February 10, 2011
By Aakash Shah
Mr. Williams* is a storyteller at heart. Each time he catches my gaze fixed on a picture frame, he lets out a knowing sigh and then launches into the memory behind each photo. There was Michael’s graduation, Nathan’s wedding, Lauren’s first child, and the entire family, three generations in all, gathered together around the Christmas tree. Mr. Williams has been blessed with a beautiful family – a wife of 55 years, four sons, three daughters, and nine grandchildren – and he knows it. Turns out, he also knows a bit about what ails our healthcare system.
As a first year medical student, I’m attracted to primary care, with its strong physician-patient relationships, but my exposure to it is limited. Growing up, my visits to the pediatrician were few and far between and I had no interaction with other doctors. That all changed during my first month of medical school, when I met Mr. Williams’ primary care physician through a course designed to allow students to view our healthcare system from a patient’s perspective. We decided that I would follow Mr. Williams over the course of the year to better understand his primary care experience. A few weeks later, I found myself sitting in Mr. B’s living room drinking tea – green is his favorite – and enjoying Mr. B’s life story.
While recounting a memory about a visit to the hospital as a teenager, he joked about wishing “that diabetes was more like tuberculosis.” Glancing at his medical history, I noticed that he had an episode of tuberculosis when he was in high school and had been diagnosed with diabetes about four years ago. Feeling as though I had missed out on the punch line, I asked him to elaborate. He went on to explain how he felt that the health care system handles cases of tuberculosis (TB) much better than diabetes.
Those words echoed in my head as I rode the elevator down from his apartment later that evening. It struck me that Mr. Williams was describing what Sendhil Mullainathan, the MacArthur Award-winning Harvard economist, has dubbed the “last mile problem.” The medical community has invested a tremendous amount of energy, creativity, and resources into finding solutions to diseases like TB and diabetes. The effort has paid dividends. It has taught us how to harness the power of antibiotics, insulin therapy, and a plethora of other life-changing treatments. However, in the case of diabetes, we’ve yet to go the last mile and perfect the science of delivery and of chronic disease management.
Though I’m not sure exactly how to go the last mile on diabetes care, I know that the road ahead is through primary care. And like many others who see the potential of primary care to revolutionize health care delivery, I’m excited for the journey.
*Identifying details have been changed to protect the patient’s identity.
Aakash Shah is a first-year student at Harvard Medical School who has an interest in health equity, particularly in the pathways through which large-scale social policy can affect access to medicines and healthcare for the underserved.