Her blood sugars were terrible, more than three times the normal level. She was not a new diabetic, so to my thinking this was inexcusable. She should have known better. Frustrated, I told her she needed to get serious about her blood sugars and her diet. I told her to write down everything she ate into a log book along with the blood sugar levels I wanted her to check at least three times a day. I told her to follow up with the log book in a week.
A week later she was back in the office as requested, the only part of my recommendations she had followed. Her log book was nearly empty, containing only four entries for the entire week. She told me that she had been “trying” but it was clear that our definitions of "trying" varied greatly. I reminded her that I could not manage her diabetes without information, that dosing her insulin depended on what her diet and sugars were. The displeasure in my voice was apparent as I told her again to write down everything she ate and all of her blood sugar measurements and to come back in a week.
The next week's visit was not much better. There were a few more numbers but almost no dietary information entered. I repeated my previous admonitions and told I would need to see her every week until she had a better handle on things. Her response caught me off guard.
“I can’t afford to come back in a week,” she said.
“You can’t afford not to,” I replied, “you sugars are terrible and I can’t treat you without more information.”
“I know but I can’t afford the co-pay.”
“How much is it?” I asked
“It’s $10, but I can’t afford it. I just got out of jail and I don’t have a job and I can’t afford to keep coming in.”
I paused and looked at her, seeing her perhaps for the first time. Before me was a woman in her 40’s who looked as if she was in her 60’s. Some teeth were missing, her t-shirt was worn and had a few holes, and she wore no makeup. She was poor. As poor as she was materially I realized she was poor emotionally and intellectually as well. The stress of normal was almost more than she could handle. The added burden of checking blood sugars, of counting carbohydrates and adjusting medication levels, was beyond her reach. I realized that controlling her blood sugar would take a lot of time and effort and patience.
“Then I won’t charge you,” the words sounded right as they came out of my mouth, “I will see you in a week.”
The next week she returned, log book in hand. This time it was nearly half-filled with results. It was inadequate, but it was progress. Together we went over the log book as best as we could. As we did I pointed out how certain foods caused her blood sugar to rise and how the changes in sugar levels from one meal to the next helped me see that. I praised her progress and had her schedule another follow up appointment 7 days later.
Week after week she came, each time with more of the logbook completed and her sugars improving. After 2 months things clicked. She could analyze her results on her own, determine what she had done right or wrong, and come up with a plan for how she could do better. We started to space out her visits as he confidence increased.
Four months after our first interaction she went to the lab for blood work. To my great surprise it revealed that her diabetes was perfectly controlled. She had done it! At her next visit she was beaming with pride over her results. She was a failure no longer.
We scheduled a follow up visit for a month later. I was confident that she had turned a corner in her health and that her future was bright. I was wrong. She never came back.
She had lost her job and with it her health insurance. I offered to see her for free while she searched for another job but she did not come in. She never told me why, but I wondered if it was out of shame and embarrassment. Perhaps she was fearful in disappointing me. We had invested so much time, maybe she felt she was letting me down.
That was years ago. I never saw her again.
Her story illustrates much of what is wrong with medicine today. Our entire system is based on 15 minute visits spread out over time. While this works for many, there are those who need much, much more. People like my patient, for whom even small co-pays seem like mountains, whose health continually teeters on the edge of disaster, need more time and attention than out system is designed to provide.
People like her, whose life circumstances, educational background and emotional limitations make routine health decisions seem overwhelming, need more time, and time costs money.
There is no place for people like her in the American health system. Obamacare, with its $6500 deductibles and exorbitant premiums, provides no relief. Medicaid (MediCal in California) is a sham of a “solution”, paying a measly $24 for a routine 15 minute visit, forcing doctors to see a patient every 5 minutes in order to make a living and making good medical care impossible. Excessive regulation and documentation requirements make caring for the needy even more challenging.
I do not know what societal solution is needed. I only know what I can do, which is to make time when I can, invest time when I am able, care as much as possible, and fight off the sense of frustration and futility when my efforts prove inadequate. Every once in a while, I may be able to make a difference.