Public Medicine — Cheap Is More Important Than Quality

She was 32 years old and a child of the streets.  I wondered if she were a Down syndrome — what we medical types call the mosaic (partial) trisomy 21 — the chromosomal abnormality some still call Mongolism.  This was purely an intellectual exercise, as the county health service would surely not pay for the expensive study, so I would probably never know.

Previous doctors had prescribed anti-psychotic medication, but she did not tolerate any of the various brands available through the county clinic. I had her try a little Abilify (arapiperazole) and it did seem to help when she remembered to take it.  Or when she slept somewhere it would not be stolen.

Life is tough on the streets. The voices told her to kill.  She generally had a knife with her for protection, so I had to take her voices pretty seriously.

I always check every woman of child-bearing years for birth control since having a baby on some of these medicines could have tragic results.  Plus – a child would not do well with a mother like this.

She told me that she enjoyed sex but got her tubes tied and never wanted babies because she didn’t much think she could take care of them.  Rare insight in one with her illness. Her voices were most horrible when she is in PMS, she told me.  Sometimes, the rest of the month, she hardly heard them at all.

So I had the idea, maybe she would like an injection to stop her period, and then we would have a good chance of making the voices go away.

“I don’t want that,” she told me.

Did she think that being a woman was that important in her life?

“No — I want to get rid of my uterus.  I don’t need it.  I have endometriosis.  I was supposed to get rid of it anyway.”

More amazing insight — two very good reasons, in my estimation, to get rid of her uterus.

The one thing she did not have was insurance. She was not eligible for  MediCal. Nor anything else state or federal. I asked the nurse and the clerical help if there were any kind of programs we could get her into.  Maybe she could be a “resident case” in some teaching hospital or something – meaning a student doctor would take care of her at no charge to get the training.  I guess I was showing my age with that one.  There are no resident cases any more.

I paged through her record like a flip-book. All those hours of psychiatrist time, trying drugs that did not seem to be taken consistently, that had intolerable effects, that did not work.

My major worry was that she could kill someone with a knife at any time.  She did not even think she was dangerous, but she was.

Then inspiration hit me — I found the way to convince the county to pay for her hysterectomy.

I told them that given her history of only being dangerous during PMS, that the full removal of her womb would be, quite simply, the cheapest way to treat her. That was the magic word – CHEAPEST. Absolutely the argument that got their attention.

The happy ending was satisfying for me and for the patient.  The cheap part was satisfying for the bean counters.

I wish all patients could be helped so easily and completely. Then again, most doctors don’t seem to think like I do – actually trying to help the patient. At least none had in this young lady’s medical history.

This is what our public health system has come to.  This is what the government is trying to spread to everybody in the nation – not just veterans, not just senior citizens, not just the indigent. This is the system that has no room for quality.  Just doing things on the cheap.

If it succeeds, we can only hope there are other doctors who care enough and are wiley enough to play the system so that everybody gets a happy ending.