What the US health care system assumes about you | Mitchell Katz

A few years ago, I was taking care of a woman
who was a victim of violence. I wanted her to be seen in a clinic
that specialized in trauma survivors. I made the appointment myself because,
being the director of the department, I knew if I did it, she would get an appointment right away. The clinic was about an hour and a half
away from where she lived. But she took down the address
and agreed to go. Unfortunately, she didn’t
make it to the clinic. When I spoke to the psychiatrist,
he explained to me that trauma survivors are often resistant to dealing with the difficult
issues that they face and often miss appointments. For this reason, they don’t generally allow the doctors
to make appointments for the patients. They had made a special exception for me. When I spoke to my patient, she had a much simpler
and less Freudian explanation of why she didn’t go to that appointment: her ride didn’t show. Now, some of you may be thinking, “Didn’t she have some other way
of getting to that clinic appointment?” Couldn’t she have taken an Uber
or called another friend? If you’re thinking that, it’s probably because you have resources. But she didn’t have
enough money for an Uber, and she didn’t have
another friend to call. But she did have me, and I was able to get her
another appointment, which she kept without difficulty. She wasn’t resistant, it’s just that her ride didn’t show. I wish I could say that this
was an isolated incident, but I know from running
the safety net systems in San Francisco, Los Angeles,
and now New York City, that health care is built
on a middle-class model that often doesn’t meet the needs
of low-income patients. That’s one of the reasons
why it’s been so difficult for us to close the disparity
in health care that exists along economic lines, despite the expansion of health insurance under the ACA, or Obamacare. Health care in the United States assumes that, besides getting across
the large land expanse of Los Angeles, it also assumes that you
can take off from work in the middle of the day to get care. One of the patients who came
to my East Los Angeles clinic on a Thursday afternoon presented with partial
blindness in both eyes. Very concerned, I said to him, “When did this develop?” He said, “Sunday.” I said, “Sunday? Did you think of coming sooner to clinic?” And he said, “Well, I have to work
in order to pay the rent.” A second patient to that same clinic, a trucker, drove three days with a raging infection, only coming to see me
after he had delivered his merchandise. Both patients’ care was jeopardized
by their delays in seeking care. Health care in the United States
assumes that you speak English or can bring someone with you who can. In San Francisco, I took care of a patient
on the inpatient service who was from West Africa
and spoke a dialect so unusual that we could only find one translator
on the telephonic line who could understand him. And that translator only worked
one afternoon a week. Unfortunately, my patient needed
translation services every day. Health care in the United States
assumes that you are literate. I learned that a patient of mine
who spoke English without accent was illiterate, when he asked me to please sign
a social security disability form for him right away. The form needed to go
to the office that same day, and I wasn’t in clinic, so trying to help him out, knowing that he was
the sole caretaker of his son, I said, “Well, bring the form
to my administrative office. I’ll sign it and I’ll fax it in for you.” He took the two buses to my office, dropped off the form, went back home to take care of his son … I got to the office, and what did I find
next to the big “X” on the form? The word “applicant.” He needed to sign the form. And so now I had to have him
take the two buses back to the office and sign the form so that
we could then fax it in for him. It completely changed
how I took care of him. I made sure that I always went over
instructions verbally with him. It also made me think about
all of the patients who receive reams and reams of paper spit out by our modern
electronic health record systems, explaining their diagnoses
and their treatments, and wondering how many people
actually can understand what’s on those pieces of paper. Health care in the United States assumes
that you have a working telephone and an accurate address. The proliferation
of inexpensive cell phones has actually helped quite a lot. But still, my patients run out of minutes, and their phones get disconnected. Low-income people often have
to move around a lot by necessity. I remember reviewing a chart of a woman
with an abnormality on her mammogram. That chart assiduously documents
that three letters were sent to her home, asking her to please
come in for follow-up. Of course, if the address isn’t accurate, it doesn’t much matter how many letters
you send to that same address. Health care in the United States assumes
that you have a steady supply of food. This is particularly
an issue for diabetics. We give them medications
that lower their blood sugar. On days when they don’t have enough food, it puts them at risk
for a life-threatening side effect of hypoglycemia, or low blood sugar. Health care in the United States
assumes that you have a home with a refrigerator for your insulin, a bathroom where you can wash up, a bed where you can sleep without worrying about violence
while you’re resting. But what if you don’t have that? What if you live on the street, you live under the freeway, you live in a congregant shelter, where every morning
you have to leave at 7 or 8am? Where do you store your medicines? Where do you use the bathroom? How do you put your legs up
if you have congestive heart failure? Is it any wonder that providing people
with health insurance who are homeless does not erase the huge disparity between the homeless and the housed? Health care in the United States assumes
that you prioritize your health care. But what about all of you? Let me assume for a moment
that you’re all taking a medication. Maybe it’s for high blood pressure. Maybe it’s for diabetes or depression. What if tonight you had a choice: you could have your medication
but live on the street, or you could be housed in your home
but not have your medication. Which would you choose? I know which one I would choose. This is just a graphic example
of the kinds of choices that low-income patients
have to make every day. So when my doctors
shake their heads and say, “I don’t know why that patient
didn’t keep his follow-up appointments,” “I don’t know why she didn’t go
for that exam that I ordered,” I think, well, maybe her ride didn’t show, or maybe he had to work. But also, maybe there was something
more important that day than their high blood pressure
or a screening colonoscopy. Maybe that patient was dealing
with an abusive spouse or a daughter who is pregnant
and drug-addicted or a son who was kicked out of school. Or even maybe they were riding
their bicycle through an intersection and got hit by a truck, and now they’re using a wheelchair
and have very limited mobility. Obviously, these things also happen
to middle-class people. But when they do, we have resources that enable us
to deal with these problems. We also have the belief that we
will live out our normal lifespans. That’s not true for low-income people. They’ve seen their friends
and relatives die young of accidents, of violence, of cancers that should have
been diagnosed at an earlier stage. It can lead to a sense of hopelessness, that it doesn’t really matter what you do. I know I’ve painted a bleak picture
of the care of low-income patients. But I want you to know
how rewarding I find it to work in a safety net system, and my deep belief is that we can
make the system responsive to the needs of low-income patients. The starting point has to be
to meet patients where they are, provide services without obstacles and provide patients what they need — not what we think they need. It’s impossible for me
to take good care of a patient who is homeless and living on the street. The right prescription
for a homeless patient is housing. In Los Angeles, we housed 4,700 chronically
homeless persons suffering from medical illness,
mental illness, addiction. When we housed them, we found
that overall health care costs, including the housing, decreased. That’s because they had
many fewer hospital visits, both in the emergency room
and on the inpatient service. And we gave them back their dignity. No extra charge for that. For people who do not have
a steady supply of food, especially those who are diabetic, safety net systems are experimenting
with a variety of solutions, including food pantries
at primary care clinics and distributing maps of community
food banks and soup kitchens. And in New York City, we’ve hired a bunch of enrollers to get our patients into
the supplemental nutrition program known as “food stamps” to most people. When patients and doctors
don’t understand each other, mistakes will occur. For non-English-speaking patients, translation is as important
as a prescription pad. Perhaps more important. And, you know, it doesn’t
cost anything more to put all of the materials
at the level of fourth-grade reading, so that everybody can understand
what’s being said. But more than anything else,
I think low-income patients benefit from having a primary care doctor. Mind you, I think middle-class
people also benefit from having somebody
to quarterback their care. But when they don’t, they have others
who can advocate for them, who can get them that disability placard or make sure the disability
application is completed. But low-income people really need
a team of people who can help them to access the medical and non-medical
services that they need. Also, many low-income people
are disenfranchised from other community supports, and they really benefit from the care
and continuity provided by primary care. A primary care doctor
I particularly admire once told me how she believed
that her relationship with a patient over a decade was the only healthy relationship
that that patient had in her life. The good news is, you don’t
actually have to be a doctor to provide that special sauce
of care and continuity. This was really brought home to me
when one of my own long-term patients died at an outside hospital. I had to tell the other doctors
and nurses in my clinic that he had passed. But I didn’t know that
in another part of our clinic, on a different floor, there was a registration clerk who had developed a very special
relationship with my patient every time he came in for an appointment. When she learned three weeks later
that he had died, she came and found me
in my examining room, tears streaming down her cheeks, talking about my patient
and the memories that she had of him, the kinds of discussions that they had had
about their lives together. My patient had a hard life. He was by his own admission a gangbanger. He had spent a substantial
amount of time in prison. He suffered from a very serious illness. He was a drug addict. But despite all that,
he rarely missed a visit, and I like to believe that was because
he knew at our clinic that he was loved. When our health care systems have the same
commitment to low-income patients that that man had to us, two things will happen. First, the system will be responsive
to the needs of low-income people. It will speak their language,
it will meet their schedules, it will fulfill their needs. Second, we will be providing
the kind of care that we went into this profession to do — not just checking the boxes, but really taking care of those we serve. Thank you. (Applause)

Daniel Yohans

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