Saturday, February 2, 2013

Down At The Clinic

[Note: Been working on this post all week. Taken me much longer than I thought it would. This is a fictionalized account of a recent morning spent at the health care clinic...]

When Americans lose their health care insurance -- or never had it -- as something like 60 million Americans who have no health insurance understand well, we make do with the system of emergency rooms and community clinics (assuming there are any) that passes for universal health care in this country. Or we go without.

The clinics have been a godsend in our experience, but I can't say the same of ERs, where, even if you have insurance, you're likely to be neglected, misdiagnosed and/or mistreated. I think it's time for Americans to understand that medical care is not considered a right, it's not a privilege, it's an opportunity for the practice of medicine. Emphasis on practice. Or not.

At any rate, I shouldn't complain.  My life may have been jeopardized from time to time by medical mistakes and/or neglect, but so far, every time it has been jeopardized, my life has been saved in the end by heroic interventions, so what's the beef?

On the other hand, clinic care has been remarkable, especially given that my expectations were so low.

Since moving to New Mexico, we've had to set up a whole new set of clinic relationships as our former health care provider in California -- Kaiser Permanente -- doesn't exist here, and the clinics we were using before we moved don't have reciprocity agreements with the clinics here.

As in California, it took a while to get a new patient appointment (though they say they will take walk ins without appointments), but once the appointment was arranged with the community clinic in town (Albuquerque), things seemed to go well. The place was clean, efficient, seemingly very well operated. I did some research and found out we would be dealing with one of the pioneer urban clinics in the country.

It's hard to imagine what things were like before these clinics sprang up in the 1960's and '70's, but I'm old enough to remember, and it wasn't pretty. If you could not pay for care, they might or might not take you at "County"* depending on factors which you were never made aware of. But generally speaking, you didn't want to go to "County" anyway, because even if they took you, they wouldn't necessarily take care of you. You went to "County" to die, in other words. (*"County" was the county hospital, often out in the country somewhere difficult to reach, or maybe attached to the jail, or by the sewer plant, where indigent patients were sent and treated, either at no charge or very low charge.)

There was very little in the way of public health care, and what there was was focused on specific ailments and infectious diseases -- STDs, TB, polio, that sort of thing -- in need of control/containment/eradication.

For the most part, doctors and hospitals would only see patients who could pay, and ERs were not required to accept patients who could not (ie: they'd be sent to "County" to take their chances.) The fear of "Socialized Medicine" was rampant for some reason. Better you should die a Free Man than be treated for illness or accident a Socialist Slave! America Forever!

The first community clinics I remember were the Free Clinics established in the 1960's by and for the hippies clogging the Bay Area of California and eventually everywhere else. It was recognized that the health care system in place at the time -- private fee-for-service doctors and hospitals that required payment or no care for you, or "County" where you took your chances -- was not working very well for anyone, and not at all for the free spirits of the era who were on the road, traveling, exploring, experimenting with substances and different lifestyles, often living on very little or no money at all, and relying extensively on one another for survival.

There may have been earlier free community clinics, but if there were, I wasn't aware of them. The hippie clinics were staffed by mostly volunteer professionals, med school students and skilled lay people, and they were often supplied by barter, strategy or donations of surplus medical materiel, some of it acquired from the then-bloated military off killing gooks in the rice paddies.

The free clinics would see anyone for anything that ailed them, without restriction, and most would offer their services either free of any charge, or on a sliding scale depending on ability to pay. There was no elaborate bureaucracy, no reams of papers to fill out, or insurance claims to make. It was simple, straightforward, and quite effective.

However, most clinics were not set up to handle serious or chronic illness or injury that required in-patient care. The hospital was the only place that could handle it, and if you couldn't pay, that still meant "County."

But county care was improving as more and more benefits of the free clinics were recognized. Basically, the clinics were taking much of the routine heath care burden off of the "system" -- both the for-profit and the public health system -- which allowed the "system" to focus more on chronic and serious diseases and injuries, and ultimately to do a better job.

Over time, the clinics consolidated, became institutionalized and plugged into the system. There were fewer of them, and for the most part their care was no longer "free," nor were they staffed with volunteers relying on donations of money and materiel. They professionalized. Though most maintained an open door policy, some restricted their acceptance of patients to certain service groups. Their funding sources were primarily from government programs -- Medicare, Medicaid, IHS, and so on -- which meant they had to conform to the operational standards set by their funders. They bureaucratized as they institutionalized. They became essentially indistinguishable from hospital or doctor-provided outpatient care.

Except, of course, that they still tended to serve a poor population rather than one better off.

The urban Indian clinics came a little late to the community clinic field, but they were advanced from the outset compared to some of the others. In most cases, they were immediately funded by government sources, so they could operate at a fairly high level from the get-go. We first encountered the urban Indian clinic in the early 1980's and we stuck with it for quite some time. We found the care to be more than adequate on the one hand, and the spirit of the personnel to be outstanding on the other.

Of course, they were still unable to take on serious injury or disease which required hospitalization. What they could do was make referrals, and usually, because of those referrals, the hospital care provided and any specialist services and follow up were top notch. In other words, you didn't just have to go ER and hope. Wait. Pray. Later on, that would change.

The Indian clinic in Albuquerque is one of the pioneers in the field, and it is very well maintained and operated. It takes a while to get a new patient appointment, but once that's done, it's fairly easy obtain health care service. Indians with "blue card" and CIB receive treatment at no charge, others use Medicare, Medicaid, private insurance, or pay out of pocket on a sliding scale -- which can mean free. No one is turned away because they can't pay. Though busy, it's surprisingly uncrowded. Much less so than some of the ER waiting rooms I've been in. The clientele runs heavily to Indians (shock!) but is by no means exclusively so. Not all are poor,  though many clearly are. From what I've seen, the clinic serves a broad cross-section of the population of Albuquerque and the area round about. We come in from the country, after all, a pretty decent drive over the Tijeras Pass. Not something you want to do in a blizzard, though we've done it more than once.

The other day we were at the clinic, and it was clear it was Homeless Outreach Day, for the waiting room was populated by numbers of homeless people trying to navigate the intake paperwork before being seen. Some were understandably having a difficult time of it.  One couple in particular was practically in panic over how to fill out the forms.

Every now and then, the Homeless Outreach Coordinator would appear -- a charismatic young Indian of indeterminate tribal affiliation,  his lustrous black hair done up in a pert chignon at the nape of his neck, his dark eyes flashing, his smile wide and welcoming. He'd briefly scan the room, talking to some of the clients who said they'd never been there before and didn't know the process. He'd explain that once they turned in their intake paperwork, they'd be seen by one of the doctors to assess their physical condition and then would be put on his list for counseling and referral to the various homeless services available in Albuquerque, and then he would point out that he was really racing from one site to another and he didn't have time to chat.

Off he'd go, sometimes with one of the homeless clients in tow -- "I'll take you right now," he'd say, "so you won't have to wait to get on my list. Did have your vitals taken already? Good!"

It's been a couple of decades since I've dealt with numbers of homeless on a continuing basis, and I can't say that I did it very well.  I wasn't particularly prepared for what I would encounter. People are homeless for a variety of reasons, most of them having to do with a chronic inability to function "normally" in the everyday world.  Drug use and alcoholism are frequent factors, but in my experience with the homeless, these factors are symptoms rather than primary causes of homelessness. In many cases, addictions and alcoholism preceded homelessness, but in many other cases, they were consequences. On the other hand, those who became homeless were often self-medicating with drugs or alcohol in order -- they thought -- to cope better with normal living. In my often ham-handed way, I would sometimes offer homeless individuals who came to me for help a place to stay, food, or occasionally money (though I rarely had much myself.)  But I couldn't deal with underlying causes of homelessness, and so I'm not sure that what little I was able to do was of much help.

Of course, mental illness is a significant contributing factor to homelessness in America. The fact is, there were few mentally ill homeless in the United States prior to the destruction of the residential system for mentally ill individuals beginning in the 1970's. The widespread failure to provide adequate and accessible mental health services, let alone access to residential care, was one of the leading causes of homelessness prior to the onset of the apparently permanent recession. Since the beginning of the recession, homelessness among the economically deprived has increased substantially.

Most of those in the clinic waiting room were able to handle the intake paperwork, though some had a good deal of difficulty and needed help of one sort or another which they typically got from one of the other homeless clients in the waiting room rather than from clinic staff.

The couple (who I'll call Richard and Ann, not their real names) who were having trouble with the forms that I mentioned earlier, however, had a lot of other problems as well, and they attracted the attention of the armed (female) guard who was monitoring the clinic waiting room and was charged with keeping order.

Richard was an Anglo in his early 40's I would guess. He was probably formerly nice looking but now was ravaged and jaundiced, his creeping infirmities taking their toll. His eyes were wide-staring, his body tension-filled. He was acting paranoid. Every now and then, he would get up from his chair and pace, sometimes in the waiting room, sometimes outside.

The younger Anglo woman with him, Ann as I call her, had even more problems. She was constantly trying to help Richard with the intake forms, but every time she would offer a suggestion, he would get upset and tell her to leave him alone. She would then get offended and go sit in another part of the waiting room. She was unsteady on her feet, though, and sometimes seemed to have severe vision problems, as if she couldn't see where she was going.

The guard, who I'll call Julie, took an interest in this couple, especially when Ann would get up and her pants would start to fall down. Ann was not wearing underwear.

At one point, Julie approached Ann and asked if she was all right. Ann replied she was fine, but her speech was slurred and her head was reeling. Julie asked if she'd been drinking, and Ann replied "absolutely not!" but she could barely get the words out and at that point, she couldn't even stand up without a struggle. She said, "I'm not drunk. I'm sick." Richard said, "She's fine." But it was clear Ann was not "fine." Nor, for that matter, was Richard.

Ann was acting drunk, but I wasn't so sure that was her problem. She appeared to me to be having physical as well as mental issues that may have had nothing to do with alcohol. Her problem was that she was trying to be "normal" and failing. Every time she set Richard off, by saying something or doing something that troubled him, she would become morose. My own sense of what was going on was that probably neither of them had eaten for perhaps days, possibly they hadn't slept either. Both lack of food and lack of sleep can have profound psychological effects that can mirror drunkenness and can exacerbate any underlying mental illnesses. That's what I thought was going on based on my observations of their behavior.

At one point, Ann got up from her chair and her pants nearly fell off altogether. Julie, the guard, approached her again and said she would have to leave if she couldn't keep her pants up, that she was in violation of the rules, and she was guilty of indecent exposure. Richard said, "She can wear my belt," which he rummaged around in his backpack to find. It was a very fancy studded belt, something I wouldn't have imagined he'd carry, but you never know. He helped Ann with putting it on, and once it was done, she was quite proud of her new accessory.

Julie, meanwhile, had disappeared into the counseling section of the clinic. She emerged from wherever it was she'd been soon after Ann had been belted up and said to her, "Look, we're going to take you across the street where we'll get you a pair of pants that will fit." Ann's eyes grew huge, "Really!?" she asked. "You'll get some pants, and if you need anything else, we can take care of that, too. Come with me."

Ann was delighted, and eagerly followed Julie out the door. Richard looked worried, but he stayed put. The homeless outreach coordinator (who I'll call Standing Bear) came out and spoke to him briefly, asking if he'd turned in his intake paperwork, and Richard said "Yes," but he had it rolled up in his hand. He'd turned in nothing. "Good," said Standing Bear, "we'll call you in for counseling as soon as your vitals are taken and that shouldn't be long." "What about Ann?" asked Richard. "We'll take care of her, too. Just wait for your names to be called. It shouldn't take long."

Standing Bear disappeared back into his area, while Richard waited for Ann to return -- which she did not too long afterwards, wearing a smart pair of running pants with an elastic waist and carrying her oversized black jeans with Richard's fancy studded belt. She had a huge smile. Julie was with her.

After Ann sat down next to Richard, Julie said, "Look, you're having a real problem here. You're severely dehydrated, your breath smells of alcohol, and you aren't able to function. We're very worried about you, and so we're going to call an ambulance to take you to the hospital for evaluation. You sit here while I go call the ambulance."

Julie walked off, headed to the back of the clinic, while Richard and Ann sat for a moment stunned.

"They're calling an ambulance!" said Ann, as if she was facing the worst fate possible. "What are we going to do?"

Richard said, "We'll have to leave."

He started assembling his things into his backpack, and stuffed Ann's defunct jeans in on top. "We have to go," he said to her. Ann was near tears. "They're going to take me to the hospital? Why?!"

"They think you're sick," said Richard.

"I AM!" she said. "I'm very sick!" But she was terrified of going to the hospital. She was panicking. Richard got his things together, slung his backpack over his shoulder, and said: "Come on, let's go."

Just as they were headed out the door, Standing Bear emerged with a bottle of water saying: "Ann, take this. Drink it. You need to drink it."

She stopped and looked at him, desperation in her eyes, and said, "Thank you! You are a wonderful person." And she and Richard left the building before Julie could come back to announce the immanent arrival of the ambulance -- which so far as I know never came.

So ended a very sad episode at the clinic. It was clear that neither Ann nor Richard could cope with expectations they couldn't meet. There was no real help or hope for them. The only thing the clinic personnel could think to do was get Ann to a hospital for evaluation -- after leveling accusations about her sobriety and inability to function normally. But for Ann, going to the hospital was a terrifying thing. The most terrifying thing she had up to then encountered at the clinic.

I have no doubt that proper protocols were being followed and that Richard and Ann were not being driven out of the clinic deliberately. People having that much difficulty can be liability headaches, however, and without knowing what their underlying problems were, it was hard to serve them appropriately. Getting Ann a full-scale medical evaluation at a hospital was a logical decision, but her panic at the announcement thwarted even the best of intentions. I don't know that the clinic personnel could have handled the situation much better than they did, though it seemed to me that the guard was unnecessarily officious and harsh -- before she realized that Ann was really in bad shape and needed expert help.

Homeless Outreach Day at the clinic I later learned was scheduled the day before the annual Homeless Census. This is a full scale effort to find and count all the homeless throughout the country, and a wide variety of strategies are employed to make sure the count is as thorough and accurate as possible (though I understand some communities actually seek to undercount homeless people so as to make it seem like the problem isn't as bad as it really is.)  Asking the homeless to come into a clinic for evaluation and services is one of the strategies employed to ensure a full count. Given the sharp increase in the poverty rate over the last five years, I have no doubt that the homeless number is greater than ever.

For the most part, service at this clinic is remarkable for its warmth and humanity. Patients and clients are not just statistics or symptoms. They are people who are treated with dignity, openness and consideration, much as might be the case in a large, welcoming extended family.

I was sad to see what happened to Richard and Ann, but somehow I have the feeling things will work out for them.

Let's hope.

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