The first time I heard patients referring to a doctor as "waiting on" them was in New Orleans during my residency (medical specialization). At the time, the phrase rubbed me the wrong way -- I did not go through years of school to be thought of as a waitress. I did reflect on it, however, and found it has shaped my views on service and my approach to delivering health care. Leaving the academic world of residency to work in a community health center has made it apparent how complex it is to serve in a climate where money dictates who, what and how you are able to assist.
I recently saw a 27-year-old woman in clinic who had just had a miscarriage and incidentally was found to have low platelets (cells which help your blood to clot). She had seen a hematologist while in the hospital but could not follow up after being discharged because their group did not accept her insurance. That hematologist had started the patient on medication, but she ended up suffering from a myriad of side effects related to it. Understandably, the patient wants to see a specialist for follow-up care, but it will take months for her to be seen by another specialist, given the current health plan she is on. So the question remains: how do you get a patient the care she needs and wants?
Physicians in underserved settings sometimes have to be creative in order to get patients the care they need. I saw a patient recently who, over a period of months, had developed progressive weakness in both legs. A few months prior, she had been a stay-at-home mother in reasonably good health who enjoyed playing basketball. But, when I saw her, she was unable to walk without a cane. We referred her to a neurologist, however she could not get insurance approval for an MRI scan and other necessary studies. When she came back for her follow-up, her condition had deteriorated; she now had to use a wheelchair and had developed slurred speech. We needed to act -- and fast. We sent her to the ER with a doctor's note, hoping that the ER doctor would agree to send her for an MRI. Luckily, she was admitted and received a thorough workup, which confirmed the patient's diagnosis of Lou Gehrig's disease, a degenerative disease of the nerve cells in the brain and spinal cord that control voluntary muscle movement. She is now receiving the services she needs.
The problem with this is that the ER should be the last resort for any patient. It costs much more money to take care of patients in the ER instead of a traditional, and quite frankly more compassionate, primary care avenue. In a setting of limited resources, it is a waste of valuable resources to treat patients this way.
Should insurance companies dictate or hold hostage service to patients? The ability to provide good medical care should be a collective issue. We need to rethink the delivery of health care in resource-poor settings and shift resources so that we can keep up instead of playing catch-up and save the ER for what is really set up for: emergencies. We cannot afford to be apathetic towards the current delivery of health care in resource-poor settings as it impacts the service we all obtain.
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