As I drive down the desolate Kentucky roads in the early summer of 2017 there is no whisper on the radio of an opioid epidemic or of hurricanes that would devastate and capture the attention of the nation just months later. I would soon learn that the narrow and curved roads that weaved far from major highways caused at least one courier car accident each summer and deterred new businesses from entering this job-starved area of the country. I catch a glimpse of myself in the rearview mirror and see in my face the excitement and determination to learn and help a community through medicine. I do not realize at the time how symbolic “rearview” has become for the people that I am driving towards; for them their hope and excitement is permanently stuck behind them, and out the windshield the view of their world is bleak.
“… the residents of this community did not seek out the drug; it was provided to them. It was prescribed to them by someone they trusted: a doctor,” writes Belz, who interned in 2017 in rural Kentucky with Frontier Nursing University.
Stepping into the world of rural Kentucky I am immediately struck by the friendliness of the community. They have embraced their state motto of “United We Stand, Divided We Fall” in their support of each other and unwavering kindness towards others. There are no big shopping malls, bowling alleys, or concert venues here. There is no high-speed internet or five bars of cell phone service. There are no major corporations—there used to be, but the main source of income shut its doors years ago and, with that, shut down the future of so many. With hope diminishing for so many and few distractions from reality, there is a love for the comfort food that is not overly nutritious but delicious. It is a southern community that is struggling with poverty, but struggling together.
I work two internship positions and a volunteer job over the summer, a disadvantage in bonding with one medical practitioner, but an advantage in learning the community. As I am greeted by new people I notice the southern hospitality in their words and eyes. Friendly inquiries into my aspirations are met with disappointment when I share my goal of becoming a doctor. Although I insist I want to help others, their words and demeanor become skeptical. They have learned to distrust doctors, and not just one individual with a bad experience, but an entire community. It is here that I learn about what caused this devastating break in the sacred medical bond, and it is here that I have begun to define myself and the future of medicine.
For the community, the break began when the jobs left, the options for the “American Dream” simply did not exist, and the means to leave and start over were not realities. Depression was a very understandable result, and with no hope or money for nutritious food, diabetes and the accompanying medical conditions became rampant. The community turned to their doctors to help them find a solution and the doctors failed them miserably. Opioids were prescribed to provide a brief respite from the pain. There was no focus on treating the cause on an individual or community basis. There is no money to seek out different opinions from other doctors. The community is now facing an opioid addiction crisis. For this community, the Hippocratic Oath has been redefined to “Hypocritic”.
Addiction can be widely misunderstood by non-addicts who view the situation as self-caused and believe that addicts are making a conscious choice every time they take a drug. Although this is widely debated in topics that range from Narcan policies to treatment of addiction approaches, the residents of this community did not seek out the drug; it was provided to them. It was prescribed to them by someone they trusted: a doctor. As I intern in the different facilities, I observe the doctor-patient relationship. Although it varies by practitioner, at its worst it is a two-minute visit where previous opioid prescriptions are simply refilled. There is no discussion on addiction, no health counseling for diabetes, and no physical exam of new ailments. The counseling boxes are marked with a check mark by the doctor, but the reality is that it is an interaction between a drug dealer and an addict that they create. The assumption by the doctor is that the patient just wants the prescription, and the assumption by the patient is that the doctor does not care. As I speak with doctors, patients, physical therapists, and nurses, this reality becomes more prevalent and is the root cause for the issue in this community. This great divide between the doctor and patient has awakened in me a passion for patient advocacy.
I speak with several nurses who plead with me not to become this type of doctor. By the end of the summer, I know exactly what they mean and what path I must choose. A doctor has great power and with that comes enormous responsibility. At their heart, they must be an advocate for the patient and incorporate symptoms and causes into their treatment plan. To treat the “whole” patient requires a connectedness and understanding that goes well beyond two minutes. The trust that is built must address the current issues and build a treatment plan that looks to the future. This trust must include some moments of tough love, where the easiest path such as simple opioid prescriptions is not taken, and where true treatment options are explored. The treatment must be a partnership where the patient and doctor are working toward the same goal and where they can have honest discussions about obstacles and paths.
For the small community in Kentucky where there is an eighty-percent addiction rate, the solution is not a simple removal of prescriptions; the addiction also needs to be treated. Doctors created the epidemic here, but it will take the community uniting together to overcome the issues, and it will require outside help in this poverty-stricken area.
Six months later, the opioid epidemic headlines have come and gone in the news, but the addiction is still ever-present. Many doctors across the country understand their power and their oath. As part of the next generation of doctors, our responsibility is great. We must connect with our patients and become their advocates, and this must be the foundation of who we are before we take our first medical class. We will learn about the anatomy, medicine, and treatments, essentially the “how” of medicine in medical school and as residents. We have the responsibility of understanding the community, patients, nurses, and the “why” of medicine as undergraduate students who are building our passion to help others.