HOW I FOUND MY RHYTHM WHEN THE MUSIC STOPPED

At a time in everyone’s life, we come to find ourselves in a situation where the music stops, and we must go on.  The unfortunate truth about life is that the unexpected will happen. Some of us learn from it, some of us change because of it and some of us find our life’s calling because of it. The latter was the case for me.  After our dad picked us up from middle school, we spent that afternoon like we had every afternoon that month. We went to the oncology unit at the hospital, where my brother was admitted.

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THE MAN IN A BLUE SARONG

I remember him. I remember the man in the dark blue sarong the same way I remember the lines on back of my own hand. He was hunched over next to a column on a dirty platform at a railway station in Calcutta, India in the middle of the harsh summer sun. His hands were withered, his fingers and toes looked like tiny nubs, and he was completely malnourished and alone. He had opaque blue eyes, as if fog had taken place of his irises and pupils.

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PATIENT “OWNERSHIP”

I studied insects in college; my favorite insects were the bees (I found them diligent and so helpful to humankind).  One of my favorite classes was about medical diseases caused by insects. My professors noticed my interest in the medical side of things and connected me with a professor who did clinical research. Our work focused on a clinical trial for children with intractable epilepsy and exposed me early on to patient care and patients.

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digital health services. Instead of sending healthcare providers by car for repeated follow ups, how about an initial in-person consultation with video encounters interspersed between periodic personal visits? If the patient warrants a more thorough evaluation during a video chat, a provider can be dispatched or EMS called. The most intriguing aspect is that these video encounters can all occur with a handheld smartphone, which are already paid for and used by two thirds of Americans. Patients would not be confined to the living room in front of an expensive smart TV or bulky computer. They could video chat their caretaker from the bed when feeling too ill to get up; patients could pan across their medicine cabinet to reveal pills in short supply; those involved in a farm accident can identify the very agent causing harm. These digital approaches offer another avenue for seeing remote, rural patients where they are. Telemedicine is only in its infancy. Further advances will lay the foundation for the next great step in rural patient care: telesurgery.


Robots can mimic humans from a distance. A surgeon in the corner of the operating room can mobilize a laparoscope ten feet away. What about ten miles away? Or one hundred miles away?  The Da Vinci robot and similar devices will soon render this science fiction into reality. This means experts in the field great distances away can perform surgeries at critical access hospitals, including those in rural communities. The greatest drawback to these instruments is cost. The Da Vinci’s price tag is over a million dollars with limited lifetime attachments and exclusive maintenance by the parent company, Intuitive. But patents are expiring and competition is emerging. As Intuitive’s market fractures, costs will likely decrease and make these options more economical and more realistic for rural hospitals, increasing access to lifesaving surgeries.  These technological advances in telemedicine and telesurgery represent only half of the equation. Not only does the internet and technology allow healthcare to come to patients, they also bring the patient to the healthcare system.


Many hospitals have online portals – doors that warrant further exploration. Most online platforms allow patients to check recent labs, email their doctors, and schedule appointments. Their capabilities do not tend to go much beyond that. But what if these portals could open up to a virtual clinic? At the Cleveland Clinic, patients can meet their doctors before even scheduling an appointment by watching the provider interviews online. Floridians have access to multiple online applications created by Baycare Health System. One incentivizes patients to setup an online profile and stay updated on their health by offering a gift card at registration. Another allows patients to select their symptoms and directs them via GPS to the most appropriate level of care: doctor’s office, urgent care, or emergency room.  Instead of telemedicine solely burdening providers, these ventures encourage patients to own their healthcare. They empower rural patients with knowledge and plans of care that are understandable and navigable. They are yet another example of how technology expands the number of ways healthcare systems can unite providers with rural America.


My wife and I live several hours from our families; we do not have the luxury of seeing them in person very often. But video chats with Facetime or Skype have helped my kids come to know the grandparents they rarely see. Modern delivery services allow us to exchange gifts when we miss holidays. GPS helps us find the fastest way home. A healthcare provider at bedside will never be replaced by their face on a screen or a robot mirroring their movements. Human touch produces a real effect and patients recognize the difference.  But in those situations where physical presence cannot be afforded by patient or provider, technology bridges the gap between America’s remotest regions and its best hospitals.  

We had moved to a completely unfamiliar city for residency and to complicate matters, only one day stood between unpacking and driving halfway across the country for my medical school graduation. Our kitchen supplies were in boxes. We did not have time to go to the store. But we had our gift card; we ordered sushi. That meal delivered to our door unburdened us of the thought and planning for dinner and furnished us extra time to spend on other activities we considered more important. This is the future of healthcare delivery, especially in rural America: at your door and according to your schedule.


We are taught to “meet patients where they are.” This principle is meant to be metaphysical, but its application extends into the physical realm. Hippocrates visited bedridden patients in their homes. In the HBO miniseries John Adams, Benjamin Rush – the only physician to sign the Declaration of Independence – can be seen tending to Mr. Adams and his family at their Massachusetts estate. Regardless of the show’s accuracy, one thing remains true: house calls are not a new concept. Many healthcare systems are adopting this centuries old tradition with the modern twist of data and statistics to identify at-risk patients and meet them where they are: their homes. These programs focus primarily on “superusers” who disproportionately utilize more resources. It is not difficult to see its application to rural patients however, who are at-risk by the very fact they live miles from healthcare centers and clinics.


Meeting rural patients at home enables the doctor to take in-house

BY MICHAEL WADLE, MD

histories, administer physicals, provide medication refills, and schedule follow up appointments (where one can physically write on the fridge calendar) and spare a patient from taking an entire day off work. This will keep the client from having to drive several miles and several minutes waiting for a doctor who will tell them a laundry list of details they may forget. What’s more, in-house appointments allow a healthcare provider to observe a patient’s living conditions. A home visit ensures the elderly woman on Warfarin does not have rugs all over the floor; it affords the opportunity to check that the gentleman with insulin-dependent diabetes has a functioning glucometer; and provides insight into every patient’s social situation. Now it must be said that I have only seen and heard of these outreach programs in urban communities. No doubt the cost and time involved in driving down country roads to visit patients spread far and wide hinders their development in more bucolic settings. This makes rural home visits difficult, but not impossible. In addition, in the age of smart TVs and telemedicine, healthcare providers can now travel to patients’ homes without so much as a knock on the door.


Ninety percent of Americans are online. With the expansion of fiber optic cables and the introduction of 5G networks, people on the outskirts of society will access the internet at speeds and bandwidths far beyond those of today. This means more people are available to video chat and more patients are accessible to

ABOUT THE AUTHOR

As a second-year anesthesiology resident at the University of Kentucky, Michael's interests include critical care, cardiothoracic anesthesiology, end of life care, and hospital efficiency. He and his wife have three children (2 with one on the way!) and enjoy spending time cooking, riding bikes and meeting up with friends–time permitting.