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the below letter is from the JAMA issue 10/11/06.skip to the last paragraph if you need to. Basically, this physician questions whether the "extra effort" he makes really is part of the problem--- enabling the problems in certain areas of care to persist.
I challenge you all to think about if the pipeline of HPSP and military "culture" play similar roles -- enabling the problems/poor patient and staff care/ manning issues and many other issues which only persist because "they can" persist as long as HPSP and military culture allow them to.
The Imaginary Safety Net
David B. Kilgore, MD
Tacoma,Washington
[email protected]
JAMA. 2006;296:1701-1702.
The nursing note for my next patient stated simply, "Follow-up of nose injury." Randy (not his real name) was a young man, new to the clinic, so there was no background information available from the chart. I knocked on the door, stepped into the small examination room, and introduced myself to a short, unshaven young man with a bandage covering the end of his nose. I learned he was involved in a fight three nights ago and that his assailant had "bitten him on the end of his nose." He had been treated at the local emergency department and had been referred to a plastic surgeon for follow-up. Upon calling the surgeon's office for an appointment the next day, however, he was told that because he had no medical insurance, he would need to bring $500 cash up front just to be seen for the first appointment. When he called the ED back to complain, they gave him the number of our community clinic. Randy looked at me angrily. "I make minimum wage, Dudeno way I have that kind of money lying around. What am I supposed to do?"
Ive cared for underserved populations my entire professional life, and his is an all too familiar story. The safety net for uninsured patients, such as it exists in the United States, stretches paper thin between emergency departments and community clinics. The buck stops with us, if it stops at all. When poor people have nowhere else to turn, they come to us. After almost 20 years of seeing the results of poverty and lack of access to care, I still never know what to expect behind the next exam room door.
I reached forward and gently began to peel back the bandage. Many times patients are referred to plastic surgeons for fine-tuning of cosmetically important wounds, like facial lacerations. Surgeons have the extra training to do subtle wound improvements or scar revisions to help obtain the best cosmetic results. This young man seemed like a rough-and-tumble sort of guywhen I reviewed his basic medical history, he proudly regaled me with his various physical exploits that resulted in several broken bones, three amputated fingers, and various bodily scars. I was a little surprised he would be concerned about having a plastic surgeon attend to a scar on his nose, but then again, it was his face and he had a right to the same level of care as his insured brethren.
His problem, however, wasn't with a scar across his nose. His problem was that he no longer had a nose. Pulling back the last layer of bandage, I stifled a gasp. In the middle of his face, between his eyes and mouth, was a jagged wound. There was a small remaining upper bridge of nose jutting down, but the fleshy end was traumatically missingbitten off.
As horrific as it was, the wound at least showed no signs of infection. I rebandaged it, instructed him about further wound care, then promised him that the clinic's outreach worker would get to work on trying to find a plastic surgeon who would see himfor what? For free? Not likely. He had the classic dilemma of the working pooran injury or condition that wasn't a life-threatening emergency but still clearly needed treatment. His low-income job offered no health insurance but paid him just enough to disqualify him for Medicaid coverage.
Our outreach worker sighed when I gave her the referral request. She added his chart to the towering pile on her desk, muttering her suspicions out loud. "What was he doing that night anyway? Did he provoke the fight?" In other words, what was his responsibility for his current predicament? Is he simply paying for his poor choices? I often struggle with these kinds of questions. I struggle first with myself, to acknowledge how easy it is to pass judgment on those whose lives and backgrounds I can scarcely imagine. I struggle with how judgments of the health care community can sometimes make it more difficult to render compassionate care, whether subtly with sarcastic comments and nonverbal behavior, or overtly with substandard or denied care. And this is a slippery slope to start down. Who among us has not done something stupid that resulted in an injury, however small? Are injuries that happen to insured people somehow immune to judgment and more worthy of society's dollars? The choices of many to overeat and not exercise are resulting in an epidemic of diabetes, hyperlipidemia, and vascular disease with very expensive consequences: Are these patients therefore to blame and not deserving of coverage for their medical treatments?
During a follow-up visit, Randy asked me to check his shoulder, also injured in the fight, and I noticed persistently elevated blood pressure readings as well. I diagnosed a torn muscle in his shoulder and new-onset hypertensionproblems that at least I could treat, although in limited ways due to his lack of insurance. An MRI scan would have been helpful to confirm his torn shoulder muscle, but he simply laughed at the $800 he would have to come up with. Physical therapy would have been helpful in his recovery, but instead I printed out self-guided exercise instructions in lieu of the $600 bill he again couldn't afford. I had samples of blood pressure medication I could give him, but he insisted on postponing important baseline laboratory tests of his kidney function and electrolytes until he covered his rent that month.
On his third visit, I learned we had succeeded in getting Randy an appointment at the county surgical clinic 60 miles away, at some distant time in the future. He still wore a gauze bandage over his wound, even though it was healing well, to shield himself from stares from passersby. His blood pressure was down, and his shoulder was feeling better. As I prepared to leave the room, he reached out and vigorously shook my hand. "Thanks, Doc. Youve done more for me than any of them fancy hospitals." I was initially embarrassed by his effusive gratitude, but later, as I sat finishing his chart, I found myself feeling sad and angry. I reflected on all the care he would have received had he been insured. As community clinic physicians, we do what we can but know it's often not enough. We know that some care is better than no care, but we carry the burden of knowing what care and treatment someone with insurance would have received. At times, and especially early in my career, I have been proud of carrying that burden, of being part of a safety net for the neediest. At other times, and more so lately, I wonder if my very participation in this system plays a darker rolea complicit roleof enabling the disparity of care to persist, of helping to provide false reassurance that we actually have a safety net that provides adequate care to all in need.
A Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.
