The Challenges of Caring for People in Underserviced Areas

As a Canadian working for the first time in the US health system, and specifically in an area that serves primarily a low income African American population, it has been a huge eye opener to me. The experience so far has been extremely challenging, humbling, and at times heartbreaking. Currently, about 1 in 7 Americans live in poverty. It is no secret that those living in poverty are much more likely to suffer with health problems than those who do not. The internet is littered with articles and studies that prove this. So many people go without needed services. People either do not have insurance, or don’t really understand how to work with their insurance companies to ensure that they have their needs met. 

Let’s take the quintessential patient that is encountered in the clinic here (this isn’t any specific patient that I have seen, just a description of a typical situation).  A patient comes in at her wits end with her asthma. She has been suffering for so long. She is at the point now where it is difficult to leave the house because every time she does, she has an asthma attack. She lives in a rental unit that is old and that has mold and old carpets. These things are further contributing to her flares. She can’t afford to move into a new apartment.  In speaking with the patient more, you find out that she hasn’t been able to refill her prescription asthma medications for quite some time because they can not afford the co pay. Now she has been missing work, and is close to having to go on disability because her asthma attacks are so bad she can not do her job. You notice she hasn’t had a pap smear, a mammogram, or a colonoscopy in over a decade, but this is least of her worries because all that means for her is more money to pay that she doesn’t have. She has children at home and is often too unwell to care for them the way she wants to.

Doctors and medical students working with these people are faced with many challenges. It is so important to keep their situation in mind at all times. It is easy to catch yourself trying to teach a woman about providing nutritional foods for herself and her children without considering the fact that these nutritious foods are much more expensive than high calorie, nutrient depleted foods.

Here are some of the challenges that I have encountered during my 6 weeks here so far:

1. These patients often have unexpressed needs: either they do not recognize that they are missing something or they are too shy, too proud, or too scared to ask for help.
2. Community resources - there are several community resources available to help but many patients aren’t aware of what is out there to help them.
3. Patients often need an advocate - someone to push for them in order to get them the things they needs in order to take control over their own health and better contribute to society. Sometimes that means spending extra time talking to insurance companies to push for a required medication or treatment. Sometimes this means researching community services so that you can then tell your patients about them.
4. Patients often come in with the attitude that a physician or medical student couldn’t possibly relate to their situation. It is important to give these people your time and to allow them to explain.
5. Patients often have many many issues that need to be addressed in a single appointment. For some of them, visiting a physician is a substantial financial burden and it may be necessary to manage their medical conditions, counsel them on lifestyle choices, talk with them about any emotional issues they are facing, and help them navigate the health system all in a single visit. 
6. Patients are often lost to follow up. They seek medical care only when they absolutely have to but once they are feeling a bit better they may not be able to justify paying for a follow up appointment or to go and get the bloodwork done that you ordered for them. This is a problem because there is no continuity of care - these patients have a lot of chronic diseases that require regular monitoring. 

I don’t have a solution for this problem in the USA, but I do know that doctors can and should make a difference. No single person or doctor can turn this situation around overnight, but we need to celebrate small victories. Celebrate people. I truly believe that people, at their core, want what is best for themselves and want to do the right thing. They don’t want to be unhealthy, they don’t want to miss appointments and they don’t want to be without services and medications. People are in survival mode. Doctors should be doing everything in their power to make a difference to these people. Let them know that they are seen and heard, and that there are people out there that care about them. We can not write these people off. When you put faith into someone, they are more likely to put faith into themselves.