Category Archives: Caring for Patients

Caring for Uninsured Patients: Help is on the Way

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When I launched my private practice, it was on the Eastern Shore of Maryland in a small town.  I joined a physician who had been in practice for several years.  I managed to keep my schedule light for a few weeks so I could study for my Board Examination.  I had just finished my residency training but I was no stranger to outpatient practice.  After my return from the exam which I opted to take in Orlando, I never saw fewer than 20 patients a session.  The busiest days saw us seeing 30 or more patients.  I admit that many walked in but most were scheduled.  This was in early 90’s which was the beginning of the rise of HMO’s.  My practice was hospitable- sponsored.  In less than 1 year, I had repaid the hospital the loan and started to make a profit.  Many of my patients were uninsured but a significant number were Medicaid, Medicare and HMO. I welcomed the Clinton Health Plan and even was interviewed by local newspapers.  Sadly, for my community, it never happened.

The Affordable Care Act (ACA) will change the number of uninsured patients in the US.  While I was on the Eastern Shore in the 90’s, it was apparent that many of the residents had no way out of the cycle of poverty and the health problems neglected from being uninsured.  The reality played out in the Emergency Room of the local hospital day and night.  Being uninsured affected every family. Our community had business owners who were farmers, fisherman, mechanics, contractors and shop owners.  Many made too much money for Medicaid but they could not afford the cost of private insurance.  Many of them landed in the ER with serious medical conditions they had ignored.  Some even called my office and were seen as emergency visits.  One particular case was a bit scary.  One of my staff called and brought her brother in.  He was complaining of chest pain and would not go to the ER. They came to the office and I did an EKG.  To my surprise the brother was having an acute myocardial infarction.  He was uninsured and was still refusing to go to the ER even as the ambulance arrived.  We did get him there.  He and I had a tense ambulance ride together to the tertiary care hospital and I handed him off to the cardiologist who greeted us both and whisked him off to the Cardiac Intensive Care Unit.  Weeks later, the community came together for a fund-raiser.  I attended and was to my surprise honored by everyone for my excellent care.  Unfortunately, I had to leave to go to the ER to care for a patient that was not so fortunate.

I had hoped that the HMO’s would make healthcare affordable but that did not happen.  The reality for patients then and now is that if you lack insurance, you end up in the ER.  I worked with the local health department.  My office was ground-zero for many programs.  We saw patients enrolled in the Breast and Cervical Cancer Screening Program, Vaccines for Children and participated in every pharmaceutical company sponsored free medication program. We saw patient from the Mental Health programs, Drug treatment programs, and Adult Daycare.  My practice had so many patients enrolled in Pharmaceutical Company Patient Assistance Programs; one company invited me to give a presentation to a group of providers.

I was a member of the steering committee and a board member of the new Federally Qualified Community Health Center (FQHC) in our town. It was our answer to tacking the rate of uninsured patients.  It was hard work to get the grant written, not by me thankfully but I did read it and had to give input on the clinical operation.  I also had to pledge my service which meant clinical sessions, on call coverage and hospital admissions.  I was also involved in recruiting the first full-time provider.  We were fortunate to be designated a National Health Service Corp (NHSC) site.  This allowed us to recruit a NHSC scholar who could use our site and a 3-year commitment to repay medical school loans. The good news is that built into the Affordable Care Act is increased funding for the NHSC.  The program is now expanded and will allow an increase in primary care providers in areas where they are needed.  We were fortunate to get a brilliant young Family Physician in our community. The CHC is still there but it is now part of a bigger network. Across the US, FQCHC are providing care to uninsured and under-insured patients.

Medicine for me has always been about helping my patients. The Affordable Care Act is going to change the delivery of medical care in the US.  I am gearing up for all the excitement.  I work now as a Medical Director for Student Health Services at a major university.  All fulltime students are required to have insurance either through their parents or a plan that is sponsored by the school. The plan is also available to part-time students.  It is very affordable for students.  My task is to help students be informed about what is covered and how to access care using the insurance plan. The Affordable Care Act requires that the policy meets all the same criteria as plans to be provided by other plans.  It must provide preventive services, emergency care and coverage of medications.  There is no restriction for preexisting conditions.   The next dilemma will be if there is the capacity to care for all of the patients.

Reflecting on the SCOTUS Rulings: My Own Brush with Making History

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The Supreme Court rulings on DOMA and Proposition 8 were a great moment in history.  When I lived on the eastern Shore, I had the privilege to care for a large number of patients infected with HIV.  Many were homosexual males. At that time I was among an elite group of doctors who were Family Physicians and “AIDS Doctors” as we were called then. I had trained in New Jersey. I had several patients with AIDS in my residency training.   They were both heterosexual males and females and homosexual males. Many of my patients had suffered in silence with being gay and then had the added stigma of AIDS.

I really did not choose to be the primary provider for these patients.  They found me.  I had gained a reputation because of my patients.  Word was spreading and patients were calling.  We scheduled each patient  so they could come to the office without fear of being found out.  This was not easy  in a small town.  Everyone prided themselves on knowing everyone one’s business.  I have forgotten many of the secrets I dared not write in my charts. That is a good thing.  One of my patients was openly gay and he contributed to my reputation.  He was flamboyant and so much fun.  My favorite encounter came was when I told him his CD4 count and he fainted.  We made a deal that I would only tell him if there was a change that was significant.  That made our lives a little easier.  My nurse was especially happy.

He met and fell in love with another patient of mine.  They were as different as night and day, a modern-day Rhett and Scarlet.  One was a tall African-American male who gave the appearance of being fearless and the other a White male who  fainted.  Together they contributed to changing AIDS care on the Eastern Shore.  They became tireless advocates for patients and families. The two of them dealt with their illness in such different ways. Like many African-Americans, the one patient was diagnosed after a major illness which left some neurological deficits. That did not matter.

They invited me to the blessing of their union.  The priest who performed the ceremony was later stripped of his position. He was accused of performing a marriage.    We were all there and the celebration was beautiful.  It was a blessing of two courageous men. Here is a link to the article: http://articles.baltimoresun.com/1995-06-10/news/1995161005_1_priest-bishop-easton. Fortunately when I left, they started seeing my colleague outside Philadelphia.  She is still a Family Physician who cares for patients living with HIV/AIDS.

The SCOTUS decisions on Wednesday July 26, 2013 made me reflect on that time.  We have come a long way.  Lisa Winkler’s blog entry  SCOTUS & I Am Harvey Milk: Perfect Timing was so moving; it caused me to reflect on my own moment in history.  At the time, I was just being a good doctor and an advocate for two courageous human beings.  I still at that time had to worry about my personal reputation and the practice.  I still had patients who would not have been supportive of our being there. When I attended the marriage of my two friends on Staten Island last year, in a beautiful marriage ceremony, I had no fear of loss of patients or revenue.  Thankfully, I may never have to experience that again.

Anastasia: A Tribute to a Lady

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The First Office Visit:

“Hello, I am here to get this drained.  My doctor said I didn’t have to drive back to Baltimore if you could do it.”

She explained that she needed the fluid collection drained from her mastectomy site.  The surgeon in Baltimore said any doctor could perform the procedure.  Anastasia was her name.  She felt too tired to drive to Baltimore again this week.  I did not have time then to review her chart.  I took out a needle and syringe. I cleansed the area carefully with betadine and took off 20 cc of fluid.  She thanked me and left.  I would perform this procedure several more times in the next month.  She would sit there very poised without any expression of pain.  During that time we formed a bond. I learned she had a daughter around the same age as my son.  Her husband had died a few years ago. She was teaching school this summer for the Migrant Program and had plans to return in the fall to a full schedule.  I would later meet her long time friend who would provide support for Anastasia’s daughter and mother through the long ordeal.

That first time in the office, I noticed her beauty and her battle scars.  She had her head tied with a beautiful scarf to hide the loss of hair from chemotherapy.  Her makeup applied to perfection to camouflage her ashen skin.  She carried strapped to her waist an infusion pump for continuous chemotherapy.  The beautiful outfit she wore hid her thinness.  I imagined that before all of this she had been stunning even more stunning than she was even now.   Her friend accompanied her to some of the visits.  She showed a warm and supportive spirit each time I met her.  She and Anastasia taught at the same school.  She would be the one to suggest that we get help for Anastasia’s daughter and I arranged this with one of the best psychologists in the area.  She was obviously holding back the tears.  She had the special role of godmother and took it seriously.

I realized after two years in private practice that I did not feel prepared to assist and comfort patients when dying was the only outcome.

Her Story:

I later learned her story and knew that I was embarking on a long journey with this woman. She was the pride of her family and community.  Everyone who knew her loved her.  Anastasia was fighting a battle with recurrent breast cancer. She had won over 6 years before.  During the time of remission she had a child, a beautiful little girl that she adored.

Anastasia continued to see me even after her wound healed.  She had been my partner’s patient.  I felt an immediate kinship with her.  I knew that I had been chosen for the task of helping her to die with dignity.  She was not ready to admit defeat and neither was I.  Meeting her mother was difficult.  She made it clear she was not ready to lose her only daughter.  She represented all her hopes and dreams.  No mother ever dreams that their child will die before them.  For this mother, death would bring with it the responsibility raising her grandchild.  Each of our encounters would clarify her fears.  Her daughter was a perfectionist.  Her grandchild was not deprived.  She was not sure if she could live up to her daughter’s dreams for this child.

“What am I going to do?  This is not fair.  God’s will be done.”

The next few months were emotionally draining for me.  However, I learned so much about myself.  I grew from Anastasia strength and courage.  She challenged my empathy and removed the fear I had about allowing myself to care.

“ You have to help her.”  I can’t stand to see her suffer.”  Anastasia’s mother came to depend on me.  She was frightened when she witnessed her daughter’s seizure and learned she had a metastatic brain tumor.    She accompanied her to radiation treatments.  She and I took over more of the decision-making as her child weakened.  We were prepared but reluctant to make the final decision to not resuscitate her daughter at the end.  Physicians do not admit easily that their patients are terminal.  Oncologists have the hardest time.  Prior to and after the seizure we were fighting the HMO to allow Anastasia to enter the clinical trial using Taxol.  They finally agreed but realistically it was too late for her from the start.

The Final Days:

I was leaving on vacation the Monday before Christmas.  My colleague kept saying she hoped Anastasia died before I left.  I knew what she feared: if I left before Anastasia died, the responsibility would fall to her  to deal with Anastasia’s final moments. I had become for Anastasia’s mother a strong support, almost like a daughter.  I knew I had to make the transition back to myself and sever the ties before I left.  Anastasia died the week before I left.  She was admitted to the hospital.  I pushed for her to die at home with Hospice. Her mother could not sit home alone and watch her child die.   Instead, she died in a hospital bed.  Her friends and family were there.  The continuous morphine drip kept her free of pain.  She drifted into a deep sleep. Her family was emotional.  I allowed them stay in her room until she departed.    All who knew her loved her.   I was in the office when she died on Monday.  I walked over to the hospital to pronounce her and complete the death certificate.  Anastasia’s funeral would be on Saturday.

It was a cold day.  I was on call the day of the funeral.  I asked the operator to hold my calls unless they were urgent. I got there late. I hoped to sneak in the back of the church.  When I walked in the door, Anastasia’s mother grabbed my hand and held on tightly.  She wanted me to sit with the family.   She was so beautiful and still on the satin drapes of the gray casket.   Her make-up was to perfection.  Her beautiful black dress and hat transformed her.  In the distance she was radiant.  The soloist sang softly “Don’t cry for me.”  Her long time friend and high school classmate who was now a Methodist minister gave the eulogy. “She inspired all who knew her to reach for their highest goals.  She did so herself.  We who knew her will miss her.  Those who supported her in her time of greatest pain are overjoyed that she is in God’s hands.”

The soloist sang, “I am going to better place.”  We all knew she was there as we looked at her peaceful face.  No sign of the terrible pain she had just before coming into the hospital.

The Superintendent of Schools, city council members, friends and family from across the United States, attended the funeral.  Many of her friends and classmates were still living in town and I immediately recognized them as my patients and colleagues from the hospital.  They paid tribute to her as an alumnus.

The Farewell:

“Don’t cry for me.” They cried.  I cried.  I could not go the graveside service.  I was drained and on call.  I couldn’t bring myself to watch the final ceremony.  I had seen it so many times.  My grandfather was eighty and my father-in-law was seventy at the time of their deaths.  Anastasia was going too early.  I went home. In the car, I realized that this had been a revealing experience.  I could only hope that my own funeral would be so full of celebration of life and regret for the loss.  I knew she was in a better place.  Free of the pain, rid of the dreadful disease and as beautiful as she had been before the cancer. I felt Anastasia was pleased with our performance.  It would take us all to support her mother and her child.  I would be there for several years. I will always stay in touch with them no matter where I go.

I hugged my child when I got home. I answered my calls and started to pack for my vacation.  I was ready for the drive to Birmingham.  I would be seeing my own mother for the first time in months. When we finally got in the car and crossed the bridge, I sighed with relief and slept as my husband drove.  The music was soothing.  My mother would be there to comfort me.