health by Ivan Illich. Copyright 1976 by Pantheon Books.
As a nursing student, my entire clinical experience was rife with
assignments caring for iatrogenic patients. There was the World War II
vet hospitalized for a series of pulmonary studies even though his
physician concluded that only palliative measures were applicable to
his advanced chronic obstructive pulmonary disease and congestive heart
failure. And 78 year old “Loonie,” dying from end-stage
renal disease and hospitalized in part for painful radiographic studies
that he felt he didn’t need. The studies only confirmed that the
man was in systems failure and within a few days he was dead. Then
there was the three year old boy, intubated and transferred to the
hospital’s pediatric intensive care unit with a mis-diagnosis of
“possible epiglottitis.” The child’s attending
pediatrician admitted that he did not know how the previous diagnosis
could have been derived. Then there was John. Around 1960, John was
forced into early retirement from the power company because of
debilitating rheumatoid arthritis and gout-—a condition he
struggled with for almost 30 more years. Finally, at age 81, he took a
knife and attempted to sever his left arm in an effort to end both his
life and the pain in his festering limb. He was discovered and admitted
to the rural hospital near his home. From there, he was helicoptered to
Kalamazoo. When I met him, he nodded to the stump that used to be his
arm and said he was glad to be relieved from the pain. John had no wife
and no children, however, he showed me a letter from a sister in
Indiana who only hoped that he would find Jesus before he died. He was
very hard of hearing, but he made it clear that he did not want to
spend his last days in the hospital. The house officer assigned to
John’s case requested and obtained a consultative psychiatric
examination-after all, the patient tried to kill himself-to determine
whether the patient was capable of making decisions regarding his care.
I was John’s student nurse for two days. I elevated his stump
while it was debrided in surgery and I provided his bedside care when
he was returned to his room. He did not want to eat, and he was
humiliated when I had to change his bedding and wash him up because he
had lost control of his bowels. The house officer wanted an IV started,
but John’s hand and feet were twisted and swollen, and his arm,
legs and torso were bloated and seeping fluids. On the morning of the
day before he died-after the surgeon and house officer blew through his
room-John looked at me, gently shook his head, and muttered,
“Jesus Christ. The fucking doctors.”
The premise of Illich’s analysis is that physicians continue to
ply an endless supply of medical interventions and therapies that,
after reaching a certain threshold, are a menace to individuals,
families, and society. John did not need a helicopter, nor debridement,
nor IV’s, nor a psychiatric exam during his last days. He needed
mercy, and that was in short supply when his care was secured from him
by the hospital.
Once the individual has lost his autonomy, modern medicine becomes a
nemesis. The physician now rivals the individual’s control over
the latter’s living and dying.
Illich further contends that as self—care is given up, health
care becomes “a sick—making enterprise;” health as a
commodity. People are essentially contracting out much of what it is to
be human. Living is greater than the sum of its parts; and health is a
gestalt of pleasure and pain, coping and suffering, and savoring and
risking one’s very existence.
Social and cultural influences have generally enabled individuals to
manage their own selves. Illich elaborates: “Each person’s
health is a responsible performance in a social script. How he relates
and how he acts towards others whom he perceives as suffering, as
weakened, or as anguished determine each person’s sense of his
own body, and with it his health.” However, as a society consumed
with standards and measures and materials gives way to
“heteronomous management,” good health and self-care are
lost to the forces of specialized modern medicine. Ultimately, the
health of the population becomes over-managed and over-medicated.
Modern medicine must be assessed within the context of modern society.
Medicine, as other institutions, has embraced and clung to the
prevailing measurable, mechanical and material view of the universe. In
total, Illich states that our society functions in an “industrial
mode.” In the industrial mode, historical myths, beliefs and
values that limit or impinge upon the destructive elements within
society are curiously absent. In their place is the prevailing myth
that society can experience unchecked materail growth. We have become
obsessed with quantity and material progress: more wealth, more goods
and services, more markets, and more weapons to uphold our myth. Illich
illustrates how this function affects the perception of health in
society by tracing the historical evolution of society’s attitude
towards death.
Prior to industrialization, death was viewed as a part of the cycle of
life-a continuum of birth, life, death, and renewal. Less than three
hundred years ago death as a part of the cycle of life began to give
way to death as introspection; what Illich calls “macabre
self-consciousness.” At that time the philosophical tenets that
led to industrialization took root. Standards and measures gave society
a linear view of existence, and the death of the individual became akin
to death as the technical and mechanical end: “hospital
death.” The hospital death bed is the final charge of a long list
of purchases for individuals conditioned to get things rather than do
them. Death is a commodity-—measured and quantified. (I recall
two house officers reviewing John’s case, they never stepped into
his room, they only wanted his lab printouts.)
In the industrial mode, the role of the individual as consumer is
reinforced by every structure within the social system. Therefore, our
autonomy is not taken away, it is given away. Modern medicine is only
an institution-one of many-that fosters the prevailing demand for
specialists, managers and agencies. The individual does not determine
his health needs; professionals determine his health needs. When
medicine does wrestle control away from the individuals and families,
it does so with the blessing of most of its clients: “More health
damage is caused by people’s belief that they cannot cope with
their illness unless they call on a doctor than doctors could ever
cause by foisting ministrations on people.”
Our cultural health is bound by society’s style with regards to
living and dying. Mechanical systems and medical codes are bestowed
upon society by industrial myth. Therefore, the real nemesis is
industrialization. Iatrogenesis is only one aspect of the disabling
domination of industry over society. Ironically, medicine has exceeded
its capability as an able servant of society and is now too often a
threat.
The National Arbor Day Foundation’s1991 spring catalog arrived in
the mail yesterday. It offers a wide variety of fruit and nut trees,
shade and ornamental trees, hedges, ground cover, shrubs, etc., to
members at very reasonable prices. Right now it’s hard to think
spring with almost a foot of snow on the ground, and more expected.
Fortunately, filling out the order form gave me a needed lift. The
address is: 100 Arbor Avenue, Nebraska City, NE 68410.
The next meeting of the MLT is set for Sunday, March 17th (1991), at
the home, of Mike and Lisa Phillips. The meeting will begin at 3 pm,
with a potluck following. Business includes further considerations for
coordinating efforts with Habitat for -Humanity to integrate aspects of
permaculture into housing projects in the Kalamazoo area. All are
welcome. Phone (616) 624-6968 for information or directions.
As always, your thoughts, comments, criticisms,’ and concerns are
welcome and encouraged. Also, please feel free to submit poems,
essays, reviews, observations, and personal updates for upcoming
newsletters.
——Michael Phillips, editor