Saturday, November 14, 2009

For Medical Students: Primary Care, the Uninsured and Painful Lessons that Lie Ahead

On a rainy and blustery evening last week, I had the pleasure of speaking to an amazing group of first and second year medical students at Downstate Medical School in Brooklyn – part of the State University of New York. I am not sure whether they came for the Thai food or to hear me speak but I had the opportunity to tell stories of my medical school, residency and practice experiences – each highlighting some of the fundamental values underlying primary care. My message was that patients are increasingly demanding primary care as a trusted way of negotiating an otherwise incredibly confusing and fragmented health care system. I stressed that primary care physicians must stay focused on the needs of their patients above all else and that our loyalty and responsibility towards our patients must always remain first and foremost in our minds and actions – unfettered to the maximum extent possible – by advertising and loyalties to our hospitals or peers.

As I wrapped up my comments two questions came from the audience. The first, quite predictably, concerned my feelings about the “government controlling health care” and how I felt about that. I asked if the young woman asking the question from the very back of the room was asking about the much debated “public option” in the current health care plan passed by the House last week and she nodded affirmatively. I explained that the plan does not call for the government to control health care, rather that we would be adding another type of government subsidized and managed health care plan to the already existing government plans – namely Medicaid and Medicare.

A tougher question came from a young man in the front of the room who asked how our community health care system could survive financially taking care of the number of uninsured that we currently cared for. And that question truly cuts to the heart of the health reform debate, though I wasn’t fast enough on my feet to realize it at the time. Our 24 site community health care center network in Manhattan, Bronx and the Mid-Hudson Valley cares for over 10,000 uninsured individuals and provides them with over 35,000 visits a year. I explained that to pay for this we literally cobble together funding from dozens of sources. Our Federal 330 grant pays for some, New York State indigent care funding picks up another piece, and grants that support the care of the Homeless, the care of some uninsured patients affected by HIV and dozens of other grants for sub-groups of our uninsured patients – all go to support this work and keep us afloat. I stood there proud that our organization – the Institute for Family Health – had been able to accomplish this.

Yet I missed a real opportunity to underscore the fundamental reason we need health reform in this country. People need health insurance. Our country cannot depend solely upon health centers like ours as the safety net for everything patients who are uninsured need for their care. They must have coverage to pay for all the essential health care services they need. Primary care is the front end of an entire health care system which must provide access to people for diagnostic services, treatments, hospitalizations and medicines. With people of color 2 to 3 times more likely to be uninsured in New York City providing insurance for everyone is an absolutely essential step towards eliminating racial and ethnic disparities in health outcomes. And with primary care providers already struggling to create viable practice models in underserved areas, only full insurance coverage of the people who need these providers can sustain these practices and attract new doctors to these areas.

I am sorry I missed the opportunity to explain more to the students in Brooklyn last week about the failings of our current health care system. But I am not worried that their education will be lacking for very long. Soon the students will begin their clinical rotations in the hospital and there they will no doubt experience, first-hand, the failings of our current system to provide health care for all our people. They will see people suffering the effects of poorly treated chronic diseases – losing their legs and their kidneys to long-standing diabetes. They will see people with cancers that would have been curable if only they had been detected earlier. They will see people with advanced infections that have gone untreated for days or months and now require prolonged hospitalizations. These lessons will hit hard and perhaps some of them will understand and will choose to become the next generation of primary care physicians and the new champions for needed change in our health care system.

1 comment:

helen said...

dear dr calman, i stumbled upon your article while trying to find a way i can get the surgery i need. i just had the mri yesterday and the dr`s secretary called to inform me that i need surgery and to find a way to pay for it or find out about indigent care in my county. when i first started seeing this doctor i had very good health ins and went in a few times a year for cortisone shots in lower back which helped but over the last few years i have lost my husband in an accident, several other members of my family and had been scammed out of thousands of dollars to contractors for home improvements. i tell all this because i look to myself and my faith that i will stay strong and see my dreams for a business of my own with a hands on art gallery for the community. i have and still do volenteer work with a missing persons org and feel good in my heart to unconditionably to help others in the lowest time in their lives. maybe i have neglected putting my own affairs first and about 3 weeks ago i started having extreme pain and numbness in my left leg and lower back. i was told several years ago that i have several herniated disc. and now i cannot standup straight nor walk more than about 30 feet and in constant pain. i already have incurred emergancy rm bills and felt to guilty to go back so i went to a neighboring town when the pain kept me in tears. the doctor came in and looked up at the ceiling and told me there wasn`t anything that they can do but if i had $125.00 they can give me some shots for pain and a few days of pain pills. i said ok but this doctor didn`t look me in the eyes or muchless touch me. i felt like thats all he thought i wanted, but i really wanted someone to tell me some options since i no longer have ins. i really felt like a freeloader but maybe so. i owe others and currently barter my services to show good faith. i live in south texas and felt compelled to write you because your story conveyed to me that you hope these med students will have compassion to all under all circumstances and to provide their best to all human kind. my question, do you know of any doctors that would consider bartering a surgery or would it be an ethical issue? i am an artist in many mediums, hand made tiles, stainglass, just a few. if not, i do want to say, keep up the good work. thank you, h. davis