• Rosalind Kaplan, MD

Why Can't We Do This in Real Life?

I just started volunteering at a community medical clinic, and I'm blown away by the experience. The clinic serves patients who work and earn enough that they are rendered ineligible for Medicaid, but who cannot afford commercial health insurance. Essentially, these are the folks who could easily fall through the cracks of our severely cracked medical system. The fact that many people working full time can't afford health care is an eye opener, isn't it? Low-paying jobs without benefits and the high cost of medical insurance conspire to create a risky situation for these patients.

The clinic is almost entirely staffed by volunteers. There is a paid, full-time medical director, who recruits, vets, and trains all the medical volunteers, as well as caring for patients herself. There are also a couple of paid administrative people, who keep the place running. Everyone else--nurses, doctors, schedulers, translators, and more--is a volunteer. There are a variety of services available, including dental care, physical therapy, psychotherapy, and nutrition counseling, in addition to the medical primary and specialty care provided. Volunteer pharmacists run a dispensary that provides medications to patients at no cost.

I spent my first afternoon shadowing another doctor, in preparation for my own first patient session. I was thrilled to see that the coordination of care and the collaboration of different disciplines is what I'd always wished I could have provided to my patients when I was in primary care practice. Sadly, the labyrinth created by the business of medicine often threw up barriers.

Here's an example. We saw a middle aged patient with a complaint of shoulder pain for three weeks as well as heart palpitations on and off for over a year. She spoke only Spanish and the doctor I was shadowing was an English speaker. A translator accompanied us to the exam room and helped the doctor obtain a complete history of the problems. The doctor then examined the patient, and ordered an EKG, performed by a nurse, and a holter monitor, which was arranged by one of the schedulers. Medication for the shoulder pain was dispensed at the visit, and a physical therapy evaluation was scheduled, as was a follow-up medical visit in a month. Had the patient needed to see a cardiologist, or one of a number of other specialists, they are available right on site. If she needed emotional support, or required dental care, these, too are available.

Had this same patient showed up at one of the hospital-owned practices I worked for in the past, things would have looked quite different. I would have used a telephone translation service, and held my phone, set to speaker, up for the patient to yell into, and then wait for the translator to yell the question to me in English. The patient would have been given prescriptions for the holter monitor and physical therapy, which she would have then had to schedule for herself. There's a good chance she wouldn't have actually gone to physical therapy, as the copay for each visit could be between $40 and $100, prohibitive for many people. She would have gone to the pharmacy to get her medication, but might have been told that the medication required a prior authorization. She might have also been told that her heart monitor required a pre-certification. I would be notified that the prior auth and pre-cert were required, and would begin the paperwork to obtain them. Then we'd wait for approval from the insurance company. With luck, her test and medication would only be slightly delayed. Otherwise, I might have to file an appeal for a denial of care, and perhaps the test would be done weeks later, or if we lost the appeal, not at all. She'd also continue to be in pain until her medication was approved.

Because we are volunteers at this clinic, 45 minutes is scheduled for each patient visit. For some complex patients, that 45 minutes will all be used to meet with the patient. For a simpler situation, some of that time might be used to chart in the (admittedly outdated) electronic medical record, or to teach the medical students who choose this community site for one of their primary care rotations. In contrast, in 'real life', I had 15-20 minutes with a patient, even a really complicated patient, which was usually inadequate. It left everyone involved stressed and pressured, in the service of pushing the patients through to maximize our billing.

Hundreds of people volunteer at this clinic. Some are retired from full-time practice and still want to use their skills. Others, like me, work at other jobs, but volunteer for the sense of meaning and connection. For me, it is also for a corrective experience, to remember what it can be like to do medicine as part of a community of professionals who have only the patient's interest at heart. To practice medicine without feeling alone, isolated, and under intense time pressure. To perform patient care without being judged for my data entry skills or the speed of my computer keyboarding, or feeling like a cog in the big machine of corporate medicine, cranking out enough 'Relative Value Units' to justify my existence.

I volunteer because I want to remember what it feels like to make eye contact, and to learn more about my patient than her diagnoses. I want to remember what it feels like to do the right thing (like sending a patient with a tooth abscess to the dentist instead of throwing penicillin at it and hoping for the best, since my patient has no way to pay for a dental visit). I want a taste of working in a place where solid, compassionate care by someone who gives a shit is considered a right instead of a privilege. I want to give that compassionate care and then go home with my soul intact. If I grieve, I want it to be for the suffering of my patient and not for the failings of our broken healthcare system.

When I leave the community clinic, I feel at peace with the profession that seems to have gone to war against its own soldiers. Why we can't find a way to make 'real life' medicine just a little more like this?

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