During my first year of practice, I served as a National Health Service Corps physician in inner-city Los Angeles, assigned to a clinic in Watts. Fresh out of pediatric-residency training, I looked and felt like a newly hatched doctor, but despite my youth and inexperience, I was determined to save lives–or at least not to kill anyone my first week on the job.
It didn’t take long for signs of trouble to appear. I should have suspected something was amiss when I found myself fighting to treat one of the most common maladies affecting children: middle-ear infections. Understandably, kids aren’t thrilled at the prospect of an ear exam, but to properly diagnose an infection, you have to look at the eardrum, which may be swollen and inflamed. This sometimes means that a nurse is needed to hold the child still while you peer into the ear. Although wrestling an angry 2-year-old can make you feel like you’re in the ring with Mike Tyson, there’s really no choice. Untreated infections can lead to serious complications like hearing loss.
Unfortunately, every time I needed a nurse to assist me, I had to beg someone to go one-on-one with a toddler. The other doctors didn’t routinely conduct such exams, so my actions seemed odd and out of place. As a rookie, I probably wasn’t the ideal candidate to revolutionize the clinic’s way of doing business, but cast into the role of chief rabble-rouser, I did my best to carry the torch. The nurses, meanwhile, did their best to snuff that torch out.
I soon found myself facing a tough choice: keep the peace or keep doing the exams. The nurses were in open rebellion, yet I was simply trying to take care of my patients the way I was trained. I was at a loss about how to handle staff mutineers–this wasn’t a subject they taught in medical school. I chose to do the exams.
A few months later I was summoned to a meeting with a senior HMO official. He informed me that my tenure at the clinic was over, and that I would soon be reassigned to another needy location–like an Indian reservation in North Dakota.
Since I hadn’t been planning on a move to the Great Plains, I didn’t take the news well. I was shocked to learn that my dismissal had to do with ear exams.
I frantically explained to the official that the crisis stemmed from “philosophical differences” over how to deliver medical care. It came down to a simple choice–we could provide either appropriate care or sloppy care to the Watts community. The choice was his.
I left the meeting convinced I was bound for the northwest territories, but the HMO ultimately decided to uphold the sanctity of ear exams. To my surprise, I was unceremoniously “un-fired.” A short while later, the nurses who had fought me the most were gone.
My second year as a practicing physician went much more smoothly than my first. There were no more clashes over ear exams, and I gradually began to feel like a part of the local community. Freed from the field of battle, I had the chance to develop some close bonds with single mothers struggling to raise their kids against all odds in South-Central L.A.
As I look back now, I realize that the industrial approach to health care–in which patients are shuttled in and out of examining rooms like auto parts on the line–wreaks havoc with the doctor-patient relationship. The problem isn’t unique to inner-city clinics, but it tends to be more pronounced in communities where patients are less likely to complain or file malpractice suits.
That’s why programs like the NHSC–which brings doctors to underserved areas–are so important. With additional providers, clinics are under less pressure to maintain an assembly-line mentality. As shrinking budgets threaten the solvency of many federal programs, it’s imperative that worthy ones like the NHSC survive. Otherwise, the level of care in places like Watts could get even worse.
Of course, I was lucky. As a young doctor, I fought some heated battles, but I never had to pay dearly for my convictions. Still, it could easily have gone the other way, and it often does. Yet even in the inner city, the patient sometimes wins. It may be a cold world out there, but in the end, Hippocrates emerged unscathed.
