Vision & Aim

This is the unfortunate story of Mr. Smith, one that is not unique to him and is all too familiar for individuals in the rural communities of Washington state. Our story starts in the 1990s, at a time when Mr. Smith is in his late 20s and living in a small town in the northern cascades. He works as a logger, is fit and healthy but suffers from a poor diet as well as tobacco and alcohol abuse. He has limited access to, or knowledge of the importance of preventative care. Over the next 20 years he goes from working on rigging to primarily operating machinery and has become sedentary. His poor diet and use of alcohol and tobacco continues. He has gained 50 lbs. and unbeknownst to him has developed high blood pressure and diabetes. Mr. Smith continues this way until 2018 when he collapses at work with chest pain and shortness of breath. His co-worker radios the local sheriff’s station and he is emergently transferred to the nearest urban hospital, Providence Medical Center in Everett, Washington (PRMCE).

Mr. Smith spends the next 12 days in the hospital recovering from an ST elevation myocardial infarction which has resulted in congestive heart failure with an ejection fraction of 40%. He undergoes angiography with stenting of 2 coronary arteries. His diabetes is controlled but requires the use of supplemental insulin. He is also found to have COPD and is started on 2 inhalers to improve his breathing. At the time of discharge Mr. Smith is on multiple medications including 3 for CAD, 4 for CHF, Insulin and 2 inhalers. He has declined functionally and unfortunately is unable to return to work. He has applied for Medicaid and disability.

Mr. Smith struggles physically and emotionally to adjust to his new way of life. He has difficulty making his follow up appointments as the nearest primary care doctor accepting Medicaid is 70miles from his house and he must drive over 3 hours to see his Cardiologist in Everett. As a result, 2 years pass without Mr. Smith being seen by a provider until he ends up readmitted to the hospital with difficulty breathing. He is found to have decompensated heart failure and his ejection fraction has decreased to 20%. Mr. Smith is hospitalized for 8 days and treated with IV diuretics. At the time of discharge, he is stable and back on medications for his CAD, COPD, DM and CHF. Unfortunately, Mr. Smith is now requiring oxygen which further limits his functional capacity and worsens his isolation.

Sadly, outpatient management of his complex medical conditions remains challenging due to Mr. Smith’s remote location and poor access to care. Over the next year he is readmitted to the hospital several more times for decompensated heart failure as he has difficulty managing his volume status. His functional ability continues to declined and physical therapy recommends he move into an adult family home. Mr. Smith loves his community and is happiest when he is at home however his health has forced him to move to Everett to get the care he needs. He now lives in an adult family home where he has help managing his diet and medications. Living in Everett has enabled him to make it to his doctor’s appointments and he has managed to stay out of the hospital for over a year. Despite his improved health, Mr. Smith is depressed over his loss of independence and sad about no longer living in the community he so loved.

How could this story have been different if Mr. Smith had access to high quality primary care? If he was cared for by an internist in his community who was an expert in the management of complex disease? An internist who was part of a larger network of physicians who worked together to optimize the care of the most medically challenging of patients. The goal of our internal medicine training program is to change the narrative of Mr. Smith. Let’s explore how we may have changed his story.

Suppose early intervention had occurred in the form of preventative medicine. Perhaps Mr. Smith had annual visits in his 20s and 30s with a local internal medicine physician practicing in the community in which he lives. A physician who spent part of his residency training in rural communities and understands what it means to care for individuals in such areas. A provider who formed a trusting relationship with Mr. Smiths and advised him on healthy eating, limiting alcohol use, tobacco cessation and regular physical activity. Is it possible that the above scenario could have been avoided by these annual preventative visits and monitoring of Mr. Smith’s weight, blood pressure, cholesterol and glucose by this highly trained general internist?

Let’s now pretend that Mr. Smith did not have access to this highly trained internist until after his first hospitalization. But upon discharge he is able to see a provider in his community who is specialized in the treatment of complex adult patients. A physician who had dedicated rotations during residency training caring for the 3-5% most medically complicated patients with the goal of preventing hospitalizations. If this were true, it would ease the burden on Mr. Smith as he could see a provider in his community who would work with specialists remotely to optimize his complex medical conditions. Thereby allowing Mr. Smith to remain in his home and in the community he so cherishes.

We aim to change the above narrative by decreasing health disparities and improving access to highly trained general internists in the rural and underserved communities of Washington state. Allowing individuals to get the care they deserve while staying in the community they hold dear.