“What’s that white guy doing here?” my medical assistant whispered as she passed me in the hall at my clinic in south central Los Angeles.
A quick glance at the reception window, indeed, revealed a tall man with sandy blonde hair, requesting an urgent care appointment. I overheard the equally tall and blonde woman accompanying him explain to the receptionist, “There’s like blood and pus coming out….” A second, more studied look at the man revealed a patch of angry red skin barely peeking out from the neck of his shirt. I swung by the receptionist and told her to pass him in, no matter that we were overbooked that afternoon.
At my clinic, the clientele is primarily Latino and largely undocumented. Another percentage is black, and there are always a few others—some Anglos, a few Pakistanis, and we once had a Korean woman. With his tousled hair, tanned skin and angular features, casual button-down, and flip-flops, this guy looked like he had just blown in from the beach.
Probably an abscess, I thought, as I pulled his chart off the rack in the exam room door. Jeff was sitting on the exam table when I entered the room. As he unbuttoned his shirt, I suddenly understood the wardrobe choice—it concealed a tumor the size of a baseball growing out of his chest. A thin layer of gauze awkwardly affixed with tape barely covered the purple-black fleshy mass. “The crazy thing is that it kind of has these two lobes, and if you pull them apart, it starts pumping out blood,” he said.
Jeff’s girlfriend sat on a chair in the corner, hugging her purse to her chest. She leaned in to hear what I thought. I did a perfunctory general physical exam to, I don’t know, to cushion the blow, to make them think I had considered all the possible alternatives before jumping to the obvious conclusion. “You have cancer,” I said. “Of course I can’t prove it, but I have to be honest with you. That’s what it is.”
“Yes,” he said. “I thought so.” His girlfriend wiped away a tear.
Jeff worked as a poker instructor, and he earned nearly double the Medicaid cutoff when he was employed. He had no insurance and was afraid that the medical costs would ruin him if he sought care at an emergency room.
For years, Jeff had noticed a small, flat lesion on his chest. But the tumor had grown up over the previous two or three months. Jeff wasn’t much of an eater when in the best of health, only one meal every one or two days, and he hadn’t noted much of a difference in his appetite. He only felt a bit more fatigued, and the tumor was painful at times.
Jeff had tried to make an appointment at another free clinic closer to his West Los Angeles neighborhood. But, like all other free clinics in the Los Angeles area, the recent economy has resulted in patient volumes 30 percent above average. The first appointment they could give him was not for another two months. I’m not exactly sure how he found our clinic.
Immediately, the conversation switched to money. How would we pay for this care? His income left him with few options. “How well do you know your boss?” I asked him. Maybe he could call his boss, ask to be laid off, and then go to the emergency room and state that he was unemployed with no foreseeable income. I checked with our benefits coordinator, and I made another call to the lawyer who has partnered with our clinic to provide free legal aid. Finally, among all the ideas, the best was to be laid off.
I called Jeff a few weeks later to find out what happened to him. “Well, they told me it’s definitely cancer,” he said. “As soon as I got there, they admitted me, and then all these people kept on coming in just to look at the thing—residents, students, doctors, everyone. They gave me all these clinic appointments, but I keep showing up, and they tell me I’m not on the list. Then I wait for hours until they finally get someone to see me. My next appointment is tomorrow. Maybe they’ll tell me what kind of cancer it is then.”
Jeff seemed glad for the opportunity to talk, and I was eager to listen. By chance, I was the first doctor he saw. He thought he needed my expert medical opinion, and at some level, I did, too. But by the time Jeff sat on my exam table, he already knew he had cancer. In fact, in the 30 or so minutes we spent together, we probably spent only three actually talking about cancer. The most important thing I did was talk to him about money.
“And the cost?” I finally asked. “Did they find you some kind of insurance?” I asked.
“Well, that’s kind of a funny story,” Jeff said. “That first night, I was meeting with the benefits person, and she was asking me all these questions about my income. All of a sudden, I look down and notice that my pants are wet. And I realize that the tumor had started bleeding again, so they immediately rushed me back to the ER. I never went back to the benefits lady, and no one has said anything about payment since.”
Ellen Rothman, HMS ’98, practices at a community health center in Los Angeles.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions or Harvard University.
