:: to the teeth ::    thoughts on social justice, medicine, race, hope and beats

"Another world is not only possible, she is on her way.
On a quiet day, I can hear her breathing." :: Arundhati Roy ::

"The most common way people give up their power is by thinking they don't have any." :: Alice Walker ::
Thursday, October 27, 2005  

Case Study

33 year old woman, spanish speaking, undocumented, great sense of humor calls early in the day. she works until 6:30pm washing cars so she's glad we are open until 7pm. She complains of right sided numbness and tingling, both arm and leg, for two days which is now beginning to improve.

Later in the day, at the clinic, she presents as a jovial, slightly overwieght, intelligent woman, single mom with a six year old child. Her concern is clear - "am i having a stroke?" she starts by telling me that she felt so bad the day before she went to the public hospital ER. After 7 hours waiting, 6pm-1am, feeling worse, she went home "to die." of course she didn't die and after a thorough physical exam, reassuringly normal vital signs, a normal family history, and no strong risk factors, it was clear her symptoms were of a myofascial pain symdrome, not vascular disease.

I let her know she was lucky that she left the ER. they probably would have done too many blood tests, a CT scan of her head, EKG and charged her $1-2 thousand for the workup. as a single mom washing cars all day, the last thing she needs is a bill for 3-4 months of her yearly income.

So we talked about her job and it turns out she just transferred two weeks earlier to a busier location where she doesn't even have a break of 15 minutes for lunch. she drinks sodas all day for energy and downs an occasional greasy burrito. at home she doesn't have enough energy to make dinner so they do fast food. no time for stretching, for basic exercise, for play or dance. it's an untenable existance, an impossible paradox. the human body cannot sustain such rigor and stress for more than a few months before symptoms arise and eventual serious illness.

not many options available. probably the only two important things i did were to reassure her she wasn't going to die from a stroke and to acknowledge her stressors (legitimize and humanize her experience of suffering as wrong). i tried recommending she and her car wash colleagues try to organize for a break or at least create a coverage system for each other, she didn't think it would be possible. i recommended massage as a vluable investment and offered her an appointment with our awesome massage therapist volunteer, Jennifer. (she's been massaging our patients for a few months now, every wednesday. it's a beautiful gift of hers to our patients. for many, it's the first massage experience in their lives, the first times they have let themselves physically relax, release stress, and enjoy the touch of a therapist. Thanks Jennifer!!).

There is a story in this story that needs to be a driving force for health care reform. the way we practice medicine on uninsured patients is detrimental to their health. our protocols, our fear and lawsuit driven testing strategies shift huge cost onto these tired, ill individuals, those least able to suck it up. this happens with so many myofascial pain syndromes, from headaches to neck pain to chest pain to unilateral weakness, etc. the cost of the ER visit would pay for 1 years worth of appropriate massage/exercise, physical therapy, time off work, etc. and the ER visit doesn't even diagnose this kind of pain after all the tests since many docs don' touch their patients. this leaves the patient with the large bill, no education, no emphasis on healthy lifestyle modifications... how did we go so wrong? maybe it's just my local environment. i'll hope that's it.

posted by andru | 10/27/2005 07:04:00 PM | (3) comments |

Thursday, October 13, 2005  

The Grace of a Late Payment

a few months ago I took care of a young man with pneumonia. he was quite sick, with moderate dehydration. he had a history of IVDU (using intravenous drugs) and was Hepatitis C positive. the man was now hard working in the construction business, a day laborer, a devout Christian, and sober. he showed up at the clinic when we were closed and I happened to be there, trying to finish some administrative chores. he looked awful. I started an IV, gave him 3 liters of fluids and IV antibiotics and advice to return the next day for follow-up. he came in once more two days later and got another shot of IM antibiotics and then a sample of some strong antibiotic pills for 10 days. at that point he disappeared, still owing me about $50 for all the treatments. a week ago, I was calling folks who owed some money and spoke with his brother. i left a message for him to call the clinic.

this evening, consistent with the previous visit, he showed up after we were already closed. I almost didn’t recognize him since he looked healthy. he respectfully and humbly asked if we could talk for a moment and then i remembered who he was. he shared with me his story of the past few months.

he is from Mexico and when he realized how bad the illness was, he decided to go home to rest and recover. he was worried that he might get worse and wind up in the hospital, which would have cost him too much here. once home, it took him a few weeks to recover from the pneumonia. then he had to get back to the U.S. which cost him ALOT of money at the border for safe passage. he was back at work and embarrassed that he still owed me money. when he finally saw his brother today and got the message, he came right over to apologize and let me know his intention to pay the balance.

I’ve touched on this before but will say it again here. in the year we’ve been up and running, we have probably “given away” about $700.00 in free care from folks who don’t or cannot pay. that’s out of approximately $35,000.00 in revenue working with mostly poor uninsured immigrants, students and artists. that’s 2% loss. it feels frustrating when you do a good job caring for someone and the person walks away without sharing some kind of fair exchange. but as practitioners we have to really make a decision – do we get all tight and wound up and freaked out and angry and make a mountain out of a mole-hill? or do we appreciate the many beautiful , graceful moments that happen with the majority of our patients, who even in their difficult financial struggles, act with integrity?

I don’t want to be angry or mean to the small handful of patients who disrespect me. I won’t give them that power. Likely they are wounded and frustrated people. what disturbs me is that this personal choice to act with anger or compassion gets translated into social policy and whole systems that are supposed to be part of the “safety-net” wind up operating on the punishment mentality. Using stereotypes based on the actions of a tiny minority of manipulative patients, entire philosophies are born that wind up trapping people of integrity with lesser means into hostile payment systems and prejudicial thinking. this is cynical. we all know there are criminals, upper class and lower class, who take advantage, who manipulate. we know that anyone can abuse the generosity of another. being alive is a continuous struggle to renew, to refresh, to shed old tight skin, to breath deeply every now and then and realize that if I have enough, then I can share, then I can relax. Don’t get me wrong, I respect cynical people, I’ve been one before and I periodically slide over the line. Life can bite hard. But the goal is to not stay there too long, to let yourself soften, let love and laughter and food and play soften our hearts and open again.

As I relax into this non-institutional health clinic, I am amazed almost daily by the glimpses and vistas of grace that people exhibit when they are treated with respect. I often hear people sigh after a visit and say that they were at the end of their rope, that they had lost almost all confidence in doctors, in medicine. I’m not sure if it is really my intention to revive that hope since the system is so corrupt, but I think I understand what is really being said – it’s not about medicine or doctors, it’s about humans caring for humans. it’s about people with professional training acting like people and not machines behind thick walls and desks and 5 minute time limits and frustrating nonsensical narrow perspectives, etc…

the moral of this story is that a few scoundrels aren’t going to stop me from appreciating the grand beauty of so many of my patients.


posted by andru | 10/13/2005 09:54:00 PM | (0) comments |

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