The cradle of the best and the worst,” sang Leonard Cohen, a reference to democracy in our applies equally to rural US medicine as it transforms from the Norman Rockwell doctor of the mid-20th century to the 21st century technologically savvy interdisciplinary rural health care provider who may be as culturally diverse as the population being served.
Many books have been written about country doctors and they all focus on the romance of a bygone era: dedication to a community, the horse, the buggy, the dog sleigh, the homemade snowmobile, getting stuck, going through the ice, the difficult problem and the innovative solution. Doctor Olds of Twillingate (Gary Saunders) and Memoirs of a Cape Breton Doctor (C. Lamont MacMillan) are two good examples. The Country Doctor Revisited is perhaps the first book to take a broad view of the new rural reality.
The editor of The Country Doctor Revisited, Therese Zink, uses vignettes, poetry, essays and even a blog to marshal voices from all aspects of rural US medicine that provide a picture of what is good and bad in the system. The bad aspect of rural medicine both in the US and Canada continues to be recruitment and retention. The US has additional problems, the crippling effects of malpractice fees ($130 000 annually to provide rural obstetrics) and an insurance system that is costly, time-consuming and distinctly user and doctor unfriendly.
The book also gives you a sense of the enormity of coordinated effort it will take to effect change. To balance the downside, I counted at least nine positive features about emerging rural medicine in the book. The once isolated rural physician now practises collaboratively, can get information instantly online, such as digital radiographs reviewed immediately, and is trained to diagnose and stabilize complex problems for patient transport. And, the old small community problems of boundaries and dual roles are being examined and framed positively. These and other aspects are explored with literary sensitivity in several essays.
Godfrey Onime, a physician writer on the best side of the cradle, resists urban flight and returns to rural medicine. From his experience, he gives the finest explanation of medical boundaries in a small community you will ever read. The notion of physicians’ dual roles is further explored in Megan Wills Kullnat’s essay, “Boundaries.” Can a rural doctor be both your physician and friend? The answer is yes. A rural physician can learn to maintain objectivity in a dual role and the dual reward in this type of relationship is that patients become more candid and honest, resulting in better outcomes.
Some of the insights and writing in this book are exquisite and one piece by Tom Bibey (pseudonym) gives us a humourous rant worthy of Mark Twain. Tom tells of his battles over the years with the insurance “chart jockeys” (bureaucrats). US medical insurance comes across as avaricious and unfair to the patient and an unremitting hassle for the care provider. What kind of political resolve will it take to do battle with that dragon?
David Loxterkamp poses thoughtful rural medical questions in his essay, “A Vow of Connectedness.” Are doctors agents of social or political change? This prompted me to reflect on an unspoken theme throughout the book. Are rural physicians agents of stability? Do they become a living breathing infrastructure as important in maintaining a community as the garage, the store, the school? And does this contribution help produce what happens best in a small community, “a sense of connection and interdependence”?
Richard Berlin, a rural psychiatrist, provides in two poems the bookends of futility and hope. The futility of spending a career preventing patients from committing suicide only to have them die of cancer and the hope, “[a]ll round, the grass a rumor of green.”
The Country Doctor Revisited provides the glimmer of hope that the sense of futility can be overcome and great things can happen with a rural grassroots awakening.