PERSONAL VIEW

Including Welfare

Patients in One’s

Private Practice Some

Philosophical

Dominck Mele, M.D., Paul

Comments

Premsagar,

M.D.

~T

IS SAID that the very rich and the very poor are hard to treat. Both types of patients _ often make such demands on the physician’s time and on his office personnel that he sometimes wonders if it is worthwhile to take care of such patients. In the American scene, health care presently works on a voluntary basis. The physician has the choice of whom he will treat and the patient has the choice of who will treat him/her. This article is an outline of our observations in private pediatric practice on

rendering

,

health

care to

patients

on

Medi-

caid and, in particular, on public assistance for several years. The decision to accept or not to accept a patient on Medicaid for treatment is a matter of personal choice for the physician. Some physicians have elected not to accept and treat such patients for some very good reasons and this article is not directed against them. We feel, rather, that our observations will be of particular interest to those physicians who do treat welfare patients and to those planning health care for those on public assistance. With the medically indigent, the government assumes the financial responsibility for paying for the physician’s services. The schedules of remuneration in many communities are not so high as with patients who pay for their ow n services, but some remunera1726

Campbell Avenue, Schenectady,

N.Y. 12306.

tion is available nevertheless. But money is only one of many factors involved when offering adequate medical attention to the poor. The problems go beyond dollars and cents. What are the obstacles which hinder these people from receiving adequate health care? There are many. Some of the parents who have been recipients of public assistance over an extended period of time seem to have an emotional disability of which they are unaware. This disability makes it difficult for them to hold jobs. They have gone from pillar to post and in many instances have lost their spouses. To all outward appearances they are able-bodied men or women who are labeled &dquo;

&dquo;lazy.&dquo; Many

persons lack the initiative to bring their children for periodic examinations and protective inoculations. Sometimes it is simply a case of apathy or procrastination, with failure to realize the importance of visits to the doctor. Others are caught in a web of inextricable family problems; they may not be in a position to make a rational decision, or too many psychological or social difficulties lie in the way of being faithful about medical ap-

pointments. These problems cannot be legislated out of existence. In fact, they cannot be solved by financial aid. These families need guidance, sympathy, and understanding, which are, unfortunately, in short supply. Another group of problems is the economic

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Many of these families cannot afford a telephone or a car, and live too far away from

ones.

doctor’s office or clinic to be able with their child, especially when there go the child is sick. They have to depend on a neighbor or friend (few in number) to give them a ride to the doctor’s office. When these resources fail, they cannot keep their appointments. Money is usually not available for a taxi, which is relatively expensive. Take the situation in which a woman living alone has a sick child with a temperature of 105 at 3 a.m. What else can she do but bundle up the infant and try to get to the nearest emergency room? Domestic difficulties such as this one help to explain why so many indigent parents take their children to hospital receiving units which are open at all hours for so-called &dquo;emergencies&dquo; and &dquo;walk ins.&dquo; In our private office, we keep these matters in mind when treating these patients. We try to understand the child’s health problem within the framework of the family setting. We do not expect his parents to reason as clearly or to analyze the situation as a physician does. Due allowance is made for their approaches to understanding and cooperation. They are encouraged to ask questions (some are afraid to ask) and their questions are answered to the best of their comprehension. When the same questions are asked repeatedly, we give the answers and reassurance with illustrations and without showing any impatience. Our instructions are brief and precise ; they are written out on a sheet of paper which is to be taken home. And before they leave the office, our receptionist goes over the instructions with them again. This, incidentally, is a standard procedure in our office with all patients. With some cases, we call on the public health nurse or community social worker to follow through on our recommendations. As a rule, these will not only follow through, but often report back to us on progress. The incidence of hospitalization among welfare patients is significantly more than with other patients and their average stay is also more prolonged. The reasons are usually the

nearest

to

.

related to the family situations, which the interns and the nursing staff in the hospitals do not always appreciate. At times, staff pressure to send these patients home early has to be tactfully resisted. Nevertheless, the availability of medical services such as ours, and the assumption of financial responsibility by the government do not guarantee that all those in need will be served. In order to reach every child, sick or well, some form of totalitarian method would be required and this thought is repugnant to us. Yet, because a significant number of medically indigent do not avail themselves of the services (and these are often the ones with the greatest need), certain steps for improving their health care in addition to existing community services would seem helpful. l. Maintenance of walk-in clinics or offices for sick children where no appointment is needed and the patients are seen on a first-come first-served basis. 2. Using the skills of a pediatric nurse

practitioner to perform , periodic screening examinations in the homes of the children. Recording all immunizations on the back of the birth certificate. 4. Storing the immunization data in an available computer for retrieval at any time of the day or night. 3.

There have always been physicians who treated the poor long before there were any Medicaid laws, and there will be many in the future. To refuse service to the medically indigent because of bureaucratic nd legislative complexities or underpayment is comparable to punishing a child for his parent’s faults. Poverty, after all, is a symptom of many an emotional as well as physical illness.

disabilities are not difficult to recogcare for. Emotional disabilities are less easily recognized. Who is better qualified than a physician to detect and remedy both types? Perhaps this is what Rudolph Virchow meant when he said &dquo;The physician is the natural attorney for the poor.&dquo;

Physical

nize and

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Including welfare patients in one's private practice. Some philosophical comments.

PERSONAL VIEW Including Welfare Patients in One’s Private Practice Some Philosophical Dominck Mele, M.D., Paul Comments Premsagar, M.D. ~T I...
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