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Patients, Medications, and Limiting Factors
Written by: Arlyn Duval

Managing Medications while working in a Rural Health Clinic here on the California/Mexico border is always interesting and challenging. There are many difficulties with Medications – I will address only the problem of limiting factors such as ability to go physically to the pharmacy or the clinic, ability to purchase the medications written by the provider and the patient’s interpretations of the directions on how to use the medications.

Physical travel is not merely restricted among those with physical disabilities. Often our unemployed and underemployed patients simply do not have the money to buy the gas to get to the clinic if they live out of town, or the taxi fare if within the town. Bus travel from outlying areas into the clinic is often further restricted by hours available. For example, a trip to/from Winterhaven, California  to El Centro, California ( 55 miles away) for tests and appointments takes all day – the bus leaves early in Winterhaven, and there is only one round-trip, returning in evening. This is tough if one is in pain. Yuma is of course closer, but California’s  Medical is not acceptable in Arizona.

Acquiring the medications can be another obstacle. The MediCal and CMSP formularies change frequently, as do the MediCare Part D programs. Therefore, the provider writes a script, and the patient goes to the pharmacy only to find out medication not covered today, although it was last month!  The pharmacy must now spend time to contact the clinic, which must locate the provider (who may have worked only a few hours in the clinic and is no longer there) and determine the best possible substitute.

Or it can happen that the provider simply writes meds that are not covered at all.
Innocently because the Provider believes this is the best medication for the situation, or because the Provider is unaware of the Formulary.

Finally, there is the interpretation of the order… by the patient. For in the last review, it is the patient’s use or non-use of the medication that matters. What does “twice a day” mean? Every 12 hours?  8 am and 5 pm? or 8 am and 12 Noon? We have frequently seen patients who interpreted it as 8 am and 12 Noon. Does it make a difference? Really? Yes, it does!  Frequently we have found just simply correcting medications to an effective schedule was all that was required to bring an uncontrolled diabetic patient under control.

And it really helps to write why the medication is ordered- on the script.
This is particularly helpful for elderly or illiterate patients relaying on in-home assistance. These patients have upwards of 10 prescriptions and without a diagnosis on the medication label, often have no idea whether this medication is for blood pressure or that one is for diabetes. The danger, of course, is inconsistent use and possible overdose or underdose (“I didn’t need this one today”, or "I took an extra one of these pick pills because I had a headache.”)

We are working in Rural Health with its multiple limitations. I simply try to provide the best medicine possible…adjusted to the patient’s abilities and needs. It does no good to order meds they won’t use or cannot afford, or do not understand why they are using them.

About the author:
Mr. Duval is a master’s level  Family Nurse Practitioner in El Centro, California for past 12 years.  Employed by El Centro Regional Medical Center – and works in the Rural Health clinic. Also member of Disaster Medical Assistance team – (DMAT) from San Diego (CA-4) with history of deployments to Louisiana (more than one), Guam, St Croix and Katrina in New Orleans. All for hurricane aftermath.

Adjunct professor at Imperial Valley College- Science, Math and Engineering Division –
Content Editor for California Rare Fruit Grower’s magazine.

Comments or feedback? Email us at advocate@csrha.org.

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