Man, I had forgotten just how bad our health care system is if you’re lacking health insurance. And if I’ve forgotten it after only a couple months, I can’t imagine what kind of skewed perspective most physicians have.
We have two excellent free clinics run by the medical students, Pacific Free Clinic, and Arbor Free Clinic. Medical students, PA students, and undergrads see patients, and then an attending sees the patient with the student. I used to work on the steering committee at both clinics, and spent many weekends at both helping to run them. But since my own clerkships started, I hadn’t been back. So this weekend, I volunteered to see patients at both, and what a shocker I was in for.
I saw a man and his wife at one of the clinics–both overweight, both diabetic, both with high blood pressure–and neither with health insurance. They weren’t checking their blood sugars regularly, they had run out of medications. (They were fine up until he lost his job a year ago.) This meant that when we checked their sugars and blood pressures, they were of course sky high. Long-standing high blood pressure is a major risk factor for strokes, heart attacks, and kidney disease. Long-standing high blood sugars are major risk factors for developing diabetes complications–heart attacks, nerve damage, retina damage, etc. So we diagnosed the problem of these uninsured folks, but treating them was the bigger challenge. An aside: I was completely surprised by how much I really have learned in only 6 months–I pretty much knew how to manage these patients from a theoretical standpoint. Their lack of insurance, however, upgraded the treatment to a level of complexity for which I hadn’t trained.
How do you treat them? With education, medications, and doctor visits every few months. We could do some basics of education in the clinic, but understanding diabetes is a pretty hefty bit of education, since so much of it requires patients to manage themselves. Medications we could also do to some degree–we have donated meds in clinic, and we can also give vouchers for free meds through a local pharmacy (the clinic foots the bill). Unfortunately these patients had been on a bad set of medications–some wrong ones for diabetics, and we wanted to start some new ones. This meant we needed labs. We drew some blood, and Stanford gives the clinic a great deal on blood processing. Finally, for the doctor visits, we referred the patients to a local clinic, but judging by their body language, they were hoping to get their long-term health care through our free clinic. Now, we’re happy to try to see patients like this, but our list of similar patients has grown so large that we’re not able to see them as often as they need to be seen. Throw on top of this that it’s a teaching clinic, with bad continuity of care and mostly students, and the clinic is less than ideal for chronic disease management. But we tell ourselves (and patients probably tell themselves the same) that some care is better than none, and hope that today just means that we’re one day closer to some sort of better health care system.
Fast forward on this DVD to the next chapter, where I see an uninsured patient whose chief complaint is “shortness of breath and leg swelling.” Heart failure? The undergrads have put the poor guy in an isolation room because of our constant vigilance about TB, and after getting a few more details from the patient about his “cough and night sweats,” I determined tuberculosis wasn’t my main concern. So we moved into a normal exam room, and I could have sworn I was on Med School Candid Camera (or for the kids out there, Med School Punk’d). Every question about heart failure I asked seemed like it was a scripted response–exactly what one might expect. Almost too classic of a presentation. He had chronic atrial fibrillation, thyroid dysfunction, and had been taking medications for heart failure already. He had run out of medicines three weeks ago, right when this shortness of breath and leg swelling started. He had huge legs, full of fluid. He had huge neck veins, full of fluid up to his jaw. He had a previous heart attack, he thinks. He had had this before, and taken a water pill — “furomide, I think” — and everything got better. So I go present to the attending, and she’s scared of even touching this patient, with all these problems. We tell the patient he needs to go to the ER to have his medication levels (digoxin, coumadin) checked, as he doesn’t get them checked regularly, and we’re worried that his heart is in trouble. The attending asks the patient to promise that he’ll go to the ER, and while he does, I’m skeptical. (The patient I’m sure knows that he’ll get a huge bill from the ER that he can’t pay.) Three hours later, I’m in the lobby calling another patient in, and I see this first patient, waiting for his son to pick him up. I seriously doubt the patient went to the ER.
Don’t like my story-telling? If that’s the case, try these similar stories: one about a family who has been denied health insurance by the only insurer in the state, because he, his wife, and their daughter have all been seen for medical conditions in the past. Or a Sacramento Bee Op-Ed about how one man’s family is dealing with the health care system.
Don’t like my story content? Well I’m sorry, but this is becoming more and more common. You’re going to hear these stories over and over, if you haven’t already.