"I understand that you can't afford to do a lot of the things I'm recommending, but then why keep coming to these doctor appointments? You can save your copay." She was speechless for a moment, like that was even an option. The thought of NOT seeing the doctor is anathema to her. She wants to be healthy. She wants to do better. But she is swimming upstream without a paddle, and that paddle looks suspiciously like another $300 a month in her budget. I do a lot of counseling and education for her, because maybe she can keep up serious lifestyle changes, and maybe that will be an adequate replacement for lisinopril.
I have a sickle cell patient who is frequently in the ER or hospital. She can't stay in school, can't hold down a job, can't have any semblance of a normal life because for her, a normal life involves spending on average 2 days a month in the hospital or ER. How is she supposed to better herself when she cannot access the tools by which people better themselves? Whenever I see her, I encourage her that she needs to work on avoiding triggers for a crisis. She needs to bundle up warm in the winter. She needs to stay really well hydrated in the summer. She needs to keep active, but not too active. She needs to wash her hands so she doesn't catch any colds. Her life is a constant vigilance to prevent her own body from betraying her. When does she have time for bettering herself, when all of her time and energy is put into avoiding being sick?
The job of physician sometimes involves interfacing with a cold and uncaring world on behalf of someone unable to change their circumstance, and trying to make an improvement in a system that is fundamentally flawed. If you're not prepared to roll that rock up that hill, then think about something else. Because that is what I love about my job, that I get to fight for things that mean something, even if I'm not going to win.