The sky was gray, a gust of rain occasionally spitting. Quite a while before we opened, a dozen people were in line. Deb, our intake coordinator, kept moving back and forth, between practitioners and patients, maintaining a coherent flow, against the odds – like herding cats, as they say.
At first, I was committed to working cooperatively (as a physician on the bus) with our nursing students, but since we were at capacity almost immediately, rapid “processing” of ill, injured, and worried humans took precedence over thoughtful collaborative education, and we separated to each perform our separate duties.
We were blessed with a three-nurse team, who cared for people with wounds and complicated self-care issues. Dr David appeared out of the blue – I hadn’t expected him! – and took over on the bus for a couple of hours. I went out to visit with people on one of the rain-soaked park benches, getting all but the physical exam, to try to “cut down on the list.”
A number of patients couldn’t wait to be seen, and had to leave. I think we can start giving people estimated wait times, just as you’d do at a popular restaurant: count up the number already on the list, and multiply by 12 minutes each. Ordinarily, we see about 20 patients per four-hour day, so that would work: ordinarily, a visit would average twelve minutes or so.
Twelve minutes is not enough! However, we just don’t have unlimited resources. People really need medical attention. So we try to move people though as quickly as is practicable, and hope they don’t feel uncared-for.
This Sunday wasn’t ordinary, though! With two doctors available part of the time, we saw 27 people. Average, eight minutes and fifty-three seconds a visit.
Eight minutes and fifty-three seconds is not enough.
“How can I help you today?” We* sit down on the wet park bench.
A terrible pain in the belly – a recent bereavement – a stressful new job with a lot of heavy lifting (kept just under full-time, so no health insurance would be offered). Couldn’t afford the tests the old doctor wanted (and now the old doctor refuses to follow up due to past due doctor bills); high blood pressure and keeps forgetting to take the medicine – and can’t sleep because of joint pain.
After talking for a while, we got on the bus for a physical exam – “Occupying” one of the curtained exam “rooms.” A careful history and physical indicated the belly pain was probably not a cancer or a blockage; straining made it worse… a hernia. The blood pressure recheck, resting and lying down, showed it really was through the roof. We talked about improving it; and how to safely handle joint and muscle pain at home; and how to start the process of finding a surgeon (without insurance or money), while preventing the hernia from getting much worse, given the circumstances (a new job with heavy lifting) – and, with tears and sniffles, how to adjust to the loss of someone very dearly loved – given the circumstances.
“How can I help you?”
An “eye infection,” “caused by drinking alcohol” – lasting “for the last year.” It really looked more like an allergic problem, in both eyes. Dizzy spells: a while back, the emergency room prescribed a diabetes medication that drops your blood sugar, but they weren’t eating regular meals, and, as I said, drinking a lot. Not taking their blood pressure medicine… I hunted down the pharmacist, who was stocking the back room with vitamins and over-the-counter remedies. I ended up writing a prescription for antihistamine eyedrops, which are expensive – don’t know if we can get the charities to cover it, though. We bagged up a bottle of sterile water and an eye cup, with written instructions. See you next week for a recheck.
Eight minutes and fifty-three seconds, or twelve at best, aren’t long enough to give somebody a set of guideposts to keep chronic or recurrent problems from becoming severe.
Removing one set of ingrown stitches from one elderly patient’s eyelid took a long time. Why didn’t they go back to the hospital to get them removed weeks ago? “Nobody told me to.” Convincing another to seek out an AA meeting – and to keep going, every day – to help with intolerable loneliness (“I just can’t take it anymore”) and depression (“self-medicated”, unsuccessfully, with heavy drinking) – that took another long time. Trying to help people figure out how to get the specialist consultation their condition required – when they didn’t have any money, but weren’t yet sick enough to go to the emergency room – when I don’t WANT them to get sick enough to go to the emergency room – twelve minutes, eight minutes and fifty-three seconds? Really?
My new motto is, “Two hours ain’t bad!” Because I want my colleagues to come on down and help out for two hours a month.
There are 732 hours in a month. If, like most doctors, you work 50 hours a week, that’s about 225 hours a month. This month, there were 192 weekend hours. You probably spent about 60 of them asleep. Two hours ain’t bad! If five more doctors or FMNPs would donate just two hours a month, then our current three doctors could cut back to two hours a month, too. However, we’d be thankful to just have two more practitioners. They could just put in two hours a month; we’d keep doing four, but all the shifts would be filled; all the patients could be seen.
So much strategizing.
Sometimes it seems like a wonderful and grand experiment: what would it look like if we really regarded health care as a human right? What if people with skills just dug in and started providing it? To me, it’s a simple matter of social justice, most of the time. I remember when I was a young mom with three kids on Medicaid and couldn’t find them a doctor when I needed one, and I remember clearly how it was out of the question that *I* could have a doctor myself, without any “coverage” or cash. I just tolerated sickness as best I could. So the social justice idea is pretty visceral for me.
But then I actually get on the bus, and now the problems are even more visceral. How can you manage your blood sugars when you are living outside? How can you heal up that tendititis, that fractured scaphoid bone, when the only job you could find was grunt labor with constant heavy lifting? You stupidly got mixed up in IV drug abuse, which was a bad mistake, but you also missed the lecture about why safe sex is important and how to keep from getting pregnant – what will become of you? You’re injured, but the water company turned off your water. How will you keep that wound clean? I was vocally frightened by your bright yellow eyes and swollen belly, and I talked you into going to the special “homeless clinic” for labwork – and they put you on a two-month waiting list. Every single thing about health is about money, unless you stumble across our clinic bus.
I go home from the bus both tired and inspired, after this FOUR hour day, a traffic flow so unexpected but so crucial. I can’t help but be a little apprehensive about the challenges to come… Winter is coming. Bronchitis and pneumonia and “boot rot,” and all the messed-up blood sugars and blood pressures and everything else that goes along with people being under-cared-for, “under-covered” in the winter – they’re coming.
*Details have been altered to protect identity, but reflect real peoples’ complex situations.