August 20th, 2009


Remote Area Medical Comes to Southern California

This group, which was featured on 60 Minutes, and mentioned in Bill Moyers' Journal came to Inglewood and The Forum, where the Lakers used to play, for a week that ended on Monday. The Los Angeles Times covers the effort as to how this foundation came to an area that wouldn't normally be thought of as a Third World community, but more and more, as the numbers of uninsured and under-insured grows, the United States begins to look like something other than a developed, industrialized nation, with its priorities straight. Of course, it is the priority given to health care for all our citizens that is distorted.

This being well into the second week of the month, and with my dialysis clinic rounds largely completed, I found myself with a bit of spare time. This appeared to be a project that was more than a political demonstration, and it was an opportunity to pitch in and help. I was curious to see how RAM would try to meet the healthcare needs of this under-served population.

I called the number that California Physicians Alliance had provided and spoke to a friendly lady, telling her that I was a nephrologist, and I'd like to help. She didn't have a lot of details but she said, "Come on down," in a pleasant Tennessean twang.

Lin wanted to help, so off we went on Day 2, August 12th, a Wednesday. We parked at the Forum in the volunteer lot. Lin suggested that the right vehicle for the occasion was the Toyota Sienna Minivan, and we were inconspicuous in our studied informality. We were directed to a man at a computer, had our volunteer forms accepted, and without asking for any proof that I had a license, we were ushered into the auditorium and down to the Forum floor where at least 50 dentists were at work, oculists were fitting glasses, and primary care doctors were seeing patients in mobile clinics. I was introduced to a couple of GP's who explained that they were evaluating patients referred from the dental triage area who had high blood pressure.

There was an area, previously set aside by an enterprising nephrologist who brought a team of 3 aides, his own medical history form, and I later learned, an arrangement with RAM to run Basic Metabolic Panels, and CBC's, and apparently UA's via dipstick. During the 5 hours that I spent there, over 2 days, he was not physically present, so I used his space, without benefit of the lab tests. It was very primitive. Mostly, I explained hypertension and encouraged appropriate therapy. Without labs, I couldn't safely write prescriptions save for one lady who had symptoms of urinary tract infection, and no previous history of kidney or bladder disease. In all, I saw about 7 patients, and was delighted that one of them, a blind diabetic appeared to be getting excellent advice from a pharmacist, knew what a hemoglobin A1c was, and was doing a great job. It can be done!

Mostly, for me, the lesson was that this was a very sub-optimal setting for treating the kind of chronic disease that I spend my life confronting. I need labs, time and followup. People need to be educated and they must somehow be motivated. This setting was fine for dental extractions and eyeglasses, and screening, but in chronic disease, follow up is everything.

The nephrologist had a plan, and I hope it worked. It certainly seemed to have good intention, but I wonder about the capacity, in this setting for follow-up. I began to really appreciate Clinica La Amistad, run by St. Joseph Hospital, and Share Our Selves, run by Hoag Hospital Presbyterian, where I have access to the laboratory and imaging services, as well as medical records, and medications. For followup, this nephrologist would still be dealing with uninsured patients, a need for drugs and lab tests, let alone his own remuneration.

I have problems enough with CalOptima (Medicaid) and their rigid adherence to drug indications as listed in the FDA-mandated drug enclosure. This ignores that Secondary Hyperparathyroidism occurs in Stages II, IV and V of Chronic Kidney Disease, and gives an indication only for dialysis patients. Nephrologists simply ignore indications when they're dealing with insured patients and prescribe what's medically indicated, in the patient's best interests, but to get this out of some insurance companies and CalOptima, is an impossibility.

At the free community clinics, I can come close to practicing the kind of ideal medicine that I would like to practice, but, of course, somebody is paying for the lab tests and drugs, even when there is no remuneration for me. The somebody is the contributor to these non-profits.

Anyway, I believe more strongly than ever that Single Payer Health Care is the way to go....Medicare for everybody, and failing that, at least a government option. The Coops are a very lame delaying tactic by the Blue Dogs who are responding to their private sector contributors.