Don't become a doctor #20 - treating the source

I am fond of telling people that all the advances of modern medicine account for maybe about 3% of the improvement in the health of the human condition. The other 97% of the betterment of humanity can be credited mainly to three things: clean drinking water, sewers, and immunizations. There are some other things too, like labor laws and pollution controls, but pretty much everything we do now in modern medicine is the equivalent of sprinkles atop an ice cream sundae. Your toilet has done more for the betterment of humanity than I ever will.

And really, the future of the improvement of the health of humanity doesn't lie in anything I can do or modify. If I wanted to make the biggest impact in the improvement of the health of humanity for the betterment of the general public, then I would institute universal basic income and mandatory pre-K through 12 education. I can do a lot of things right now: I can treat hypertension and diabetes, I can diagnose and treat complicated medical conditions, but I do not have a pill to treat poverty. I have no prescription for socioeconomic oppression.

Mrs B can't afford her medications. She has Medicare, yes, but she pays a monthly premium for a supplemental plan that only gets her out of pocket expenses down to $10-15 per prescription. How is that going to help her pay for the 8 pills I am prescribing? Best case scenario, that's $80 a month, but she only gets $800 from Social Security, and she spends $500 of that on rent. She literally cannot afford to be healthy. I see her every 3 months for what purpose? The diseases I am treating are not the principal problems of her life. Another $300 a month would make her far healthier than another diabetes medication. Having a blood pressure under 150/90 isn't going to get her electric bill paid. I asked her about it once. 

"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?

In America we always talk about pulling ourselves up by our bootstraps. But really, that assumes you have boots. If you don't have boots, then what? Forget boots, what if you don't have feet? We do not have equal standing in any respect. We do not have equal opportunity, equal adversity, or equal ability. If we do not share equally for the potential of success, then how can we expect people to be successful? So I don't spend much time with the successful. I spend most of my time with the losers on the battlefield of life: the injured, wounded, and crippled from chronic stress or poverty or oppression or injustice. They're the ones calling out for a medic.

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.