CASE 25

Bobby Napier

A 68-year-old Caucasian Appalachian man with type 2 diabetes

Elizabeth Lee-Rey, MD, MPH,1 Sonia Crandall, PhD, MS,2 and Thomas A. Arcury, PhD2

Educational Objectives

TACCT Domains: 2, 3, 4, 6

Case Summary, Questions and Answers

Mr. Napier is a 68-year-old Caucasian man with type 2 diabetes who lives in a rural Appalachian county. He and his wife have come to a small primary care center in the neighboring county for a checkup. He is seen by a resident, Dr. John Cox, who is doing a month-long rural medicine rotation. Mrs. Napier tells Dr. Cox that she is concerned that her husband is shuffling his feet when he walks, but Mr. Napier denies having any problems. Mr. Napier smokes about a pack of cigarettes each day and has smoked or chewed tobacco since his early teens. He does not drink alcohol. At his last visit to the center over a year ago, Mr. Napier complained of burning in his feet, polyuria, and some blurred vision. His random blood glucose 1 year ago was 215 mg/dL (<200 mg/dL) and HbA1c was 11% (normal 4.8% to 6.4%). He was prescribed Metformin, but admits that he only filled the prescription once. Today’s 2-hour postprandial glucose fingerstick result is 290 mg/dL. Dr. Cox then accuses Mr. Napier of neglecting his health, specifically citing his refusal to take his medications, monitor his glucose, quit smoking, or change his diet. Dr. Cox states angrily, “Your diabetes is so out of control! If you keep ignoring what you eat and don’t start monitoring your blood sugars regularly, you are going to lose a leg!”

1 How might the attitude that Dr. Cox expressed to Mr. Napier affect his care?

Although Dr. Cox may have been concerned about Mr. Napier’s health, his response was inappropriate and unprofessional. Dr. Cox failed to establish a rapport with Mr. Napier and took his denial of anything being wrong as evidence that Mr. Napier was disinterested in his health. Dr. Cox also did not appreciate that this visit was likely initiated by his wife. He instead chose to react to laboratory results, providing unsolicited advice, and resorting to fear. Therefore, Dr. Cox’s attitude could irreparably damage his ability to develop a relationship with both Mr. and Mrs. Napier and may cause Mr. Napier to be even more reluctant to seek or receive appropriate medical care.

2 What are some of the factors that need to be considered when prescribing treatment for patients who are poor?

Factors that influence adherence to treatment include a patient’s insurance status, access to locally available health care and educational programs, convenient and reliable transportation, and ability to pay for medications either out of pocket or by payment assistance. All of these factors are relevant to Mr. Napier.

If asked, Dr. Cox would have learned that Mr. Napier lives 15 miles away from the nearest pharmacy, and the closest hospital is a small, rural primary care center located in the next county. He was prescribed diabetes medications last year, but these are expensive and Mr. Napier does not have sufficient income or insurance coverage to pay for these medications. His lack of health care insurance arises from the fact that although Mr. Napier is eligible for government sponsored coverage, he has refused this type of assistance, calling it welfare. Mr. Napier’s lack of adequate insurance leads to lack of access to resources such as diabetes prevention and educational programs. Together these factors have made it difficult for him to follow through on his diabetes management at home.

The county health department has limited group programs for people with diabetes, but it would require regular travel to the county seat. There is a comprehensive diabetes program in a state university medical center approximately 70 miles from Mr. Napier’s home. Mr. Napier’s car is old and not dependable for traveling much farther than the county seat. All of his children and their spouses work, and it is difficult for them to take time off to transport Mr. Napier to the university diabetes program.

Dr. Cox presents Mr. Napier to Dr. Jennings, the supervising attending physician at the center and says, “Mr. Napier is a noncompliant patient. He was last seen here 1 year ago and doesn’t seem at all interested in controlling his diabetes! Frankly, I have other patients who care more about their health who are waiting to be seen, so I don’t want to waste anymore time with him.”

3 What would be an appropriate response from the attending to Dr. Cox’s statements about Mr. Napier?

This is an opportunity for Dr. Jennings to challenge Dr. Cox’s impression of Mr. Napier. This can be done by asking Dr. Cox to elaborate on his conclusions, with the goal of helping him to understand that ethical and professional obligations require him to try to understand the patient’s lack of adherence. Effective physician–patient interactions are not, “I say-you do.” Dr. Jennings can give feedback on Dr. Cox’s communication style by inquiring about what he knows about Mr. Napier’s understanding of his diabetes and what he views he can realistically do to control his symptoms. As Dr. Cox has not addressed these questions, Dr. Jennings can help him reframe the encounter to improve the interaction. Part of this process is to accept that Mr. Napier has returned to the health center with the intention of receiving treatment for his medical problems. Unfortunately, whenever the patient’s and the health care provider’s treatment plans are not aligned, the patient is often labeled as “noncompliant.” These are the kinds of labels that may prevent health care providers from truly understanding their patients.

4 What additional information would have been helpful to Dr. Cox in developing a treatment plan?

A thorough and detailed social and family history obtained in a culturally sensitive, thoughtful, and respectful manner is essential to understanding the particular challenges and obstacles that limit Mr. Napier’s care and reduce his ability to adhere to prescribed treatment. To discuss a therapeutic plan with Mr. Napier and his family without understanding the ecological/environmental context of his life will negatively affect communication, cause frustration for everyone involved, delay care, and worsen his health outcomes.

Mr. Napier and his wife have been married for 49 years and have never spent a night apart while married. In addition to raising their six children, the Napier’s have worked together throughout their lives, whether in the garden, cutting tobacco, or building their new house. Mr. Napier lives on 500 acres of mountain land that he owns, and his house is on land adjacent to the farm on which he was raised. Four of his six children live on plots of land he has given them; he can see their homes from his front porch. He has walked on and knows all the land in this valley and the surrounding ridges. He knows everyone who lives in the neighborhood. Many of the older residents have been his friends since youth. Many of the younger residents call him Uncle Bobby, whether or not they are actually related.

He has never made more than $10,000 in any year of his life. However, he has worked hard his entire life and supported his family by selling tobacco and vegetables from his garden. Mr. Napier’s cash income came from operating a small portable lumber mill (he cut and sold railroad ties), producing tobacco sticks used in the production of burley tobacco, and driving a school bus.

5 How might the social information obtained above be used to promote adherence to his diabetes treatments?

Mr. Napier is a resourceful fellow and has been industrious, given his limited means. Asking him what he would suggest if one of his family members or friends had problems with burning feet, excessive urination, and blurred vision might help him to see his diabetes in a new light. Additionally, sharing your opinion with him about his ability to problem solve, which is now needed regarding his health issues, might be useful. He is not only a dedicated family man with close-knit family members (who may also have diabetes or may help him change his behavior), he is also an important and valued member of the local community. Consequently, enlisting the support of members of his family or his community (while acknowledging his pride in strength and autonomy) may also be beneficial.

Dr. Jennings and Dr. Cox return to the exam room to talk to Mr. and Mrs. Napier about his diabetes; however, they have both left the clinic. Dr. Jennings was told by the receptionist that Mr. Napier was upset with the way he was spoken to by Dr. Cox. Three days later, Mr. Napier is brought to the Emergency Department (ED) in the neighboring county after falling from a ladder while picking peaches. Mr. Napier is seen by Dr. Joiner, the family medicine resident on call, who tells Mr. Napier and his son that he has a broken ankle and an elevated blood glucose level of 472 mg/dL. After having his ankle cast, Mr. Napier is admitted to the hospital for management of his diabetes and followed by Dr. Joiner.

6 What are some of the things that could be done to increase the likelihood that Mr. Napier’s diabetes will be controlled in the future?

The management of diabetes requires a multidisciplinary approach, one that includes the patient, the family, health care providers, and resources that will facilitate effective negotiation of the health care delivery system. An assessment of Mr. Napier’s understanding of diabetes and its significance to his health and lifestyle is necessary before interventions can be offered and discussed. After reading the patient’s chart and conferring with the resident, the attending asked Mr. Napier what his blood sugar readings have been and what his blood sugar goals should be. Mr. Napier admits that he has no idea! Dr. Joiner also needs to assess Mr. Napier’s beliefs and understandings about his diabetes and health in general (i.e. illicit Mr. Napier’s explanatory model of illness; see appendix) in order to enlist Mr. Napier’s critical participation in his care.

It is important to recognize that issues such as smoking cessation, risk for poor healing, and potential complications from an ankle fracture are germane to his care and must be addressed. This should be done in a culturally appropriate manner that recognizes the importance of the sociocultural and economic reality of Mr. Napier’s life and experiences, which include raising tobacco as both a source of income and pleasure. Unfortunately, in every instance, the interventions that were offered to him did not take into consideration Mr. Napier, his family, or support systems. In rural Appalachia, poverty and its resultant burden of scarce resources further limit access to care. The connection to land is sacred and the pride of self-sufficiency and reliance on family and church remain the core of Appalachian life. Mr. Napier’s story appears to be a reflection of this.

It will be important for Dr. Joiner to identify resources that are available for Mr. Napier and his family. A doctor cannot expect a patient to adhere to treatment if the patient lacks basic health literacy. A recent study (see Smith and Tessaro, 2005) that looked at patientperceived barriers to preventive health care in diabetes among indigent, rural Appalachian patients found that there was a lack of knowledge about diabetes before and after their diagnosis and a lack of awareness of the risk of diabetes (absent family history). Participants in this study also reported insufficient information about diet, physical activity, and other resources, such as affordable diabetes educational prevention programs and access to medically necessary items. The pervasive lack of knowledge and high costs were found to hamper preventive health behaviors in rural Appalachia.

Mrs. Napier has not left her husband’s side since his admission. When the doctor stops by to see him, she pulls the doctor aside to suggest that maybe the minister and elders can help convince her husband “that he needs to do the Lord’s work and he can’t do that unless he is healthy.” The doctor says, “I’m not sure that I see the benefit of inviting more people to speak to your husband. Let’s see how he feels in a few weeks.”

7 What role, if any, could the minister and elders play in Mr. Napier’s care?

As part of a detailed history, it would have been ascertained that Mr. Napier is an elder in the local Disciples of Christ Church. He has been very active in the church for many years, and a visit from the minister and some elders may be helpful, especially if his wife feels that this could motivate him to take better care of himself. In order to better understand the request, the doctor might have asked his wife what would be involved in this visit. Facilitating a visit that would be consistent with the patient’s religious beliefs and not be disruptive with the hospital staff would be a valuable goal. Finally, after more discussions, the doctor agrees, and later that evening, the minister and elders from Mr. Napier’s church come to visit. The minister explains to Mr. Napier that “a man must accept the law of the Father, the grace of the Spirit, and the mercy of Jesus to have salvation.” Although he believes that miracles do occur, and prays for a miracle to cure his diabetes, he also conveys that it is God who has made modern medicine available to us and this medicine may be the miracle. After the visit, Mr. Napier informs the doctor that he is ready to start his prescribed medications.

8 What resources may be available to rural communities to help patients control their diabetes and overcome many of the barriers that exist?

Prior to discussions with Mr. Napier and his family, it is important to identify local county health resources and community intervention programs available to help families in the areas where they live. For example, traveling clinics may be offered by a university hospital. TeleCare, which utilizes communications technologies, especially interactive videoconference systems, connects rural patients and clinicians to the health care resources at a local university medical center. Additionally, recruiting the local clergy to develop a health ministry that includes and have diabetes evaluation could augment current services.

State and federal programs and community consciousness-raising activities can influence development of programs and revenue that will enable diabetic patients, such as Mr. Napier, to become familiar with and able to access diabetic outreach programs that are closer to their home. It is clear that diabetes has reached epidemic proportions, and it is no surprise that in medically underserved rural communities, such as in the Appalachian regions, the need for expansion of diabetes public health programs remains urgently needed. Health care policy must focus on heightening awareness and finding ways to improve access to care, self-management of diabetes, treatment options, and education programs.

Urban vs. Rural Health Care Challenges

The lack of health insurance and not having a usual source of care (i.e. not having a person or place to go to when sick or in need of advice about their health) significantly impacts access to health care for all residents living in the United States. The Agency for Health Care Research and Quality, Medical Expenditure Panel Survey examined variations in the health care expenditures in urban and rural areas between 1998 and 2000. Results showed that, although the proportion of elderly people without Medicare supplemental coverage appears highest in rural counties (38.6%), the difference from metro, near metro, and near rural counties was not significant.

Another study that examined differences among rural, urban, and suburban residents found that rural citizens fared worse than their more urban/suburban counterparts. This study also reported that the most rural and the most urban were found to lack health insurance coverage, when compared with suburban areas. A resident living in the South Bronx, where the percentage of residents living below the poverty level is more than 30% (three times the national average), presents to his or her doctor with a strikingly similar story to Mr. Napier. Lack of insurance may lead to inadequate referrals to a specialist and avoidance of highcost medications. Even fewer choices exist when trying to adhere to exercise recommendations, such as “go out and take a walk,” when personal safety is an issue.

References: Case 25

Astrow AB. Puchalski CM, Sulmasy DP. Religion spirituality, and health care: social, ethical, and practical considerations. Am J Med 2001;110:283–7.

Betancourt J.R., Green A.R., Carillo J.E., Ananeh-Firempong O. Defining cultural competency: a practical framework for addressing radical and ethnic disparities on health and healthcare. Public Health Rep 2003;118:293–302.

Buryska JF. Assessing the ethical weight of cultural, religious and spiritual claims in the clinical context. J Med Ethics 2001;27:118–22.

Cooper L.A., Roter D.L. Patient-provider communication: the effect of race and ethnicity on process and outcomes of healthcare. In: Smedley B.D., Stitch A.M., Nelson A.R., eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. The National Academic Press, Washington DC, 2002, pp 552–83.

Eberhardt M.S., Pamuk E.R. The importance of place of residence: examining health in rural and non-rural areas. Am J Pub Health 2004;94(10):1682–6.

Indian Health Services. Available at: http://www.ihs.gov.

Kleinman A., Eisenberg L., Good B. Culture, illness and care: clinical lessons from anthropological and cross-cultural research. Ann Intern Med 1978; 88:251–88.

Lo B, Kates LW, Ruston D, Arnold RM, Cohen CB, Puchalski CM, Pantilat SZ, Rabow MW, Schreiber RS, Tulsky JA. Responding to requests regarding prayer and religious ceremonies by patients near the end of life and their families. J Palliat Med 2003;6:409-415.

Murphy E., Kinmonth A.L. No symptoms, no problems? Patients’ understanding of non-insulin diabetes. Fam Prac 1995;12:184–92.

Rural Health. Available at: http://www.ruralhealthweb.org.

Sharon L., Larson P.D., Steven R., Machlin A., Nixon M.A., Marc Z. Chartbook #13: healthcare in urban and rural areas, combined years 1998–2000.

Agency for Healthcare Research and Quality, Rockville, 2004.

Smith S.L., Tessaro I.A. Cultural perspectives on diabetes in an Appalachian population. Am J Health Behav 2005;29(4):291–301.

Tessaro I., Smith S.L., Rye S. Knowledge and perceptions of diabetes in an Appalachian population. Prev Chron Dis 2005;2:2;A13.

Zimmerman R. South Bronx environmental studies: public health and environmental policy analysis final report. Institution for Civil Infrastructure Systems 2002;1–135.

1Albert Einstein College of Medicine, Bronx, NY, USA

2Wake Forest University School of Medicine, Winston-Salem, NC, USA