AMA Journal of Ethics^®

Case

Dr. Benson is a primary care physician practicing in a town of 5000 people. He often manages patients with complex medical issues and prides himself on his ability to stay current on advances in medical treatment. Each year he exceeds his continuing medical education (CME) requirements, is well respected among his colleagues, and is often consulted by other physicians for difficult cases.

Last week Dr. Benson received a troubling phone call from Sandy, the mother of one of his patients. He has known the patient, Carla, since she was a child. She was always what he thought of privately as a "difficult" patient, and during her adolescence he spent a great deal of time helping her through a substance abuse problem and a bout of major depression. Carla is now 24. Sandy called Dr. Benson to tell him that Carla's behavior had grown increasingly erratic over the past several weeks; she lost her apartment and moved back home, has maxed-out her credit cards, and does not seem to be sleeping more than 2 or 3 hours a night. Following the conversation with her mother, Dr. Benson asked Carla to come in and visit with him. Dr. Benson suspected that Carla was abusing drugs again, but acknowledged that she could have a psychiatric disorder.

After talking with Carla, who insists that she has been "clean" for several years, performing a thorough physical exam, ordering lab work, and asking Carla to consent to a urine drug screen, Dr. Benson thinks he is seeing an acute manic episode. Dr. Benson gets Carla's permission to have her mother come in from the waiting room so they can all discuss the diagnosis.

With Sandy present he explains what he believes to be the diagnosis, but says that a definitive diagnosis for such a serious disorder should be made by a psychiatrist.

"Where do we have to go to see a psychiatrist?" Carla's mother asks.

Dr. Benson explains that the nearest one is in the city, 100 miles away.

"We can't get there." Sandy cries. "The car broke last week and we don't have any money to fix it, and nobody's going to drive Carla 100 miles for a doctor's appointment. Can't you just give her something?"

Dr. Benson hesitates. He has managed patients with bipolar disorder who were sent to him already stabilized on their medications, but he has never diagnosed and started a patient such as this on a new regimen, and, moreover, he does not track the constantly changing literature in psychiatry and neuropharmacology. He also knows that, even if Carla sees a psychiatrist in the city for a diagnosis, she will not be able to make the long trip on a regular basis for follow-up appointments.

Commentary 2

The broad scope of rural practice allows physicians to encounter patients of all ages and in a wide variety of clinical and financial situations. There is a multidimensional aspect to rural-based care that integrates knowledge of medicine, relationships, finance, and health care systems. A challenging patient such as Carla, the person described in this case, requires the physician to have as much interpersonal skill as medical expertise.

This case is further complicated by a patient who is:
1. Unpredictable,
2. Limited in ability to care for herself,
3. Diagnosed with a complex illness, and
4. Living in a setting with limited mental health resources.

Although Carla's diagnosis falls within a narrow range of possibilities, the most likely of which are drug abuse relapse and bipolar disorder, the treatments vary widely, and the wrong one could worsen her condition. Moreover, many pharmacotherapies have significant side effects and costs that can make adherence difficult. The risks of treating a case like Carla's are considerable, given that the threat of harm she poses to herself and others is moderate as assessed by Dr. Benson. Had this been a high-risk case, emergency transport to a psychiatric facility would have been necessary.

The assistance of a third party (the patient's mother, Sandy) is an essential element in this case, but it also complicates matters since Sandy's interests, concerns, and relationship with her daughter must be fully ascertained. Based on her reaction to Carla's latest behavior and the patient's previous history, it is possible that Sandy is experiencing a significant degree of "caregiver burnout."

Given the resources available in their town, Dr. Benson might consider taking the following steps.

First, he must secure permission to discuss Carla's case with other health care professionals. Next, he should call the nearest psychiatrist and, at the same time, ask his own staff to pursue transportation options with the local senior center, a church group, or another community resource. While he waits for the psychiatrist to return the call, Dr. Benson can investigate his clinical suspicions by reviewing diagnostic criteria, possible treatment options, and other information for patients with bipolar disorder.

Another concern is that Carla is at risk of "falling through the cracks" due to her financial and insurance situation. Her greatest difficulties revolve around affordable care and access to medications. If there is a "sliding scale" fee system at a local clinic or pharmacy, Dr. Benson can explore this option on Carla's behalf. As with primary care, the physician and his staff must gain the patient's trust, help her to anticipate side effects of any medications she is prescribed, and work through the challenges that each stage of treatment brings. Again, the clinical advantage lies with an experienced medical group that knows their patients and their community, as well as their medicine.

When the psychiatrist returns Dr. Benson's call, the 2 can fully discuss Carla's case, and the psychiatrist can suggest treatment. With Carla's consent, an evaluation with the psychiatrist should be scheduled for a time when she can be transported. In a situation like this, where setting up and keeping regular appointments is difficult, it may be appropriate for Dr. Benson to start Carla on a pharmacological regimen based on the advice of the psychiatrist even before her first psychiatric appointment. In addition to the psychotropic drugs, an example of a possible plan of care might include counseling at a local mental health center twice a week with periodic visits to the psychiatrist for overall symptom management. If the psychiatrist is willing to accept Carla's case, some of these follow-ups might require travel 100 miles to the city, and some might take place when the psychiatrist is supervising at the local mental health center. No matter what the doctors agree to, consent must be given either by Carla, if she is deemed competent, or her mother before any decisions are made.

It is possible that an easier care plan might be available for Carla and Dr. Benson. Integrated care clinics—the latest trend in rural mental health care—have mental health specialists on-site, either on a part- or full-time basis. Besides effectively merging mental health into overall health, this arrangement helps remove the stigma of going from a small town to an urban mental health facility for care. Two competing primary care offices in Moose Lake, Minnesota, for example, have even employed a psychiatrist to assist with care.

It is not uncommon for rural physicians to provide care outside of their specialties, though it must be acknowledged that patient care might be compromised by the rural physician's lack of specific training. This absence can involve either lack of depth (primary care) or lack of breadth (specialists), hence, a physician's recognizing his or her own limitations is a key aspect of quality care. Fortunately for Carla, behavioral issues are a common part of primary care training, although, as this case illustrates, care for mental illness can quickly exceed the scope of most physicians.

According to rural health researcher Jack Gellar at the University of North Dakota, the "safety net" for mental health patients in rural areas is primary care. With each patient and each passing day, rural primary care physicians extend their abilities to care for more complex patients.