Beating the Numbers Racket
Thuy D. Bui
“What’s my number?” shouted Betsy as I entered the examination room one day last fall.
“Oh, you mean your A1C? It’s nine-point-four!” I answered. A sentence sped through my mind: "The hemoglobin A1C number tells how well a patient’s diabetes is controlled--seven or less is good." In my seven years as Betsy's primary-care doctor, I've repeated this information at visits and included it in appointment reminders as well.
Betsy is a pale, stocky woman in her sixties, with short, neatly cropped hair. Her rather tentative smile, to me, always seemed a bit forced, as if covering up for underlying pain. And she's had plenty of pain in her life.
Her medical record displays many problems besides her diabetes--overweight, high blood pressure, arthritis and, tellingly, a history of recurrent liver inflammation, most likely from alcohol abuse.
She used to work as a home health aide, but now collects worker's compensation after an injury on the job left her with a herniated disk.
Improving her health has been a struggle for Betsy. Her chronic back pain and arthritic aches make it hard to exercise. For various reasons--habit, stress, lack of motivation--she's found it difficult to follow the standard low-calorie diet. And for years she couldn't afford to buy the insulin and the hypertension medications that I prescribed.
Her medical record listed only one family contact, an estranged son. “At my age, I prefer to keep to myself," Betsy asserted. "I don’t trouble anyone, and I like it that way.”
Thanks to comments like this, I've always viewed Betsy as a remarkable person; despite her many medical and psychosocial difficulties, her humor, grit and unsinkable spirit shine through.
I've sometimes felt bad about taking her to task for her health shortcomings, because I imagine there's already plenty of self-blame in her life. But, in fact, I've also felt my own self-blame. Often, while reviewing Betsy's dismaying A1C numbers, I've remembered my own mediocre performance data in the clinic's quality-improvement reports.
If only these numbers could reflect Betsy's real-life challenges, I've thought. And it wouldn't hurt if they reflected some of my struggles to help her, too.
That was how we went on, for the first five years or so.
About eighteen months ago, things took a turn for the better. Betsy began attending AA meetings and managed to abstain from alcohol, and her Medicaid kicked in, so she could afford to take her hypertension medications and insulin regularly.
In Betsy's eyes, achieving abstinence was her greatest accomplishment. Lowering her A1C number--by controlling her blood sugar--was secondary. So I was delighted when she asked, "What's my number?"
Hearing my answer, she chuckled. “So you want my A1C to be less than seven?”
“Yes, or else I don’t get paid," I answered teasingly. "You know, if you don’t look good, I don’t look good.” This elicited Betsy's usual half-smile.
Clearly, though, my preoccupation with numbers had finally seeped into her awareness. In our subsequent visits, she tried to follow along as I pointed out her blood-pressure and A1C readings. Still, it was a torturous process.
Once, seeing my obvious anguish over her elevated A1C, she said consolingly, “Numbers are only skin-deep.”
After about six months of this, I realized that she was right.
Honestly, I thought, our fifteen-minute visits would be better spent if I quit obsessing over the numbers.
I pushed the computer keyboard away.
“Betsy, what would you like to do with the rest of your life?" I asked. "What’s the one thing you wish you could do right now?”
To my pleased surprise, she replied, “I never finished high school. I want to be a writer.”
So I devoted time in our next few visits to gently encouraging Betsy to take the classes required for a general educational development (GED) diploma. To my delight, she enrolled in those classes and also signed up for a writing course at the local library.
Needless to say, it wasn't all smooth sailing.
"I'm thinking of quitting," she told me one day.
Oh, no! I racked my brains for ways to keep her from dropping out.
Finally, I blurted out desperately, “Poor and less educated people die younger!”
At the time, Betsy's only response was a puzzled silence; but she stayed in her classes. Not only that, but this marked the beginning of a change in her overall mood and mindset.
She started to ask about a different set of numbers: the data that link health outcomes to socioeconomic status. For instance, we discussed the difference between the heart-disease death rates in the county's upper- and lower-income areas, which she'd read about in the newspaper.
She'd always had some inkling, it seemed, that her living situation--a dilapidated old apartment located in a noisy, high-crime neighborhood with few amenities and low walkability--might be bad for her health. But, until now, no one had helped her connect the dots.
A heartening step forward came when Betsy reconciled with her son. It was unclear who reached out to whom, but I suspect that Betsy, inspired by her writing class, may have sent him a letter. Betsy learned that her son's wife had recently given birth; Betsy was now a grandmother.
Although the ups and downs of Betsy's blood pressure and A1C numbers still kept me guessing, now she'd come up with solutions: “I’ll cut down on the salt,” or “I need to stop snacking at night.” These statements always squeezed a half-smile out of me; though I still felt concerned, I also saw Betsy's increasingly upbeat mood and assertiveness as evidence of a growing transformation.
Her most recent milestone brought a full-fledged, elated smile to my lips. Over the years, I've completed many necessary but rather depressing forms for Betsy--requests for shuttle service for disabled persons, petitions to reverse threatened utility shut-offs. This time, Betsy wanted me to endorse a letter to the local housing authority, asking that she be allowed to move into a new, low-income housing unit far from her current neighborhood.
And her doorknob moment at our latest visit set my heart pounding with joy.
“Doc, you know about the thirty-five percent cut in the bus service? Well, I’m going to a hearing to protest that," Betsy said. "I’m going to tell them how that will be bad for my health!”
Pondering the reasons for Betsy's newfound hope and energy, I know that her schooling and her writing class have helped a lot. Her new grandbaby is another wonderful incentive to live a long and healthy life.
I also know that once I stopped crunching Betsy's numbers and started focusing on who she was and how she might realize her goals and dreams, that opened the door to new perspectives--for both of us.
Betsy's medical record has no numbers or quality benchmarks that reflect this positive change. The proof is in our smiles.
About the author:
Thuy ("Twee") D. Bui is an associate professor of medicine and medical director of the Program for Health Care to Underserved Populations at the University of Pittsburgh School of Medicine. "My life's passions are humanism in medicine and addressing the social determinants of health. I also try to cultivate reflective writing by my trainees in local and global settings." Check out her Social Determinants of Health portal.