Robert C. Bowman, M.D. rbowman@unmc.edu
I have been actively involved in patient care in Texas, Oklahoma, Tennessee and Nebraska. I have a reputation of working with some of the most challenging patients, those who have a complex combination of mental, social, financial, legal, and medical problems. There are many gaps and more with each passing month. My efforts have sometimes required extra work with lawyers, testimony at court, home visits, physician presence at disability hearings, conversations with state troopers, letters to the attorney general and district attorneys, and efforts with local, state, and federal law enforcement.
In one particular case a patient suffered 27 episodes of domestic abuse despite numerous court appearances and protective orders. You have been or will be taught and socialized that the primary reason for continued abuse is failure of the abused to follow through. You would be wrong in this assumption in this patient and in many patients. If this case sounds familiar to one for M-2 ICE you had involving domestic violence. The fact is that there are a number of similar cases, all who have learned not to trust authorities. The abuser finally ran out of money, lawyers, and new judges. Unfortunately the health of the victim, although improved with reduced levels of stress, has deteriorated with new diagnoses. She has managed to have a constant series of friends who have supported her through her troubles. Her latest friend was just beaten senseless, another domestic violence victim. On many occasions the patient, her friend, and I could do little more than hold hands, hug, and pray. Few have the kind of strength demonstrated by such folks.
Another patient had a daughter that forged her name on student loan applications and now she is being held responsible for loans totaling $15,000. She got behind on home and utility payments and tried to use her monthly check to make up the differences by gambling. She lost the whole check and has not repeated this mistake. She ordered a Medicare lift chair and the company was paid $1200. The chair was the wrong color and leaked hydraulic oil all over her carpet. Instead of a replacement, Medicare requires it to be fixed. It kept getting fixed, but continues to break, and leak. It is not a comfortable chair with little padding for the legs or back. It was so slow in lift that she was not able to get to the door or phone in a timely fashion.
In my first few years in rural practice in Oklahoma in the mid 1980s I worked closely with social workers, visiting nurses, hospice nurses, and health plans for the unemployed. We even established efforts together to help with teen pregnancy rates. During residency training we had even better coordination of care with efforts combining the city, county, medical association, both hospitals, public health, medications, specialists, and residency training.
In the past 20 years I have had no significant contacts with social workers outside of those hired by the hospital. My calls have not been returned. I get the feeling that most are overwhelmed. Patients talk about some social workers that appear to care and others that seem to do little. My daughter recently had a stint of Medicaid coverage. The social workers often require those on welfare to attend meetings where they fill out meaningless paperwork regarding jobs that have little potential of meeting the needs of the 7 or 8 that attend out of the 100 that were supposed to be there. The meetings seem to be an excuse to exclude patients from programs and benefits. There is no real plan to help regarding education, job skills, or rehab. Day care used to be supported and provided a route for welfare moms to establish their own businesses and care for kids and work to escape welfare. These programs have had drastic cuts and agencies now do the work. Conversations with taxi drivers reveal that Medicaid pays the transportation for many, as much as $40 – 50 dollars for care from the specialists that have moved to west Omaha, as far away from poor patients and as close to rich patients as possible. East Omaha has few physicians in certain specialties and long waits. When the state cut 50,000 people from Medicaid, an estimated 13% of the 100,000 in east Omaha lost all forms of health care coverage. The clinics and physicians caring for these patients lost a major source of revenue, the few private physicians remaining and the academic centers. Training programs often have 50 – 70% Medicaid patients. States have forced medical schools to take less funding in exchange for Medicaid support to match federal dollars. Medicaid is the second most important direct line of support for graduate medical education. Our national ability to train physicians is more and more impaired. On many days I see patients that would be better off seeing lawyers, social workers, or representatives of the city, county, state, or federal government.
In another case a woman had worked herself out of poverty to own two cars and literally days away from owning her own home. She suffered a workers injury that disabled her. She was a healthy strapping country girl that often did the heavy lifting for other grocery workers. After the injury her work abilities were diminished. Her recovery was prolonged. The workers comp insurance company sent in an agent to patient care appointments. Attempts to work with this company agent to get medications, therapy, and communications did not work. Her boss, initially supportive, no longer responded to her calls or mine after it became apparent that she was not going to recover well. Her workers comp insurance company somehow managed to avoid the responsibility of coverage for her injury. Her company employed workers compensation physician spent six minutes with her, filed a detailed report documenting examinations that were not performed, billed hundreds, and declared her healthy. My calls to the state did not result in changes to her situation. In fact none of my calls to the state insurance investigators, 4 so far, have resulted in any discernible activity on their part. Only a state senator has moved them to action. The state was stuck with $30,000 in medical bills. Instead of getting paid full fee with private insurance and workers compensation, our hospital was forced to write off the majority of her charges. Usually specialists rely on past reports to fill in their own new reports. I warned new specialists involved in the case to be sure to do their own exams and not to rely on previous reports. I noted that this case was being reported to the county medical association. A state senator was not able to help with this case. After a 2 year delay I continued to work with the patient to compile the evidence and testified at her Social Security hearing. The Social Security judge chose to believe the patient and her personal physician over the reports of the company physicians and she obtained the benefits that she should have been receiving from her workers compensation insurance. She now has a reasonable if painful existence although they still have not recovered to the point of a reliable car and a home of their own. Only recently have they been able to move into housing that resulted in a cure of the asthma in several family members. This was the second family in the past 6 months to be cured or remarkably improved by a move. After this I began to wonder about family history of asthma and to think more and more about bad environments, housing, income, and education.
Another patient working in a nursing home was disabled. A mental patient jerked her unexpectedly and injured her significantly and permanently. Her employers initially were supportive, but their tune changed when her condition did not improve. They also attempted to discredit her excellent work record. She was appalled at the change in behavior of “friends.” Since the facility was associated with the state of Nebraska, the situation changed with contacts to her state senator. Apparently the facility did not want to run the risk of potential investigations and funding problems. She was able to get fair treatment and because of her education she was able to transit to a new job that did not require as much physical work.
Another older patient was severely disabled with a number of diagnoses including depression. She had also worked most of her life. Because of her mental health problems, she was unable to keep her disability paperwork current when the federal government attempted yet another round of reductions. This required the efforts of family and neighbors to support her as well as new evaluations by physicians, even though she had no coverage. She was able to obtain the support that did help her through the severe depression that accompanied her problems, and help her recover her benefits.
Past gambling problems and major medication costs took its toll on another patient. She was suckered in to gaming by casino appeals to lonely seniors. She lost a fortune literally nickels and pennies at a time. She refinanced her home, gave up her cable and phone and even missed phone calls from her dying mother. When our inhaler samples ended, her finances collapsed, and her bank gave up on her. I drove her to my bank and got her new account set up so she would continue to receive her government check. She will soon be losing her home, her car insurance, her car, and probably her life. Bad choices and predators that we encourage as a society will eventually do her in. The death of her husband to lung cancer via tobacco and her own poor health due to second hand smoke is a big part of her problem too. She has been hit 3 times from the rear in motor vehicle accidents, she has a workers comp claim, she has recently filed a malpractice claim regarding her past lawyer and the accident claims. Our fragmented system of health with competing insurances, workers comp, Medicare, and legal issues is a quagmire for poor patients who have little access to lawyers, especially quality lawyers.
I was the family physician for two families, linked by the same town for the two sisters, one a widow to a husband who died age 34 or colon cancer and the other an aunt in the situation. The primary subject was the 11 year old daughter of the dead husband and his wife. After his death, his wife who was the child of alcoholic and abusive parents was left alone to parent the children. She provided no discipline and the 11 year old daughter used conflicts to basically take over the home. A school social worker brought the situation to the attention of the family court and I shocked the judge by being present. The judge warned the mom and the daughter that this would not be tolerated and the children would be placed if truancy continued. I testified regarding the situation in the home although I was unaware of how dysfunctional the home had become. Only a few weeks later, the judge called it quits to the “family” and placed the children with the mother’s sister and her husband at their request. They also were not aware of how bad the home life had become, or would become. They attempted to force the 3 children to go to school. The 11 year old was defiant. Soon after transfer to her new home she charged the uncle with molestation, likely in the hope that she would be placed back with her real mom who was easy to manipulate. The major evidence against the uncle was the testimony of the 11 year old, a 15 year old one time charge of being a peeping tom, and the rehearsed testimony of the 4 and 6 year olds (this was in the days when you could get away with coaching children to testify instead of having experts take care to be sure not to bias young children). Efforts to get the county attorneys to see the light in the family court actions and the big picture failed. Legal representation was worthless from the state. Social workers for the state were also less than worthless and completely overwhelmed, as in Nebraska now. The conviction rate for child molestation in the county and surrounding counties was 100% at the time. All were found guilty or plea bargained. The uncle and his wife, my patients, were supported during this time. They were able to get their church to put up bond so that he did not have to stay in jail for the 9 months of delay. Eventually the uncle and aunt managed to get a pro bono lawyer who was as outraged as I was. He was also one of the best attorneys in town. He filed a put up or shut up for the county district attorney and the case was finally dismissed, as it should have been long ago. Unfortunately on the day of dismissal, to save face for the one blemish on his conviction record, the county district attorney stated that he believed the uncle to be guilty. The story ran on page one of the newspaper without any rebuttal by the patient, his lawyer, or any that supported him during the ordeal. I was asked to sit on a jury to hear a similar case in Omaha, I was excused by the judge as I felt unable to render a decision, although the defending lawyer dearly wanted to have me stay. Another long term patient had the same thing happen to her father and the accusation and the investigation that followed did not result in conviction, but destroyed the family and left her a borderline patient incapable of life alone, caring for her children, and more.
Most physicians (and even those who get the privilege of going to college), especially those who are younger, those from families with money, and those with higher MCAT scores, will make career choices that will avoid primary care and direct patient care, especially patient care involving poor patients. They have little frame of reference to attempt to help such patients understand care or to be able to explain courses of action. They will insulate themselves with assistants and nurses and receptionists. They will wonder why health care and insurance costs go up. A few will mourn the loss of some of their children as random encounters with the underserved and their children or friends or family turn deadly.
Those that “have” in this nation scarcely appreciate the nurses and teachers and public servants and servicemen, all who tend to be children of lower income or immigrant or rural or inner city peoples. It is the insulation work of these serving young professionals who make it possible for them to have more possessions than anyone else without risk of dying or having someone take them away. But if they increasingly grow out of touch with these realities and fail to support education, health, and equity, even these will no longer be possible. When societies break down, the major victims tend to be those with the most.
Rwanda is given as a prime example of this area. Those killed were those who had money, food, status, and land as much or more than tribal conflict. Pastor Mark Zehnder of King of Kings Omaha was recently in Kenya. He noted that during the 4 day conference attended by ministers from many African nations, there was a question and answer time. One African minister described a difficult situation and asked for advice. Pastor Zehnder reflected back on a time when his own church faced overwhelming challenges. A minister from Rwanda then rose to address the question. He noted that when he was absolutely powerless, when his friends, family, and all around him were dying, he felt the most power that he had ever felt. He could only depend on God and God alone. Every minute, every second of life was precious. In our comfortable American lives we try to control everything, grow frustrated about nothing, react poorly to those are attempting to obtain what we have, and miss the most important things in life.
Underserved - Overview and Models