A medical student and aspiring family physician asks his future colleagues in other specialties not to let all the social justice work fall on the shoulders of primary care providers. By Amulya Iyer
Mr. FM is a charming, gregarious, middle-aged Dominican man who lives with his wife and children in upper Manhattan. He is generally happy and healthy. Though he has an enlarged prostate, this shouldn’t prevent him from living a full life. In an ideal world, I would never have met him as an inpatient, but unfortunately, he came to the emergency room with dangerously high potassium, after a month of vomiting and a week without urinating. His untreated prostate had led to urinary obstruction. Mr. FM was hospitalized and dialyzed, but never regained complete kidney function. When he was discharged with nephrostomy tubes on both sides - catheters inserted in the kidneys through the skin that drain urine into a bag outside the body - he was at risk of being on dialysis for the rest of his life.
During his hospitalization, I spent a lot of time with Mr. FM, partly because medical students have time to spend with patients, but also because I liked him. He is an affable, intelligent man, with a supportive family. His wife and brother-in-law were always at his bedside bringing him snacks and coffee that he would lovingly force upon me. When I asked him why he hadn’t gone to the doctor sooner, he responded that he did not like doctors and never had a good experience with them. In fact, the only reason he came to the emergency room at all was because his wife dragged him there.
Looking back in his chart, however, I saw several visits to primary care doctors over the last year that repeatedly noted his enlarged prostate and his medication noncompliance. Yet none made any reference to the potential barriers to his compliance. Maybe his noncompliance could be chalked up to the language barrier. Mr. FM speaks Spanish only. Maybe he didn’t understand how or why he had to take the medication. Whatever the case, the doctor’s job isn’t simply to know that you treat an enlarged prostate with an alpha-blocker. Any computer can tell you that. And clearly that knowledge had not been enough to prevent the potentially life-threatening repercussions of the condition. It is the doctor’s job to think of Mr. FM’s illness in the entire context of his life.
Throughout medical school, I saw scenarios like Mr. FM’s repeat themselves again and again. So many advances in science and medicine are inaccessible to patients because the healthcare system isn’t designed to include time to educate and advocate for the most vulnerable. As a primary care doctor, I want to be a patient advocate and combat the systemic inequality patients face.
Since expressing my desire to go into primary care, however, I have received various responses from my classmates, the most puzzling from a student applying to dermatology who said, “Wow, that’s really good of you.”
But it doesn’t feel like a sacrifice, or a “good deed,” to forego the higher-paying fields that make up most of my school’s match list - a school that tried to eliminate the family medicine department just last year. I love people and hearing their stories. I love the challenges of motivational interviewing. And I love grassroots community engagement, which is possible in primary care.
Primary care is often held up as a beacon of morality, a field that “righteous” students pursue, but social justice in medicine should be the purview of every field. All of medicine and healthcare should be altruistic and dedicated to service. The homeless man who sleeps in Central Park and the man who looks over it from his penthouse apartment both need primary care, but they may also both need dermatologists - or urologists in the case of Mr. FM.
Despite following him for nearly two weeks as an inpatient, recommending nephrostomy tubes and outpatient prostate surgery, the urology team would not see Mr. FM for follow-up because they didn’t accept his insurance. So rather than have follow-up with a doctor walking distance from his home who knew his entire case and had access to his records, Mr. FM was forced to see a urologist 45 minutes away. And he only got that appointment because of the relentless phone calls that another medical student on the team made. On the day of Mr. FM’s discharge, with tubes sticking out of his kidneys, I couldn’t help but be disappointed about the additional barriers we were placing in front of him.
I’ve been in touch with Mr. FM for the past few months through phone calls and text messages, ensuring that he understands his medications and attends his appointments with a complex array of specialists. When I met up with him at a recent appointment, he was doing quite well. I know when I become a family doctor and have thousands of patients, it will not be possible to follow each one so closely, to walk them through every step of their care. That’s why we need system-level changes, which won’t happen without advocates throughout medicine - not just primary care.
After all, in medicine - not just primary care - every human being is a potential benefactor of your skills and has a right to the care that you can provide. Of course, I don’t expect all my classmates to enjoy the same things I do and go into primary care like I will. But I would like to make a plea that every medical school graduate be thoughtful about the way they practice medicine, the patients they treat (and the ones they don’t treat), and the imperative they have to use their training and skills to address the irrefutable health care disparities in our country and around the world.Amulya Iyer is a fourth-year medical student at Columbia University and plans to pursue a residency in family medicine.