Presenting Complaint: Social Injustice

By ANISH KOKA, MD

Bobby

It took some doing, but I had finally
made it to Bobby’s home.

It was a rowhome tucked into one of those
little side streets in the city that non-city folks wouldn’t dream of driving
down. As I step in, I’m met by the usual set up – wooden steps that hug the
right side of the wall leading up to the second floor.  Bobby certainly hasn’t made it up to the
second floor in some time. At the moment she is sitting in her hospital bed in
the living room. The bed is the focal point to a room stuffed to the gills with
all manners of stuff. At least three quarters of the stuff seems to be food.
Cinnamon buns, Doritos, donut holes, chocolate frosted Donuts, crackers,
Twinkies. The junk food aisle at Wawa would be embarrassed by the riches on
display here.

Bobby weighs in at four hundred pounds, 5
foot 5 inches. She has a tracheostomy from multiple prior episodes of
respiratory failure that have required ventilatory support. I’m here at the
request of a devoted primary care physician that still makes home calls. I’ve
looked through the last number of hospital stays. The last few discharge
summaries are carbon copies of each other. Hypoxemic respiratory failure
related to pulmonary edema complicated further by morbid obesity. Time on the
vent. Antibiotics. Diuretics. Home. Return to the hospital 2 weeks later. The
last echocardiogram done was 3 admissions ago. A poor study. Not much could be
seen due to ‘body habitus’.

I sit on the side of the bed trying to
acquire my own images of her heart. I talk to her as I struggle. Bobby is 58,
the youngest of three sisters, and the only surviving member of the family. Her
elder sisters died of respiratory complications as well. They both died with
tracheostomies. The conversation is circular. The problem according to Bobby is the tracheostomy. Everything was fine
before that. I explain that a prolonged period of time on the ventilator on a
prior admission prompted the tracheostomy, and that the multiple recent
admissions to the hospital that required a ventilator seemed to validate that
decision. She doesn’t waver. Both her sisters died shortly after they got
tracheostomies. Bobby thinks the physicians taking care of her sisters had a
hand in their demise. “They didn’t care”. “We told them they
were sick.”

Perhaps.

The picture on the nightstand suggests
Bobby was the smallest of the three sisters.

It doesn’t take much to get Bobby
talking. Her favorite holiday is July 4th because she makes the family favorite
tuna casserole, and her favorite niece, April, helps her with the casserole
every year.

Meanwhile, the echocardiogram shows a
large right side of the heart. Her pulmonary pressures are elevated, and she
seems to be fluid overloaded. Review of her bloodwork from the hospital also
strongly suggests her weight may be hampering her ability to expel carbon
dioxide. She really needs to be on a ventilator nightly. In other more normal
contexts there are additional diagnostic steps to take, but trust won’t be
built in a day. She’s heard variations of these recommendations before. She is
adamantly opposed to any other invasive tests.

But a small victory. She agrees on the
higher diuretic dose.

Bobby is black. I’m brown. We hail from
very different zipcodes.  She clearly
harbors a deep mistrust of the medical system. But I’m hopeful to make some
inroads. It doesn’t seem to  matter to
Bobby that I’m brown, or that I was born in Delhi, or that I reside in a much
different zipcode than her.  At the
moment, I’m just another caregiver in her living room.

I sense a thaw.  As I pack up, she asks me when I’ll see her
again.

Hopefully soon, Bobby.

Mr. Chalhoubi

Hussain Chalhoubi is in the office with
one of his three devoted daughters. It’s a different daughter every week and I
can never keep their names straight. I met him after he had suffered a stroke
that leaves him frustratingly aphasic. He enjoys food and drink, and like
clockwork would appear in my office in the early years frequently with swollen
hands and feet days after a dietary indiscretion. He always had a sheepish look
on his face as his exasperated daughters would tattle on him.

At some point I learned there was little
point to piling on. Scolding only gets you so far. Instead, I asked him about
Syria. Boy do those eyes light up. His family had fled shortly after Syria had
been plunged into civil war.

I’m curious who he blames for the mess.
Assad, the dictator who the US has held responsible? He vigorously shakes his
head. His daughter chimes in.

“We are Christians.”

Not much more needs to be said. Assad may
be the boogie-man to many, but he is an Alawite, a minority sect of Islam in a
sea of Sunni Muslims that makes up the Levant in the Middle East. The rebellion
against the Alawite Assad is of the 
behead-first-ask-questions-later extremist Sunni kind that scares the
Syrian Christian minority much more than the ruling dictator accused of his own
share of atrocities.

As the conversation comes back to the
medical, he forwards through his daughter that he has been trying to flush out
his kidneys by drinking copious amounts of water.  I try to explain to him that his kidneys and
his heart don’t function normally, so they can get overwhelmed. 

No flushing.

Over time, he’s started to listen
more.  He doesn’t skip his medications,
avoids drinking too much.  He used to be
in the office monthly, but now every 3-4 months for routine visits. 

Serving patients, or populations ?

It is now a rather quaint idea that
outcomes for patients are best improved one doctor-patient relationship at a
time.  I understand the sentiment.  For most patients the outcome is decided well
before their encounter with me.  Your
zipcode seems to be a lot more important to your outcome than your doctor, and
unsurprisingly a movement to address matters that have traditionally lived
outside of the health care system has gained steam

In an earlier era the doctor’s mission
was to recognize and manage diseases.  
Medical students were taught to hear the severe aortic regurgitation
that was causing the progressive shortness of breath.  The advances in the management of disease
over the last half century have been nothing short of magical.  Crack open a chest, arrest the heart, replace
an aortic valve, bring the heart back to life. 
The power of medicine realized was to change the natural history of
disease for the ill patient that arrived in distress seeking help.

And here the very reasonable human desire
to address systemic inequities in society found synergy with a darker current
of thought within medicine that felt the resources expended to care for the
very ill are resources poorly spent.  The
focus, the theory goes, should be on preventing illness in the much larger
healthy population.  The scope of keeping
the healthy well, of course, extends well beyond the medical, and puts
everything in play.  Sanitation,
transportation, air quality, climate change, access to the means to pay for
healthcare are just the start of a long list of priorities for those in
charge.  These programs need scarce
budgetary dollars, and so it was only a matter of time after the government
started paying for healthcare that politicians and the public health gurus they
empowered to manage the health of the population began to voice their disdain
for the care of those deemed “too ill”.

The tension here is that medicine’s
greatest strides in the last half century have come in those with afflictions
that brought them to death’s door.   The
inroads in this group of unfortunates have come by way of super-specialists far
removed from the concerns of the worried well. 
Richard Lamm, the former governor of Colorado famously derided the work
of Thomas Starzl, the father of organ transplantation, questioning the great
surgeons use of public health resources to attempt to save individual patients
at death’s door.  These were the early
days of transplantation, when successes were a far cry from the results enjoyed
today.  As the passage of time made
transplantation success rates north of 90% and the public watched children
destined for death skipping down hallways, Lamm’s cold calculus came to easily
be rejected. 

Yet in 2000, writing for Health Affairs,
Lamm doubled down.

“Colorado’s
doctors were constantly reminding me that in medicine, ‘cost was never a
consideration.’ But health care was the fastest-growing segment of my budget,
demanding increasing amounts of public funds for the medical school, for new
equipment at the hospital, and for Medicaid. Daily, if not hourly, hospitals in
my state would effectively appropriate state funds for a high-risk, low-benefit
procedure, while I knew that those funds could easily save more lives elsewhere
in the health care system or outside of it, say, by buying three new teachers,
fixing a broken sewer main, or adding two police officers to a high-crime area
for a year. How could cost not be a consideration in making a public
budget?”

“How
can patient advocates feel so good about the system they work in when I, as
public advocate, feel so guilty for having so many people without even basic
health care?”

It never strikes Lamm that the citizens
he is so desperate to ‘cover’ with health insurance may want to choose not to
die and opt to receive an organ transplant. 
What good is a health insurance plan that doesn’t pay for life saving
therapy when you actually need it?  This
would be akin to paying for a fire suppressing sprinkler system, but not paying
to have firefighters come to battle a structure threatening blaze. 

The kinder, gentler, smarter society the
ideology Lamm represents is a society that turns its back on the tangible,
acute needs of the sick for hypothetical needs of the well.  In a perfect world, perhaps one could do
both.  Unfortunately, when it comes to
interventions for the worried well, controversy abounds for how exactly one
accomplishes this.  Does one advocate for
zoning and tax policy to allow fresh produce and groceries to be sold in poor
zip codes to address ‘food deserts’ so Bobby has more healthy options?  Should we advocate for sin taxes on alcohol,
tobacco and sugar containing products that by their very nature are meant to be
regressive taxes that affect the behavior of patients like Bobby?  Does caring for Mr. Chahloubi mean taking a
position on US foreign policy interventions in that country, or perhaps
advocacy for immigration for asylum seekers?

In an age not so long ago, it was easily
recognized that the answers to these questions were to be wrestled with well
outside the purview of the medical field. 
That a growing number in the medical community think medical training
gives us special expertise to solve these problems speaks to a self-important
medical echo chamber that believes society’s values should mirror its values.

We would be wise to heed the words of
C.S. Lewis – “Of all tyrannies, a tyranny sincerely exercised for the good
of its victims may be the most oppressive. 
It would be better to live under robber barons than under omnipotent
moral busybodies… those who torment us for our own good will torment us
without end for they do so with the approval of their own conscience.. This
very kindness stings with intolerable insult. 
To be “cured” against one’s will and cured of states which we
may not regard a disease is to be put on a level of those who have not yet
reached the age of reason or those who never will; to be classed with infants,
imbeciles, and domestic animals.”

Bobby and Mr. Chalhoubi aren’t
particularly interested in my views on sugar taxes or my feelings about Bashar
al-Assad.   They want someone invested in
them, not in some abstract population. 
Advocacy by physicians has its place. 
Its just not in the exam room.

Anish
Koka is a physician in private practice in Philadelphia.

The post Presenting Complaint: Social Injustice appeared first on The Health Care Blog.

Presenting Complaint: Social Injustice published first on https://carilloncitydental.tumblr.com/

Author: BrighterLife

I am a certified Dietitian and won many accolades for my award winning The Nutrition Guide. I am also co-founder of Step Consulting and guiding you to live a healthier you for more than 20 years. I have more than 30 years of work expertise if you are looking for overall wellness and not just about shedding your weight. I have the quality to empower whoever comes in contact with me to take charge of their health and wellbeing. It is all about balance and moderation, with simple concept of eat less and active more. A Master's In Public Health keeps me abreast of the latest health concerns and on the cutting edge of intervention. Focusing on aging and longevity with a holistic approach to living your best life is my pathway to inner peace and happiness.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s