A better approach to primary care is imperative for improving the delivery of health services to our nation’s population. As a family medicine resident, I see the need first hand in the mountains of East Tennessee.
It’s 11:30pm on a Sunday night when the medical student and I receive the ER call.
“A thirty-two-year-old diabetic male with uncontrolled sugars and right arm cellulites, I think he needs admission.”
When I reach the ER, Mike is waiting for me. He is a mildly obese man with an unnaturally swollen, red arm. It hurts to the touch and I can guess that it is infected. As I begin the exam, I ask why he hasn’t visited a primary care physician already. His simple answer is disturbing: “I don’t have the money and I don’t have insurance.”
My attending staff arrives to continue the patient’s evaluation, but the simple emergency room visit is complicated. My supervising attending intervenes.
“Dr. Reddy, this is more serious than it looks. Let’s get a surgical consult, MRI of his arm and start him on empirical antibiotics—STAT.”
This is not an unfamiliar scenario. Mike is one of many individuals unable to purchase the necessary medications to manage their medical conditions. Unfortunately, he is neither the first nor the last in this regard.
The high cost of living
Beth is a 55-year-old retired nurse with a history of type 1 diabetes when she visits the health clinic in Sevierville, Tennessee. She’s stopped in for a routine check-up and mentions troubling pains in her forearms after repetitive movements and occasional numbness in her fingers.
“How long?” I ask.
“Six months,” she answers.
I test to evaluate her current condition to check for carpel-tunnel-syndrome. The result is positive. This is not encouraging news. Beth is a patient who visits the health clinic because no insurance company will provide coverage on account of a “pre-existing illness.” In addition to type 1 diabetes, Beth now adds carpel-tunnel-syndrome to her list of current medical conditions.
“If the pain worsens, go to the emergency room straightaway,” I tell her.
Beth smiles weakly, “Thank you.” She is not the only troubled patient I encounter at the Sevierville Health Clinic.
No money, no medications
Sophie and her husband, Jay, are next, walk-ins with complaints of upper-abdominal pain exaggerated with food intake. They share that they both have jobs, but no health insurance, an explanation often classified as the “working poor.”
“We don’t know what to do, doc.” Jay says. “The acidity is killing us!”
“Have you tried any medication?” I ask. The first lines of available heartburn medications are cheap and available at our clinic. The second line is comparatively expensive and we have no samples.
“Yes, we’ve tried those.” Sophie refers to the first line medications. “But they don’t work. We’ve tried antibiotics, too, but those don’t seem to work either.”
As a long-term sufferer of heartburn myself, I can relate to the unnecessary distress they are suffering through. That very same night, my wife and I stop for a meal at a local restaurant. As we walk to the car, my heartburn flares up. I stop at a nearby pharmacy and make a purchase to quell the symptoms. It is almost a reflex to take what I need to for my health’s sake, expecting it to work as always—without a second thought.
But I felt guilty remembering the morning conversation with Sophie and Jay. The memory is vivid in my mind as I recall asking them about possible medications before they left the clinic frustrated and empty-handed. There was nothing else I could do for them then. As my own heartburn faded, I wondered if one of them might have had a stomach ulcer or worse—if they were bleeding from a possible ulcer.
Primary health care: Haves and have nots
As a doctor, I am disappointed to realize the failure to relieve human suffering, especially when the treatment was simple and available. In one of the most advanced nations on earth, I refuse to believe that there are individuals and families who cannot afford basic primary health care.
It troubles me to witness similar encounters over and over again. In most other countries citizens can live pain-free and disease-free from such conditions. Why must these patients suffer? Why are some families forsaken? Why do I have the privilege of affording simple medications while my patients cannot? Is it because I have worked hard all of my life moving up in society to a point where I can afford insurance and thus, be entitled to good health care? Why are my patients struggling through their lives as if they do not have the same rights and privileges to good health and happiness?
It is not the individual’s fault. Our displeasure should be directed towards the faults of a structure that remains unsuccessful in properly sharing the benefits of medical discoveries and technological advances. In the name of individual responsibility, low and middle-income families have been overlooked, neglected and/or exploited by powerful for-profit companies. Such companies use the media to spin anything or anyone supporting basic health access for all citizens. Supporters of basic health access are labeled “socialist” or “European” thereby muddling the public’s understanding of the true matter at hand.
The patients I talked about earlier and whose names have been changed to protect their identity, originally had minute health issues which could be easily treated with affordable solutions under a hundred dollars. Because they had no access to a primary care physician, these patients landed in the ER while in the last stages of the disease process. Medical expenses of more than $10,000 were the result, a price eventually paid by hardworking taxpayers. This is hardly their fault.
The importance of a structure protecting every citizen’s right to primary care access is necessary. While I appreciate small government, our current private sector approach to healthcare has been grossly unsuccessful in providing ways to share the advantages of medical innovations and advances for today’s society.
Where have all the doctors gone?
When it comes to health care, more money is spent per person in the United States than in any other nation. However, the United States continues to produce poor health outcomes by comparison. For instance, the United States spent 16 % of its GDP on health care in 2007, yet still ranked 28th in infant mortality rates. In various studies, particularly the research of Dr. Barbara Starfield, it has been shown that lower cost health care systems produce better health outcomes when employing more than 50% of their physicians in primary care. Such statistics should not be overlooked.
In the United States, primary care physicians account for less than 30% with family physicians a mere 12%. The education and support of our family physicians directly impacts the health of our nation, especially in rural areas where limited accessibility to good health care is alarming.
Is there a solution?
Yes. It requires a multi-tiered approach. The first step is providing basic universal health coverage and the second is to meet the demand of the first by training more primary care physicians. Unfortunately, fewer and fewer medical students are entering the primary care field because medical students see that they can earn $3 to $4 million more in their lifetime in a specialty field than in primary care. This can be remedied by decreasing the payment gap amongst physicians, providing incentives for going into primary care, and improving public relations with media to create more equitable representation of family physicians in popular TV programming to increase attraction to the field of primary care.
This will provide the physicians needed for better access to quality health care and it will inspire others to take the same path.
Pursuit of happiness
Suffering and hardships are in abundance, but when we encounter unnecessary human suffering, we should respond with compassion rather than objection and opinionated speculation towards the politics of health care.
Instead of turning away from the problem, we should think in better terms, believing that “These are my fellow men and women, mothers and fathers, brothers and sisters, all who are suffering for nothing. They have a right to good health and the pursuit of happiness equal to our own.” We all have the right to live rich and well-fulfilled lives, without our health being a burden.
I would like to emphasize that health is not a Democratic issue or a Republican issue, because it resonates deeply in both parties on many levels. This troubling situation requires action from everyone. It is universal and individual, because we can all relate to it as human beings. Let’s not demonize one party over another and sacrifice our health because we cannot agree. Remember, for the American eagle to soar proud and high, we need both a left wing and a right wing—and they must flap together.
Trishul Reddy is Chief Resident, Department of Family Medicine, East Tennessee State University.
