At a wedding recently, I met a woman, a freelance photographer in her early 40s. She was intrigued by my work as a doctor and began asking me questions related to her own health. When she showed me a picture of herself with her four children, I realized why. This gaunt woman had lost almost 20 pounds in the month since the photo had been taken and, despite efforts to stop the weight loss, was still losing more.
When I asked what her primary care doctor thought, she mentioned that she had gone once to an urgent care facility. I urged her to see a specialist to undergo testing, perhaps even a colonoscopy; but she brushed aside my suggestions, preferring instead to ask for my professional opinion on foods that might help her gain weight and treatments she could obtain over the counter.
After a few minutes of this awkward exchange, I realized that there was an elephant in the room. The woman had no health insurance. Even if she wanted to follow my advice, she couldn't afford it.
Throughout this past year, and even over the last week, it has been easy to get mired in the myriad provisions of the multiple iterations of the health care bill. But for many health care professionals, all that wrangling has only served to draw attention away from one of the health care overhaul's most salient points: that it would offer, at last, real hope for what has become a crippled, even broken, relationship between patients and doctors.
"Any health care system should be measured against the primacy of the doctor-patient relationship," said Dr. Stacy Tessler Lindau, an associate professor of obstetrics, gynecology and medicine-geriatrics at the University of Chicago Medical Center. Last fall, Dr. Lindau came up with the idea of a doctors' rally in Washington, and in early December, 55 physicians traveled to Capitol Hill to urge legislative leaders to push the health care bill forward. The doctors, unaffiliated with any trade organization, lobbying group or political party, came armed with only a letter signed by more than 500 physicians from diverse backgrounds.
There are doctors who oppose reform because of fears that it might reduce their income. Others believe that individuals' rights to health care are only, and justly, limited by whatever they can afford. But for most practicing physicians and for many patients, the untenable situation of balancing what you should do with what you can do remains a daily challenge. "The doctor may say, 'Here are your prescriptions, and make sure you get the M.R.I.,' " said Dr. Cary P. Gross, another of the rally's organizers and an associate professor of medicine at the Yale School of Medicine. "But the patient is thinking, 'I can't get all of these medications, and I can't afford the M.R.I.' "
These limitations become the silent and discomforting third party in every clinical interaction. Patients may hesitate to divulge which recommendations they have eschewed because of cost concerns; doctors may feel trapped into giving suboptimal care because of insurance limitations; and both may feel uneasy bringing up the subject of money.
Even when doctors and patients do devote time to discussing ways in which medical therapy can be modified to fit within coverage constraints, they do so at the expense of other discussions.
"The physician has to play a game of Twister to figure out how to put together parts of the puzzle so that things will work for the patient," said Dr. Somnath Saha, an associate professor of medicine at the Oregon Health and Science University in Portland and a participant in the pro-reform rally. For the last year and a half, I have been fortunate enough to work within the single-payer system of the Veterans' Administration.
Nonetheless, as I watched President Obama sign the health care bill last Tuesday, I remembered the woman from the wedding. And I remembered the far too many patients from my past who stopped or cut back on medications because they couldn't afford them, who had to be discharged early from the hospital because their insurance wouldn't cover longer stays, or who struggled — and died from — chronic diseases because they had no health insurance.
The bill is not perfect, and much work remains. "If we don't fix the steady rise in costs," Dr. Saha said, "we are still going to end up with patients worried about how they are going to afford their health care."
But one thing is now sure: there is finally new hope for the patient-doctor relationship. The playing field between patients and doctors is closer to being equalized and, for the first time in our lifetimes, there is a real chance that the elephant will at last begin to trundle its way out of our exam rooms.
