A 38-year-old man who uses crack cocaine

Amy H.W. Sur; Lawrence C. Loh

doi:10.1503/cmaj.150491

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Re: Acknowledging rural context, local and generalist care
Lawrence C. Loh, MD, MPH, CCFP, FRCPC, FACPM

Posted on: 16 December 2015
Acknowledging rural context, local and generalist care
Aaron M. Orkin

Posted on: 04 December 2015

Posted on: (16 December 2015)
Page navigation anchor for Re: Acknowledging rural context, local and generalist care
Re: Acknowledging rural context, local and generalist care
Lawrence C. Loh, MD, MPH, CCFP, FRCPC, FACPM, Adjunct Professor
Other Contributors:
We thank Orkin and Kelly for their letter around the stated rural context in our recent Decisions piece. (1)
One concern expressed by Orkin and Kelly is that our piece focuses too heavily on "taking a history, ordering a battery of tests, and referring to specialised services." We submit that this is in fact the primary purpose of the case study, in line with the expectations of the Canadian Medical Associatio...
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We thank Orkin and Kelly for their letter around the stated rural context in our recent Decisions piece. (1)
One concern expressed by Orkin and Kelly is that our piece focuses too heavily on "taking a history, ordering a battery of tests, and referring to specialised services." We submit that this is in fact the primary purpose of the case study, in line with the expectations of the Canadian Medical Association Journal (CMAJ) Decisions category, which asks authors to describe "key issues to be addressed in the first appointment [...] including "examination, investigation, treatment, harm reduction, follow-up, or referrals." (2)
Related to this, therefore, is the other concern expressed that the guidance does not sufficiently account for limitations around rural primary care practice. In response, we would submit firstly that the primary purpose of this case study was to review clinical decision making, rather than providing a broad review of care disparities that may exist between rural and urban settings. Understanding that, we can additionally disclose that this fictional encounter was originally written with a suburban setting in a major metropolitan area in mind. The change to a rural setting occurred in response to suggestions made during the review process.
We agree that care is highly contextual and therefore thank Orkin and Kelly for the kind reminder. In this instance, a seemingly simple change (literally altering a single word) resulted in presenting a case in a vastly different locale with challenges to the feasibility and appropriateness of proposed guidance. Ironically, while preparing this Decisions case, our supporting research uncovered significant disparities in access to harm reduction services between urban and rural settings. As already mentioned, our ability to address these in detail within the piece was limited by format and space restrictions. However, we fully agree that differential access to various support services would impact the nature of care provided in different settings.
To that end, we venture that further work from Orkin and Kelly would be welcome, with perhaps a specific focus on management challenges around crack cocaine use in rural settings. We also again acknowledge that the original context underpinning our Decisions piece was a non-rural setting.
References
1. Orkin AM, Kelly L. Acknowledging rural context, local and generalist care. CMAJ (online letter.) Available at http://www.cmaj.ca/letters/#731310 (Last accessed December 4, 2015.)
2. Canadian Medical Association Journal. Instructions for Authors - Decisions (webpage.) Available at http://www.cmaj.ca/site/authors/decisions-author-instructions.pdf (Last accessed December 4, 2015.)
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (4 December 2015)
Page navigation anchor for Acknowledging rural context, local and generalist care
Acknowledging rural context, local and generalist care
Aaron M. Orkin, Physician
Other Contributors:
Sur and Loh are to be commended for their piece on the management of a man disclosing crack cocaine use at a rural clinic.[1]
They do not elaborate on the rural context, nor acknowledge their recommendations' potential limitations in rural Canada.
Their guidance focuses on taking a history, ordering a battery of tests, and referring to specialized services outside the primary care clinic. This does n...
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Sur and Loh are to be commended for their piece on the management of a man disclosing crack cocaine use at a rural clinic.[1]
They do not elaborate on the rural context, nor acknowledge their recommendations' potential limitations in rural Canada.
Their guidance focuses on taking a history, ordering a battery of tests, and referring to specialized services outside the primary care clinic. This does not recognize shortages of rural addiction services nor the potential for skilled generalists to offer excellent care at the very clinic where the patient presented.[2,3] The authors offer little guidance for how a generalist might care for the patient comprehensively, locally, and realistically.
Serious drug misuse can be viewed as a disastrous form of 'self- treatment'. Our task as caregivers might include identifying and treating underlying mental health disorders and trauma within the comprehensive family practice clinic.[4] A discussion of these issues might seem a good starting point.
The paper concludes that the "physician ... subsequently referred the patient to a harm-reduction clinic for education and counselling and ongoing access to support services and the local safe inhalation kit distribution program." These services exist in some rural settings, but are not the rural norm. The authors unfortunately identify decontextualized guidelines, urban evidence, and largely nonexistent rural services.
Rural patients typically receive excellent care through a generalist model. While some may need to be referred to specialized urban centres, rural patients and clinicians need robust strategies and guidance for treatment close to home.[5]
References
[1] Sur AHW, Loh L. A 38-year-old man who uses crack cocaine. CMAJ 2015. DOI:10.1503 /cmaj.150491
[2] Sibley LM, Weiner JP. An evaluation of access to health care services along the rural-urban continuum in Canada. BMC Health Services Research 2011, 11:20 DOI:10.1186/1472-6963-11-20
[3] Canadian Mental Health Association. Rural and Northern Community Issues in Mental Health. 1 September 2009. Online: https://ontario.cmha.ca/public_policy/rural-and-northern-community-issues- in-mental-health/#.Vh08-YfdDrM. Accessed 13 October 2015.
[4] Mate, G. In the Realm of the Hungry Ghost. 2008. Knopf, Mississauga Ontario.
[5] Jiwa A, Kelly L, St.Pierre-Hansen N. Aboriginal Community Based Addictions Treatment- a literature review. Canadian Family Physician 2008;54:1000-1000.e7
Conflict of Interest:
None declared
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Competing Interests: None declared.