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On Hateful Things

This essay is modeled after Sei Shonogun’s list “Hateful Things” from her tenth-century classic The Pillow Book. She listed everything she hated about being a lady-in-waiting to the Japanese empress, ca. 966-1017.

I wrote my list as a family physician working in community health centers, ca. 2005-2020. As our nation grapples with endemic racism while also facing the COVID pandemic, my trials and tribulations may seem trivial–but they also reflect a broken medical system that badly needs fixing, for everyone’s sake.

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One is in a hurry to leave for dinner when a patient arrives thirty-one minutes late–one minute past the deadline–and asks to be seen. Her first bus was twelve minutes late, and waiting for the second bus took another twenty minutes. Our patient-service representative (a local high-school graduate) says no, she can’t be seen. So she won’t get the physical exam that she needs to apply for the job that might enable her to pay for car insurance and drive to the community health center, arriving on time. The patient appeals (successfully) to one’s authority, as the physician, to approve her visit, and one must choose between the patient’s needs and one’s own; the situation is hateful indeed.

After an extended conversation with a passively suicidal teenager, one steps into the hallway, only to see seven “patient ready for clinician” flags by adjacent rooms–rooms filled with human suffering. It is hateful to feel alone, with no specialists available to consult, while interviewing a patient who suffers from severe mental illness but cannot obtain outpatient psychiatric services for at least another nine months. Hateful too is the clinic’s overbooking–three patients scheduled into one fifteen-minute slot in hourly waves, since the administrators expect a 40 percent no-show rate; equally hateful are the cursed days when all patients arrive, and on time.

An asthmatic patient leaves the hospital after an exacerbation, possessing a prescription but no way to buy it. One week later, he arrives in one’s clinic, wheezing and coughing. He doesn’t respond to albuterol and must be sent to the hospital for oxygen and round-the-clock treatment, hopefully not including intubation.

Patients discharged from the hospital unable to buy the needed medicines, getting sicker and having to head back into the hospital; this happens too often, especially with heart failure, diabetes and severe skin infections. Oh, how hateful!

The cost of medications.

Health care only for those who can pay.

Patients who scowl when one steps into the room an hour past their appointment time; who then refuse to talk, crossing their arms, pouting and requiring an extended apology, before launching into five separate health complaints and a request for anti-anxiety meds–hateful!

Clinic administration who count success by the number of patient visits, mirroring federal grants that do this.

A payment structure that rewards physicians based on the number of patients one sees, rather than the quality of care one provides. Fee for service, which pays one for doing procedures, not for preventing disease.

Working through lunch, day after day. Finishing charts at 7:00 pm.

The EMR (electronic medical record), which qualifies as disruptive technology. One spends hours squinting at the screen, hunting for hidden point-and-click physical-exam findings, stored in no intuitive way. Diagnoses are missing. Lists of lab tests to be ordered appear in no recognizable pattern. Outpatient procedures include: “Amputation of right leg.” “Amputation of left arm.” “Lobotomy.” Nowhere is “ear-wax removal” to be found.

Hateful is a shortage of personal protective equipment (PPE) for clinic staff, as we face a deadly pandemic with minimal protection, our lives devalued. Hateful is not activating the Defense Production Act to create masks and ventilators to save our lives and our patients’. Hateful are too few N95 masks for the clinic, but none to be ordered nationwide. Hateful is the disappearance of hand sanitizers and surgical masks and gowns from the clinic, and no PPE available when someone comes for COVID testing. Hateful is the celebration of providers as “healthcare heroes” while withholding the protection we need to stay alive and to care for others.

Hateful are the terrible health disparities–more asthma, obesity, hypertension, diabetes, heart attacks, strokes and COVID-related deaths–associated with race, and with neighborhood, housing, education, jobs, transportation, medical access. Hateful too is our sanitized phrase “race-related disparities,” which never mentions racism–the horribly unjust political source of all of these inequities.

Hateful is the racism that places unnecessary, unbearable stressors on our lives and those of the communities we serve and belong to–Black, Indigenous and People of Color.

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The Antidote: Tolerable (Even Delightful) Things

When you walk into work in the morning, and colleagues smile and say “Hi!”–this lovely feeling of community acceptance and appreciation is tolerable indeed!

It is tolerable too when printed schedules are left on your desk to facilitate the morning huddle with the team. Schedules with zero overbooks, and only eleven patients per clinic session, even with no-shows.

What a delightful thing is part-time work and full health benefits, with a schedule tailored to your needs! Also, manageable, realistic demands that allow a healthy work-life balance.

An EMR designed for primary care, which lets you document your care and describe the history of present illness and chief complaint in your own words, and using your own billing code–oh, happy time-saving independence!

Completing notes by the end of the day; zeroing out charts before each weekend.

Tolerable is a positive, respectful workplace, where people work together to meet others’ needs.

A responsive EMR manager, and medical assistants who work as a team to ensure smooth, timely patient preparation and lab work.

An infectious-disease colleague who responds in real time to questions on HIV and hep C and syphilis management. A TB expert available on speed dial. A suboxone team with nurse, mental-health worker and addiction counselor sharing the burden of counseling, behavioral management and addressing the social needs of recovering opioid addicts. How tolerable is happy, efficient teamwork!

Tolerable are psychiatrists and psychologists available in real time to manage complex patient needs, such as risperidone for the depressed psychotic, dosed according to advice from an experienced psychiatrist. Delightful is the relief of practicing integrated medicine, addressing the needs of body and mind with real expertise!

Confronting patients’ needs with the right resources: Food prescriptions for those who need food, electricity for those who need electricity. Benefits referrals for those who need benefits, with health insurance available to all.

Tolerable is the use of telehealth to minimize patients’ contact with potentially infectious health centers, and vice-versa. Computer tablets given to homeless shelters and residential homes, to ensure that all have access. Housing made available for the potentially COVID-positive homeless, with providers and public-health people, hospitals and housing working together to meet societal needs.

Tolerable too is the general awareness, finally, of the deadly effects of racism, and the upswelling public commitment to address this and do better in the future. This may be uncomfortable, yes, but it is tolerable–and it will bring us to a healthier place as a nation.

This is more than tolerable. This is satisfying, soul-sustaining, meaningful work.

Oh happy work, I appreciate you!