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November 15, 2016

People : Healthcare Post-Election



Last Wednesday, it hurt to walk into clinic.

Our clinic, a federally qualified health center, is a new clinic built in 2015 from funds provided by the Affordable Care Act.  The ACA wasn't just about insurance.  Among other things, it increased access to care with 1.5 billion dollars allocated to the construction and renovation of health centers serving publicly insured and uninsured patients.

I received my medical training in a county clinic, which felt a lot like a basement.  No windows, cramped rooms, an aisle serving as the workspace for all the medical assistants.  But you grow to fit your space, and I loved the clinic for what people can make from dust.  So when I interviewed for my current job, the packed, worn feel of the clinic felt familiar, and I wanted to be there.

Then they showed me the construction for the new clinic.  Double the rooms, freshly painted walls, natural light, and just so much more space.  Housed in a building designed specifically to take into account the needs of the disabled, each detail reminds people that they are at the center. And I realized that I only wanted the old clinic because that's what I've been told we could have. This new place--this is what we should want.

Because a clean, open, loved space to receive healthcare isn't a luxury. It's the foundation for the quality of care given to people who in all other aspects of their lives get less.  As healthcare providers, we're told by society that we're entrusted with the well-being of our patients.  But as anyone who works in healthcare knows, this trust needs to be earned.  No one will listen to your advice if they feel that you don't care, no matter who gave you your degree.  This feeling starts the moment a person steps into a clinic, the space reflecting back what we think they deserve.

And so in a time when the principles of this place are very realistically threatened, so much processing this past week for me had to do with considering our role in this system.  And one thing that I keep coming back to is:

Don't underestimate the day to day.

I know it's frustrating to feel like you can't do anything for your patients when there are so many flaws and gaps in the system. When this will get worse.  Many things are uncertain how about this election will affect the ACA, but one thing is almost certainly certain: funding for Medi-Cal and Medicaid for low-income patients will be cut.  

In an already under-resourced system, I know firsthand how frustrating this is.  And I know that in the face of things like this, we often gravitate away from direct patient care and towards systems work.  I think it's important, powerful work to be involved in policy and research, to affect the bigger structure of healthcare.  And I'm not immune to the frustrations and burnout of absorbing the daily anxieties of our patients; I know we all sometimes need a break from this.

But please, please don't leave the individual interactions altogether.  

The first and last thing patients see is the face of their provider. So much of how they judge the system comes from this. So much safety and hope lies in this. We need to keep people who care in direct touch with patients, so that they have visible allies.  Patients perceive the quality of their care not by policies, but by the providers who examine them and explain medications to them and call them on the phone.  You might feel like you can make a bigger difference elsewhere, and obviously something like the ACA affects millions more people than I can by seeing twenty-odd patients a day. But the premise of the ACA relies on having people on the ground, who provide the kind of care it promises.

In medical school, I was once told by a professor that I'd be "wasting my education" by pursuing primary care.  At the time, my response was that even if primary care required less "expertise," it was something I wanted to do.  Now after three years of primary care residency and a year in community practice, I know that quality primary care involves a lot of expertise.  And if you have the privileged opportunity to gain these skills, consider all that you can do with it, especially in this time where quality might be taken from people who need it most.

You have the training to care for patients with diversely complex problems.
People often think that primary care is straightforward and boring, if you don't get to delve into the depth of a specific illness.  But for those patients with a dozen medical problems on top of food insecurity and poor housing, the primary provider is sometimes the only one who knows how all the moving parts of a person's body and life interact with one another. It takes a lot of time to develop enough dexterity with all the common problems individually so that you can coordinate them as a whole.  Now, it's even more important for patients to have qualified providers help them coordinate their medical issues through the inevitable changes in access to care.

You have the training to expand the role of primary care.
People think that all you do in primary care is high blood pressure and diabetes (and there is a lot of that).  But we also manage chronic kidney disease, heart failure, liver failure, lung disease.  We rarely send our patients to specialists because we've been thoroughly trained in how to care for most chronic issues.  In a system where specialty care for low-income patients will likely become even more scarce than it already is, we need more primary care providers comfortable with doing this kind of work.  Having well-trained primary providers can help decrease the disparities in care that publicly insured patients receive (and actually improve the cost of care overall, by preventing the unnecessary extra testing often ordered by specialists).

You have the training to remain compassionate.
I'm sometimes surprised by the care delivered by providers whose stress levels limit their understanding of their patients.  Of a patient who had arrived to the U.S. the month prior, who had difficulty understanding medical jargon while using an interpreter, one provider said: "She isn't that bright."  Of another who fought to overcome her alcohol addiction and then was diagnosed with liver cancer, a provider remembered her only by how "she stormed out of the office" when told that there "was absolutely nothing to do"--completely missing her reasonable anger and disbelief in response to an insensitive statement. When I tried to explain that she might be upset about this awful prognosis while still in middle age, he cut me off. Of another patient whose high blood pressure was unusually difficult to lower despite concrete evidence that he was taking all his medications, a provider said this was "due to his depression," and didn't warrant further investigation--a statement both illogical and unethical.  This all heightens the sense patients already have of being marginalized and misunderstood.

Of course, burnout and the many difficult responsibilities of being a provider lends itself to being less sensitive and aware, and I'm as guilty as anyone else of complaining about our difficult work and patients.  I know that these providers' behavior are a result of being fatigued by the demands of this work.  Often this includes feeling overwhelmed by the complexity of patients' medical issues.  Which is why I think that being trained well, equipped with skills to tackle medical complexity, means that we have more time and energy to consider our patients as people. And we've been trained to know that this affects their health.

If you've received a lot of medical education, don't feel like it would be a waste to do something "primary"--consider how much more you can offer patients in terms of clinical knowledge and personal care.  Consider how much people need what is primary right now.

And if you're in primary care, or any type of service for vulnerable patients whose care is threatened by this election, trust how much it matters for you to stay.

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