My medical assistant interrupted me last week at the community clinic where I work in South Los Angeles to see if I could step away from my current patient to check out another. “He cut his hand, or something,” the medical assistant told me. I often do sutures for uninsured patients to spare them the emergency department bill, but I was already far behind and not relishing the idea of taking extra time out for this patient.
But I discovered that it wasn’t a simple cut. While working on a machine (I didn’t stop to identify what kind), he had actually shaved away a chunk of skin over his left knuckle. The glistening tendon, in clear view, flexed as he opened and closed his fingers. I thought he wanted stitches, but really, he thought that all he needed was a tetanus shot—the injury was already three days old.
The economic crunch has devastated South Los Angeles. Life is hard, and as I wrote the
referral to the ER for this man, I reflected on just how desperate he must be to try to ignore his exposed tendon.
The volume of patient visits to my clinic has increased by 30 percent in the last year, and 50 percent from two years ago. We turn away patients daily. The next available appointments are two and three months away. Sicker and sicker patients show up in our clinics, creating terrible delays in services for scheduled patients.
“All we do is urgent care,” one of my colleagues said to me recently. We had just referred a patient with dangerously low oxygen levels back to the ER after he had been discharged from the hospital too soon.
When life is so precarious, our patients understandably prioritize subsistence. Patients regularly arrive in clinic with plastic bags full of medications purchased in Tijuana. The medicines have often been taken over months and years without physician input rather than risk an American medical bill. Sometimes the combinations are downright dangerous.
The push for healthcare reform has again raised national debate over the most effective way to compensate delivery of medical care—fee for service, pay for performance, capitated flat rates. In our system, many of our adult patients are seen through a capitated county program. No matter how much or little we do, we are reimbursed at the same rate. Our particular system rewards doing less.
As a doctor, I am caught between patients who deserve more and a system that gives less. I thought my main challenge would be to create care opportunities. I never expected how hard I would have to work to convince patients that they needed more. The system wants less, and many patients do, too.
Our patients often lack the energy to prioritize comprehensive care. In the face of such difficult circumstances, a healthy future is an abstract concern at best. They don’t care if their blood pressure is elevated. There are no bothersome symptoms. Take care of the cough, and patients leave happy. Never mind that they have substantial risk of developing heart disease over the next 10 years. They need to report to work tomorrow.
For my clinic in South LA, we are always financially on the brink. Last year we provided more than half a million dollars worth of care to patients who did not qualify for any type of aid. Each day is a gamble—patients line up on our sidewalk waiting for the doors to open, desperate to get in. How many can we see? If we don’t bill enough to survive, we will be of no service to anyone. Yet if we don’t provide an adequate medical home with comprehensive primary care, what is the value of the services rendered?
Clearly we need to create some balance—between paid and unpaid, urgent and comprehensive care. As I think back to the patient with the hand injury, I feel grateful that at least one clinic values his health more than he does. I hope I will see him again one day soon. Maybe it will be just to change a dressing, but hopefully on the side, I will be able to provide some real primary care.
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.
