A Little Kindness… and Equity

She was truly one of the loveliest human beings I’ve ever met. A crown full of tight black curls, soft brown eyes, and skin the color of crème caramel. She was young and vibrant, knowledgeable and intellectual, insightful, warm and kind. A professional woman. Very poised and “well put together”. She had a nice job and insurance, which does not matter to me but matters to some; I point this out only to indicate that she should have treatment options, but she feels she doesn’t. She was relegated to go somewhere she felt she would receive sub-standard care from someone who really cared nothing about her and treated her with contempt. She had purchased, as many Americans, a more “catastrophic” insurance plan. The premiums were not cheap but not the most expensive either. So, to break it down, she had a plan that literally covered nothing for a young heathy person. It was a great plan if she contracted something like meningitis, a serious injury, or something even more horrendous like a critical case of Covid that put her on a ventilator and cost a million dollars to treat. But it did not cover basic healthcare, medications or sick visits. She had an $8000 deductible. So, she was relegated to pursuing healthcare at the local health department, which should meet if not exceed the standard of care, but unfortunately did not. She felt like she was treated with less dignity than cattle. Most people feel they are treated with indignity in these settings. They are marginalized. They are made to feel, according to her, “dirty“ and “poor”. Even though she had insurance. She said that at the urgent care, we treated her with dignity and respect. Her insurance did not cover our visit. She had to pay “out of pocket”, ie, cash. And she felt like she was treated with respect, like everyone else. Shouldn’t everyone be treated with respect? Like family? Her report hurt my heart. And it grieved me that she was not the only one that felt this way. Many people come to our clinic and pay cash to be treated more respectfully. This should not be. Really, it shouldn’t matter your gender, race, ethnicity, orientation or any other blessed thing. Everyone should be treated like family. Everyone should be treated how they would want to be treated. But, sadly, this is often not the case.

When I was young, My family was extremely poor. We lived in the projects. We wore hand me downs. We ate free lunches. Sometimes, the lunch lady would give me an extra roll because she knew that I was poor and hungry. It was often the only substantial meal that we had that day. We found ourselves in this predicament partly because we were abandoned by our father and partly because our overwhelmed and depressed mother self medicated with alcohol and drugs. She was was a single parent and she worked very hard. But, it still proved very difficult to make ends meet. We were some of the poorest of the poor. We had no access to health care. Actually, today, the very poor often have substantially better healthcare than the average middle-class American. Those on Medicaid can get seven dollar prescriptions (if they can find a doctor that will accept their insurance and prescribe the medications they need). Those who pay $600 - $1200 a month for insurance often have huge deductibles and have to pay full price for care and for their medications. How many times have I been begged to please order the free medication from Publix? Or from the four dollar menu at Walmart? I am not sure that most of us are aware that the most marginalized groups of Americans have the least access to healthcare. In fact some people have called this ecofascism, according to some, “environmentalism through genocide”, the eradication of entire groups of individuals to help decrease the population , leading to a perceived “positive” impact on the planet. As a small example, I have had patients that have gone to the emergency room because they felt the could not breathe. They were evaluated and released, even though they were still quite ill and still had the sensation that they could not breathe. They likely had Covid pneumonia and may eventually have had a bad outcome, but they were not felt to be sick enough to be admitted to the hospital. They weren’t even tested for Covid. They were told to go to the convention center to receive the free Covid test from the county. They may have already waited 8 to 12 hours in the ER to be evaluated. They were not tested for Covid because only those that are gravely ill and surely to be admitted receive the Covid test in the ER. It is because it is part of a more expensive respiratory virus panel and they cannot afford to waste this test on just anyone. Only the sickest of the sick receive this test. So, after discharge, my patient made his way to the long lines at the county testing site. There were over 400 people in line. It would probably be another six to eight hour wait. He was simply too sick to stand in line. He had Covid that led to symptoms affecting the G.I. system, leading to diarrhea, nausea and vomiting. How can someone stand in line 8 hours with nausea, vomiting and diarrhea… and shortness of breath? So he opted to come over to us, wait yet again, and pay for his Covid test. $100. Just to be told that he indeed had Covid and there was really not much we could do for him. He had to return home to quarantine and use over-the-counter medications to treat his symptoms. Currently, there are no effective antibody treatments that can be given. The current strain is not susceptible to them. We can prescribe antivirals which are brand new and may or may not be helpful and may cause side effects. What a conundrum. Where does the Eco fascism come in? Many of the poor may not receive the same care as those with better insurance plans. One of our patients was transported by his wife to our clinic. He was short of breath and stopped breathing on arrival. Our staff tried desperately to revive him in the parking lot but were unable to. He died of Covid. He was 35 years old. Many do not have the same access to care that others do. Many of them are lost. Unfortunately, the most marginalized, segregated aspect of American culture is possibly the medical system. There is discrimination based on race, ethnicity, sexual orientation, even size. Many are prejudiced against obese patients. If you are African-American, you are far more likely to receive peritoneal dialysis or hemodialysis than a new kidney. It grieves me to know that many go without care or succumb to disease that could have been prevented or treated.

I recently left primary care for these and many other egregious reasons. Many of the Medicare replacement plans were created solely for the financial benefit of the selfish companies that created them. Physicians are incentivized not to treat. My brother-in-law’s doctor forbade him to go to the specialist though he had a an ischemic limb, which is a medical emergency. He needed emergency treatment and his provider refused to allow it and declined to authorize the referral recommended by another specialist because it would cost him part of his year end bonus. I could not be a part a system like this. If the consumers actually realized what was going on, there would be an outcry against, and an uproar about what is actually transpiring. It is shameful.

I felt I was working 90 hours a week to make money to “support the man”, wealthy individuals standing on top of my shoulders, cracking the whip to do more in less time with less resources. I did not go into medicine for this.

So, I joined forces with an Urgent Care. I work less hours and help more people. They are less complicated, to be sure. But still, I feel like what I do matters. I have more time to spend with my family. I am happy.

But there in lies the rub. I could do more in primary care, substantially more, to help those with less access to care. The challenge posed to the writer of this article was “Tell us the steps you’re going to take to foster kindness and inclusivity in 2022”. As much as I would love to continue in the urgent care setting, being an hourly employee, taking care of simple illnesses and injuries and having a much needed respite from a lifelong, intense family medicine profession, somehow, I feel drawn back into primary care. I have been offered a position to serve in a, “direct family practice” setting where those who do not usually have access to medical care will finally be able to. I will not have a big corporation standing on my back cracking the whip, dictating how I chart and what I do and how I can take care of patients. It will still have many challenges, to be sure, but also much freedom for the patients and for me. I will no longer have a panel of 3000 patients; it will be limited to 500. Hopefully, it will be one small effort to help open access to those who usually do not have it. Patients will be treated with dignity, kindness and respect, regardless of background, race, creed, orientation, or any other attribute. On the one hand it seems like a very small endeavor. I am reminded of the story of the little boy plucking up stranded starfish from the beach and pelting them back into the ocean. An old man approached him and informed him that there are thousands of starfish on the beach and that he could not possibly make a difference with his small, inconsequential efforts. Quietly, he picked up the starfish and launched it safely back into the warm saltwater, “Made a difference to that one”.