Redlining: A Tale From the Trenches of Primary Care in America

If you could walk in my shoes, and look through my eyes, as I daily fight the good fight in the trenches of primary care in America, you might see something like this:

It would begin with a fight between two homeless men, probably over some spare change or a scrap of food, under the I-565 bridge. One of them, a 61-year-old black male, would get the worst end of the exchange–a fist fit neatly into the orbit of his right eye, his assailant’s bare knuckles impacting like rocks from a slingshot.

The concussive force of the blow would send a shock wave through the eye and crystalline lens, which is about the size and shape of a plain M&M candy. The lens, situated behind the iris, captures the light entering the pupil and focuses it onto the macula, the bull’s-eye of the retina.

Cracks and fissures would form, allowing water in the vitreous humor to penetrate and flood the protective lens capsule. The sudden intumescence, along with a chain of deleterious metabolic events, would cause the lens to enlarge and opacify, like a milky white water balloon.

The lens, waterlogged and heavy, would start to tear away from the zonules, the tiny fibrils which anchor it to the base of the back surface of the iris. It would begin to shift forward, blocking the pupil and impeding the flow of aqueous humor from the posterior chamber of the eye to the anterior chamber, located between the iris and the cornea, where the fluid is drained away in the trabecular meshwork, the eye’s “sink”. The intraocular pressure, normally a delicate balance of tension ranging from 11 to 21 mmHG, would begin to rise precipitously.

This shift in stasis would cause the colored tissue of the iris to bow forward toward the cornea, further crowding the space where the eye’s fluid drains, causing the pressure to rise even more. The iris would shift forward so much, in fact, that it would begin to touch the back surface of the cornea, the clear window of the eye.

Soon the cornea would start to swell, too. The rising pressure would force fluid past the normally watertight endothelium, the innermost layer, through the laminated middle layers of the stroma, and finally into the outermost epithelium, where tiny blisters would begin to form and erupt.

The pressure would also drive backward toward the optic nerve, causing its delicate structure to begin to cave. The retinal nerve fibers, converging to form the optic nerve like fiber optic wires in the trunk of a digital video cable, would begin to fray and atrophy.

As the cataract became denser and the optic nerve more wasted, the homeless man’s vision would begin to fade. As the cornea continued to swell and blister, his eye would begin to hurt like hell.

The homeless man would start to make his rounds from ER to ER, begging for pain medication. He would see an ophthalmologist on call who would give him two prescriptions for eye drops and tell him that he needs surgery.

But the homeless man has no car, no money, no health insurance, and no way to get the needed medicine. He has even less hope that things are going to turn out even remotely close to well.

Because he has rendered some sort of significant service to his country in the past, he is eligible to be seen in your clinic and eventually shows up on your doorstep near the end of the day as you’re trying to finish your last two patients. How he gets there, and how he found you, nobody knows.

When the primary care physician doing walk-in intake that day dumps him in your lap (you don’t blame him), you sigh, plant your palm in your face, and pull down on your skin in an effort to relax your jaw and facial muscles.

You know you’re being tested, and you don’t want to fail.

You invite the man back to the exam room. You don’t think about how he got to be homeless, you don’t judge, and you don’t ask yourself whether or not he “deserves” care.

He has a disease, he’s in pain, you’re a doctor, and he’s standing there in front of you. Your duty is clear.

You speak very slowly and plainly, and you observe. You notice that there is swelling in the lids and tissue around his right eye, and that he is holding it as if trying to keep it from popping straight out onto the floor.

But you know the real reason for this universal gesture of distress is that he can’t stand the brightness of your office lights. You turn off or dim as many as possible, and you place him in your chair.

You test his vision in the damaged eye, and you discover that he can barely see the motion of your hand in front of his face.  You measure his intraocular pressure and it’s 45 mmHG–lower than you thought it would be, but still way too high.

You see the milky balloon of a lens, the bulging iris bumping against the back surface of the cornea, the painful blisters–hundreds of them.

You diagnose phacomorphic pupillary block glaucoma, but you don’t use big words like that with the patient. You simply tell him his eye pressure is dangerously high and that he will likely never see well out of the eye again.

But, you tell him, we might be able to save his eye, and what little vision he has left, with surgery. You tell him that will require a trip to Birmingham and hospitalization. But first things first, you say–let’s lower the pressure.

You give him two drops, chosen from a small stash of ocular pharmaceuticals that you keep in a locked drawer for such occasions. One is to lower the pressure, and one to quell the inflammation inside his eye which is raging like a Colorado wildfire.

You would like to give him some pills, too, but it’s after hours, the in-house pharmacy is closed, and nearly everyone else has gone home.

You ask where he’s staying, and he gives you the name of a local homeless shelter. You tell him that a social worker will come find him tomorrow and help him return to the clinic to get the pills.

He heads out the door and back to the streets. You wonder if you’ll ever see him again.

You think about little else that night. You’re very quiet over dinner because your brain, including the parts where words and screams are formed, is fried. You sleep fretfully.

The next day, the homeless man is the first thought on your mind. You go to work and you find the social worker and ask her to find the man. She locates him, and she makes arrangements to bring him in.

When he arrives, he says his eye feels a little better with the drops. But when you measure his vision, he says he can no longer see your hand, only light. You examine him with your slit lamp, and if anything, the cataract is even bigger and the bulging iris displaced even further forward. His intraocular pressure has risen to 52 mmHG.

You prescribe the pills, which should lower the pressure more dramatically, and make him take one before he hits the streets again. You’ve already called and made arrangements for him to be admitted to the ophthalmology department at your main facility for surgery. You try to explain to him how important it is that he keeps this appointment, how his eye will become even more blind and painful if he waits.

You tell him how he needs to arrive early at your clinic the morning of his appointment to catch the shuttle to Birmingham, and that he’ll probably be hospitalized for several days. He doesn’t like this one bit–he’s not the type of guy who likes to be held captive to a regimented routine. You persist, though, gently at first, then more firmly.

He voices his understanding of all this and promises he will be there on time, but you know the odds are he’s simply telling you what he thinks you want to hear so he can get out of there and move on. The social worker gives him city bus passes to make it easier for him. He walks out the door and back onto the streets. You wonder, once more, if you’ll ever see him again.

You do all this while trying to provide quality care to the other 15 or so regularly scheduled patients already on your plate that day.

On the drive home, you think about your country’s healthcare system and the role you play in it. You know it’s not really a “system”, because that word implies a well-coordinated arrangement of smoothly-moving parts.

You picture it as more of a million-piece jigsaw puzzle that has spilled onto the floor. You spend your days, some days more than others (this has been one of those), scrambling like mad, picking up the jagged pieces and trying to assemble them into some kind of coherent, meaningful picture.

You think about the people who speak glibly of health care, who speak ill of government doctors like you, who poo-poo the need for reform, who opine that catch-as-catch-can ER care is “good enough” for patients like yours.

You find yourself muttering things under your breath about such people, words and phrases that you thought you’d never say, ones that would disappoint and anger your mother and cause her to smack you across the mouth.

You stop yourself because you want to be a better person than that, and try to cut them some slack.

When you arrive home, you consider the three cardinal signs of professional burnout–exhaustion, cynicism, and second-guessing both your abilities and your odds of making a significant difference–and you realize that you are so dangerously close to self-immolation that your face is flushed and you’re starting to smolder.

You reach for a $10 bottle of halfway decent Cabernet to help douse the fire. You pour yourself a glass, the red line rising full to the brim. You turn toward your keyboard, and pour out your soul.

  1. Erica Davis

    The puzzle is much too large, so stop looking at it that way.  Concentrate on one part of the picture, and perhaps you’ll find it fits with other parts being reconstructed by other faithful people.  And if not, what of it?  You will have fixed something, however small it may seem.  Be frustrated when you need to be frustrated; sometimes, that brings about amazing change.  Talk about it; write about it; scream about it when you must.  But don’t let it steal your faith that you are doing good work in this world.  Go read the Desiderata.  It always helps me find perspective when I need it. Peace.

  2. Michael Brown

    Thanks for the encouraging words, Erica.

    Most days, I do pretty well. I use the gardening analogy; I try to cultivate my own little plot of ground and keep it weed-free. Like you said, I fix what I can.

    On others, the brokenness of the system–and really, the world–can be overwhelming.

    Even if you set aside all the decades of less-than-ideal circumstances and bad personal decisions that led to that fight under the bridge, had the patient been a resident in most Western industrialized countries, he would not have been turned back out onto the streets with two paper Rxs (not even any samples) and left to his own devices to wander about, in considerable pain, until he found someone who could help him–he would have probably received the surgery sooner and been spared more of his sight.

    But not here, in the richest country on earth.

    I think we can do better than that. Smart, efficient, compassionate government is an integral part of the answer.

    Back to my trowel and hoe.

  3. belinda bishop

    have you posted this on FB?  i’d like to share it there, with your permission.

  4. Erica Davis

    Well, there’s nothing wrong with tending your little piece of the Earth while doing what you can to improve the rest of the garden as well. “Compassionate government” is a wonderful concept, and I’m just Christian enough to keep pushing for that.

  5. Michael Brown

    Belinda, yes it’s on FB. Share away.

  6. CarolinaGirl

    …and I thought it tough when PCMs change out every six months b/c it’s time for that Provider to move on…after five months, I already have a new one…

  7. Charlie

    I’ve missed your blog for awhile.  Our last marathon conversation directed me back.  Keep plugging away Doc.  You are making a difference.

  8. Michael Brown

    Thanks, Charlie. We have covered a lot of ground in those marathon conversations, but I don’t think we’ve solved the problem of healthcare reform yet. We must remedy that soon. I hope McDonald’s has enough senior coffee for the task.

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