He was in his younger middle years, generally well. Before he had a wife and kids, he had been a competitive cyclist, an Olympic hopeful. He stayed active, ate thoughtfully, took no medications. But in the mornings, first his hands and within months other joints would swell and ache terribly, refusing to move. His primary doc sent him to a rheumatologist because, based on his symptoms, it appeared that an inflammatory process was to blame. The rheumatologist ran tests and then more tests; all were negative, but she agreed–this was rheumatoid arthritis.
He was started on a medication that made him feel better. Not fully better, but generally able to get up and move in the mornings without significant pain, which he certainly preferred, and his life went on.
Lou arrived alone when she’d come for her blood pressure and itchy skin. Sharp, funny, she told me of her daughters, grown up and far away, and her life in the neighborhood as it changed around her. She had lived there for decades, long after her husband left, long after raising two on her own, long after the cottages around her were torn down for industrial sites. Neighbors were scarce and stray dogs plenty.
When her daughter arrived with her, I knew something had changed. Having driven sixty miles to bring her, Lou’s daughter was here to report on the increasing forgetfulness, the neglect of her garden. She was worried her mother was developing dementia and wanted her to move closer, where she could keep a better eye on her. Lou was having none of anyone else keeping an eye on her, though. We talked about memory and independence and safety and planning—at least as much as one can squeeze into a protracted twenty-minute visit. We all agreed to watch.
She was here for her diabetes. Her blood pressure was high, she said, because she expected me to scold her. She hadn’t brought her log, but her sugars were in the 200s overall. Not good. She hadn’t been exercising, but she had been taking all her medications.
Again we talked about options: cut out carbohydrates, increase exercise, add medicines. She admitted a predilection for bread, and I talked about mood eating: how stress can drive us to eat. She smiled back at me, shaking her head. I mentioned our counselors and the option of coming just to talk. She shook her head again, but her smile broke and her eyes closed.
Her one son, whom she brought here as a six-year old, had been deported back to a country he doesn’t know, where he has no one, where life is dangerous.
My Nicaraguan pediatrician friend astutely summarized her work: First you make the clinical assessment, then you make the financial assessment. In other words, a clinician may know the right treatment, but what good does that do the patient if the treatment is entirely out of reach financially?
In the clinic where I work, we don’t take insurance. It’s not a concierge practice but a church-based one, run on grants and hardscrabble for decades. For a provider, there’s something freeing about not having to consider insurance. There’s no frantic search through formularies, no restrictive list of specialists, none of the prior authorizations that suck up time and stamina–all things that have nothing to do with patient care but must happen in the insurance world. None of that.
“You do not need an MRI,” I told my father emphatically as he stood in my living room, explaining to me that his beloved doctor had ordered this for his low back pain. He was hoping for a quick fix before meeting his brother in Spain. “You need physical therapy.”
I dislike playing doctor to my family, not trusting myself to dissociate emotion from evidence, but this was just too much. Sure, his back hurt him sometimes, but there was nothing to suggest anything dangerous going on, nothing an intervention would fix. Nothing but the dreadful aches and pains of growing old.