A Great Dilemma

While I have said we must bridge the gap between public health and community medicine. This poses a personal, ethical dilemma: When faced with limited resources to improve peoples' health, as a public health practitioner one would believe that you use resources to help improve the health of as many people possible (This is the classical utilitarian view). As a medical practitioner when faced with the same dilemma, ones duty is to his/her patient. The question is at what cost? Is there a cost that would prevent you from treating any one patient knowing that those resources could be distributed to help many more (Peter Singer frames this question more eloquently)?

I welcome comments as this is truly a great ethical dilemma for all of us. It applies to health resources and aid for the poor, health care rationing in this country........etc. I also wonder if there is a different way to frame the issue of limited resources. While in theory, I have posed conflicting views, in practice can't we be utlitarians that are also dedicated to the health and well being of individual patients and vice versa? Under what circumsatnces should we act as one rather then the other?

Advocay

I have talked a lot about individual patients and the importance of being patient centered. But I am also beginning to learn while it might be less glamorous, less rewarding in any immediate sense, we must be advocates for our patients.

We must be advocates for better housing, better shelters, better mental health and substance abuse services.

We must have the ear of politicians, community action boards, and hospital administrators

We must bridge the gap between public health and community, frontline medicine; Too often there seems a great void.

12

This is the number of CD4 T-cells that one of our patients has. A healthy person has 500+. At 12 T-cells your immune system has completely collapsed, your body is constantly overwhelmed by bacterial and fungal infections, you our on the verge of death.

A nurse once visited a patient of ours in the hospital with 1 T-cell, his body completely indefensible, but he was nursed back to health, and today I have the pleasure of listening to his Haitian music at least once a week.

This is a reminder of why we do this work.

But today, our patient with 12 T-cells has no interest in taking medications. He will soon die. All we can do is ease his suffering.

This is also why we do this work.

Anthropology

I have been reading a lot about medical anthropology of late-especially this idea that while anthropology in itself is an academic pursuit, an anthropological perspective to medicine and public health is extremely practical and useful. I have learned a lot about this practice from Paul Farmer's works and his experience in Haiti, but it also applies to my work this year in San Francisco.

Two examples come to mind: One is the understanding of punk rock culture and its influence on a number of our homeless and chronically drug-addicted patients. The second is the influence of the gay rights movement, and gay subcultures in San Francisco, on patients that engage in sexual activities that put them at high risk for HIV infection.

While I am sure books have been written on these subjects, I think it is important to understand how these social and cultural movements influence the health, life, and identities of our patients.

You cannot do motivational interviewing with a Punk Rocker if you don't know what Punk Rock is all about (I still have a lot to learn). It is difficult to do effective harm reduction counseling with a gay man that doesn't use condoms if you don't at least bring up ideas of sexual liberation and the history of HIV in the San Francisco gay community.

You have to talk about peoples identities, and how those identities relate to their health and well being. I believe the study of anthropology helps you do this.

Measuring Success

It is often difficult to measure the success of much of what we do at Tom Waddell. We have little quantitative data about health outcomes and quality of care. We simply don't have the resources to do many of the studies we want to do.

We do however have a great deal of qualitative data: Discussions with IV drug users that have administered narcan, show that the drug overdose prevention trainings we provide have saved numerous lives. The transgender-specific care we offer, including assistance with injecting hormones, has prevented deaths and serious injury that would have resulted from use of hormones on the black market.

In other words, while many of the harm reduction approaches we employ may be difficult to analyze quantitatively, we certainly see qualitative evidence to support these approaches.

On the other hand, there are certain initiatives that might require more evidence to show their efficacy: HIV testing in the urgent care clinic has been useful in detecting a few unknown positives, but without adequate time for counseling, I wonder if the more frequent HIV negative result is validating risky behavior amongst our patients

Hydrocele

A victory was had at Transgender clinic the other day. One of our male to female transgender patients was diagnosed with a hydrocele--a benign but painful fluid accumulation in the scrotum that is often removed surgically. One of our providers seized this opportunity to recommend that the surgeon actually perform a bilateral orchiectomy at the patients request. A bilateral orchiectomy is the surgical removal of both testicles, which for transgender male to female patients is an elective surgery not covered by their insurance.

Fortunately, the surgeon realized the strong desire of the patient to have this surgery done, and sure enough performed a bilateral orchiectomy to "ensure that the hydrocele did not reoccur"

This certainly was a victory in a system that makes it difficult for transgendered individuals to even get hormone therapy covered by their insurers.

The Road

I often visit our patients at the hospital or at their homes (if they have one) to see how they are doing. I will see them on the street or at the Martin De Porres soup kitchen. I never quite know what to expect.....

I have had a patient offer me weed and asked me on a date for chicken and waffles 

I have had a patient run out of his room with no pants on (or underwear) to change his cat's liter box

But I have also...

Visited a patient in the hospital who was bone thin and being worked-up for leukemia. 

I have seen patients curled up on the streets in the freezing rain. Another, in the hospital detoxing from alcohol and on so much ativan she didn't know where she was. 

Like I said,  you never know what to expect, and you never know what emotion is going to hit you next.......