Volume 1: Connectedness in Rural Medicine - Eyal Kedar, MD

Eyal Kedar, MD

The COVID-19 pandemic has highlighted, among other things, the importance of networks of care. Though countries have differed in the ways in which they have tried to contain and screen for SARS-CoV-2, what is already clear is that connectedness matters. In China, a nationwide and controversial system that initially mixed intensive local social distancing measures with remote tracking of people’s movements and which, more recently, has included near universal COVID-19 screening in the city of Wuhan, has led to a sustained decrease in the number of new COVID-19 cases. In South Korea, the early combination of free and widely available test kits with a network of drive-through testing centers in major cities that can quickly test both sick and healthy patients resulted, in the earlier days of the pandemic, in the world’s most efficient and comprehensive screening program. And yet, as there is nothing like a crisis to reveal the importance of organization and good communication, what is easy to overlook is that in many parts of both the world and the U.S. there is still little or no health care communication at all. These are the areas where there is not only a shortage of physicians, but where there is also a shortage of nurses and clinics and hospitals and sometimes of any form of reliable communication with an academic center. And while it may seem impossible that such places still exist in America, the fact is that they do and that they are almost invariably rural.

How the health care crisis in rural America evolved is not simple, and yet what is more simple are some numbers. For every 10,000 patients in urban areas there are about 31 physicians. In rural areas the number is 13. With medical subspecialists the disparity is even worse. Per capita, rural areas have roughly one ninth the number of specialists as urban areas [1]. This lack of physicians, coupled with a disturbing and ongoing trend of rural hospital closures, has left many rural Americans and in particular those with rare and/or complex disease with diseases that go either undertreated or not treated at all. It is a problem both of supply and connectedness. Simply put, there are not enough doctors in rural America, and those that are here often lack the consistent support of an academic center and, in turn, the networks of care that they need to adequately deliver care.

Here in my area of Northern New York, I consider us lucky. I live in St. Lawrence County, the largest county in the state and also one of its poorest. The distance from my hospital, Canton Potsdam Hospital, to the closest academic medical center is close to three hours. And though we, too, have a shortage of physicians, we are also one of the few areas in the rural U.S. which has a thriving and integrated local health system and in which the majority, if not all, of subspecialty care can still be locally delivered. In my own practice as a rheumatologist, I’ve tried as best I can to help close the care gap for my patients. I’ve done this through a combination of careful screening (only true autoimmune/rheumatologic disease is seen), mid-level support (I supervise both a physician assistant and a nurse practitioner), a fantastic support staff, a supportive hospital administration, and a personal and ongoing attempt to develop into what I would describe as a generalized specialist. This is the term I use for what I hope will describe the next generation of rural subspecialists. Let me tell you what I think it means.

To me, a generalized specialist is just a specialist who does his/her best to keep care local. It’s the rheumatologist who can read a chest CT and interpret pulmonary function tests and, through this, care for his/her rheumatoid arthritis patients who have interstitial lung disease. It’s the gastroenterologist who can identify and treat the extra-intestinal manifestations of inflammatory bowel disease. It’s the pulmonologist who treats scleroderma patients with pulmonary hypertension but who also knows how to do a scleroderma skin exam.

In my own example, my work as a generalized specialist has included a range of options for my patients including full spectrum musculoskeletal ultrasound services, a single physician connective tissue disease-associated interstitial lung disease (CTD-ILD) clinic for those patients (the great majority) who can’t travel regularly to an academic center, a pulmonary hypertension collaborative with a regionally located academic pulmonologist, and a general commitment to providing local longitudinal rheumatology care to all patients with all rheumatologic diseases regardless of duration or complexity.

This sounds ambitious, and it is. But when you have a small group of generalized specialists and you link them together, big problems can be much more easily solved. A generalist rheumatologist working together with generalists in infectious disease and hospitalist medicine can, in the example of my county, form an effective COVID-19 inpatient treatment team. When you add local clinical research infrastructure to the mix, the network widens further and treatment options for patients expand. Expand the network even further to include backup teleconsultation teams in academic centers and you begin to approach a scenario in which nearly all rural healthcare could be delivered locally in the future.

And so, to go full circle, let’s return to the idea of connectedness. This is one of the cornerstones of any good health care delivery system. In the urban U.S., we have many world class healthcare systems that are examples of this. Five physicians following a patient in an academic center can communicate easily over an electronic medical record system. Connected patients can email their primary care provider and, based on a particular symptom or set of symptoms, be quickly routed to the right corner of the healthcare universe. In the rural U.S., we rarely have this luxury. Rural physicians often work within a patchwork of disconnected practices and poor or absent communication with tertiary care centers. With COVID-19, we are now seeing a growing nightmare scenario in which COVID-19 is surging across rural counties in the U.S., many of which have under-resourced health care systems that lack the testing capacity, personal protective equipment, medications, expertise, clinical trials and, above all, the connectedness both with each other and with larger health systems to adequately respond [2].

I am tempted to structure this article around our own local COVID-19 story and, with this, possible solutions for rural America during this pandemic. However, network building and the formation of connections take time, and so I will close with some thoughts about the future. In order to succeed, we will need to think about building new networks of care for the rural U.S. This will include designing new incentives to recruit more primary care physicians and mental health professionals to rural areas, but it will also need to involve new methods for recruiting and training specialists (i.e., for creating generalized specialists) and new methods for connecting patients to physicians and physicians with physicians both locally and regionally. The ways in which to do this are numerous and, ultimately, exceed the scope of this editorial. But, to be sure, both new physicians and new networks need to be made and it will require a combination of research and resources and good examples to do it.

Any pandemic comes with fear, and this is a frightening time both for Americans and the entire world. And yet with fear comes the opportunity for fresh perspective, and today we have the chance not only to look around the world and watch the best examples of care coordination and communication, but also to think about the ways to implement these and other solutions here in the U.S. We should start with COVID-19, but when the vaccines come and the fear begins to lift we shouldn’t forget the lessons that we have learned. To persevere we need connectedness, and to be connected as a nation means to deliver comprehensive healthcare not just to a portion of the population but rather to all Americans regardless of where they might reside.

References

[1] National Rural Health Association. About Rural Healthcare [Internet]. Washington DC. [Cited 6/5/2020]. Available at: https://www.ruralhealthweb.org/about-nrha/about-rural-health-care.

[2] Thebault R., Hauslohner, A. A deadly ‘checkerboard’: Covid-19’s new surge across rural America. Washington Post [Internet]. 2020 May 24 [cited 6/5/2020]. Available at: https://www.washingtonpost.com/nation/2020/05/24/coronavirus-rural-america-outbreaks/?arc404=true.

Eyal Kedar, MD, is a rheumatologist/generalized specialist with

St. Lawrence Health System in Canton NY.