Using my background from Mayo, I can usually obtain from the history and targeted physical examination the information needed to make the diagnosis for my patients at Grady. Then, even with a limited formulary, we can do a good job of treating the patient. Usually, we are not handicapped or delayed in diagnosis because of lack of tests or consultations. The lack of an extravagant formulary has not deterred the appropriate and effective treatment of our patients. As a matter of fact, we probably practice much more cost effectively than institutions where resources are abundant, and I suspect our outcomes are comparable.
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Explore This IssueSeptember 2007
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Patients in Need
What about the Grady patients? Are they less compliant, less reliable, and less appreciative? No. Like patients everywhere, they want their condition to improve and they want to cooperate with their physicians. I have learned from them and, when they miss an appointment or are delayed or if they have not taken their medicines, there is usually a good reason. Many of our patients depend on public transportation, and this process is often time consuming. Their finances are frequently limited, and they have to make hard choices between paying for rent, food, transportation, children’s needs, and paying for medications. Sometimes, the medicines are sacrificed.
It is difficult to put oneself in another’s shoes, but only by doing this can you understand what these patients confront and how they may think. I constantly try to learn from my patients and understand the factors that influence their lives. I try to help them understand their disease and what we are trying to do, and make their treatment program simple, understandable, and relatively inexpensive. Yet I realize that for these patients even coming to the doctor can be difficult.
At Grady, patients must endure long waits to be seen, get tests, and get medicines. We are constantly under financial pressure to reduce costs because 40% of the patients seen do not pay for their care, and the government at all levels is insidiously reducing payment for the care of the poor. As a result, the staff is reduced and the equipment, computers, and systems are old. At the same time, there are more and more patients in the Atlanta area without insurance or jobs who seek care at Grady. The result is slow, inefficient care.
Despite these obstacles, at Grady we strive to care for these patients in the best fashion possible. This is the commitment of the nurses, attendants, residents, fellows, and staff in the rheumatology division and arthritis clinics at Grady. For example, we have an early arthritis clinic at Grady and we see many patients with early rheumatoid arthritis— mostly African Americans but more and more Hispanics. We use the treatment modalities available—namely low dose prednisone, methotrexate, sulfasalazine, and hydroxychloroquine— early and in combination and achieve outcomes comparable to what is in the literature using anti-TNF agents.
The journey from Mayo to Grady is as long as any in American medicine. It has been educational, stimulating, and insightful. In the Mayo phase of my career, I was not tuned in to the social and economic issues influencing my patients because it was not necessary for their care. At Grady, I have been forced to consider the social and economic forces influencing my patients because those factors determine my patients’ health as much as anything else. My greatest disappointment in working at Grady is the realization that our government—both local and national—disregards the health of the poor. Nevertheless, I have hope that this situation will change and that America will one day deliver equal care to all its people.