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George, A major obstacle can be finding any authority figure (board, council, etc.) to agree that a physician is incompetent to treat a PWP. Most of us who find our way to a movement disorders specialist have a few "irregular/unusual, etc." Parkinson's symptoms or are not responding tremendously well to medication.......hence, we were not able to find satisfaction with our family practioner or local "general" neuro for treatment..................so to the specialist we would go. 1. Mary mentioned several months back that her insurance provider would not cover a Parkinson's specialist for consultation or second opinion..........Mary probably felt that she received much better info from the specialist than a general neuro practice. Mary was probably correct in her assessment. 2. We in NE staged quite a protest when the only Parkinson's specialists in the state were graciously encouraged to leave the UNMC to free more space for other specialties (transplant). We were told in PUBLIC MEETINGS numerous times by UNMC Administrators that there were still 7 (or 8) neuros on staff who could treat Parkinson's. In reality........none of those remaining wanted to see us.............1 specialized in children's seizures, one in tumors, one in adult seizures and so on..... none of the remaining were PD specialists. Eventually even the nurses in the PD unit were dismissed. The administrators were dead wrong, proven so later by their own staff.......but would the admin ever admit error? 3. Some physicians are not able to handle (emotionally themselves) chronic degenerative illness. I have worked closely with oncologists who will not continue to treat a patient in hospice..........emotionally cannot handle palliative care. Wise person to admit this openly. But neuro's who find it difficult to deal with a PWP the same age as neuro......may find it very difficult to admit their own human fraility. 4.. Geographic isolation is a problem. 5. Telecommunications is available on a limited basis in NE but I do not believe there is any availability to PD patients at this time..............telecom. time is very tightly scheduled in many rural settings..........large population and small staff to support. More critical issues to support. Your ideas and suggestions are good........but incorporating some of these ideas in rural areas will/could be almost impossible. We have patients in NE (and other mid-continent states) who are more than 100 miles from nearest hospital (of any size) and probably travel 400 miles to see a neurologist (not specialist). Outreach centers from the University service telecommunications to many parts of the state, but you could still be talking hundred+ miles travel. (We have school districts in this state with less than 5 students!!!!!!!). Solutions that appear easily implemented are often complicated by sheer distance and isolation and physical fitness. Rita