God wept. They trudged and limped into the clinic. Those that could, stood in line; others waited seated, filling the waiting area and corridors. Approximately 250 patients are seen at the rheumatology clinic at LAC (Los Angeles County Medical Center) + USC (University of Southern California) each week. Our nurses see another 150 patients weekly, and we average another 10 to 15 inpatient consultations each week.
Yesterday, we saw an Hispanic woman in her 50s who had over 30 years of terrible, nodular, erosive, destructive, progressive, unremitting, deforming rheumatoid arthritis with extra-articular disease. She had no health insurance coverage and came to our facility intermittently. There were long intervals of interrupted care when she returned to her native Mexico. We noted—and discussed with her and her family, who assisted her wonderfully—the difficulties she had with activities and self-care, her limitations, and her pain. We restarted disease-modifying therapy, nonsteroidal antiinflammatory drugs, and analgesics. We hoped to provide her what medication-induced amelioration we could and addressed rehabilitative issues as best we were able. We hoped she would return in a couple of months, adding to the already overscheduled appointments for that day. We hoped our general medicine clinics could provide a measure of primary care, knowing though that they were at least as overwhelmed as we were. As we left the room, frustrated at our inability to do more for this woman with whom life had dealt so harshly, she smiled from ear to ear and thanked us profusely.
We saw an African-American boy in his late teens who had developed systemic lupus erythematosus. He had been hospitalized elsewhere several years earlier for diffuse proliferative nephritis. Apparently, treatment was with “immunosuppressive” medication and high-dose corticosteroids. Being without income or health insurance, his subsequent care was intermittent, infrequent, and fragmented. We had a few incomplete records. He, with his mom, rode a sequence of buses across town over several hours for this appointment. He was ill, Cushingoid (still on steroids), and with all the clinical problems of active lupus. Superimposed were the economic challenge of obtaining care and medications and the social dilemma of trying to develop a life other than of chronic illness. We ordered studies to help assess his clinical status, resumed an “immunosuppressive” regimen, and determined to try to reduce his steroid usage. We spoke with him about returning to see us, and talked about continuing his education. As we left his room, frustrated at our inability to do more for this young man with whom life had dealt so harshly, he smiled from ear to ear and thanked us profusely.