Center for Improving Value in Health Care
Dec 10, 2010 | 0 comments | Posted by
By Lalit Bajaj, MD
First patient: An eight year old girl with chest pain and concern for sexual abuse. Sad that my mind processes how long this will take and how complicated this will be instead of how sad this child must be. I walk in and meet the young girl and her grandmother. Grandma begins the conversation with a description of her granddaughter’s chest pain, which I quickly conclude is benign and needs no tests. I am sometimes accused of being a test minimizer, which I take as a compliment. Evolution and education gave me a mind that can occasionally make a decision without an X-ray or lab test. This is considered a form of heresy to many doctors, and I make fun of those people all the time. But then again, they drive much cooler cars than I do. I reassure Grandma that the chest pain is okay, but tell her I need to know more about her other concern.
Grandma proceeds to tell me that about a month ago, her daughter (this child’s mother) called her from several states away and told her to come get her granddaughter. She said no one wants her; all she does is cause trouble. Grandma made the very long drive and brought her back to Denver. She was not the same girl she was just six months ago. She eventually told her grandma that she had been raped by an acquaintance of her relatives multiple times, and was also raped by her mom’s boyfriend. Grandma has no idea what to do for her.
“How do I get her help? What do I say to her? Can you help us?” she asks.
I call our social worker and child protection team and they give me a clinic number to call. I am instructed to tell them to call the county social service team. Nothing else can be done. I send them back out to the world with a phone number.
Next patient: A 15-year-old boy who fell while running at cross country practice. He hit a sprinkler with his knee and cut it open. It bled a lot, not a ton. He’s fine. I tell his very tan, golf-attired father that the plan is to suture his son’s knee and that he will not be able to run for two weeks. He tells me that it is unacceptable for his son to be out of practice, so we need a better plan. I stare at him, confused.
“What other plan do you have in mind?” I ask.
“I don’t know. You’re the doctor. And, we are not like the rest of the people in your waiting room. We have insurance and we speak English.”
I can feel my blood start to boil, but smile like a good servant.
“Well, when the skin is cut open, we stitch it back up. And, when it is over the knee, we try to avoid activities that will impact the way it heals such as running.” He glares at me like a villain in a bad movie. I glare back like a superhero. ‘Make your move, Tan Man,’ says my inside voice.
“Fine,” he responds, exasperated. I go back to his son and ask if he had questions.
“Will it hurt badly to fix it?” he asks.
I respond, “No, I have some pretty good anesthetic.” I look back at his father who is typing on his iPhone, and leave the room.
I spend the rest of the shift talking care of minor illness and injury, and some serious illness and injury. It is not unlike a normal day. Then I meet a mother whose sadness can be seen from the waiting room. She holds a small girl in her arms who looks like a one year old, but she’s four. I speak to her via interpreter and she tells me that her daughter had never crawled, walked or moved independently. She can speak and has a bright personality. A few weeks ago in Mexico, a doctor told her that he couldn’t help her. If she wanted her daughter to survive, she should go to the US. She had a distant cousin in Denver. She sold all she had, and paid a coyote to get her to the southern border of Arizona. She’d hitchhiked the rest of the way here. She heard that she could come to my hospital for help. I tell her via the interpreter that we will do our best.
“Gracias,” she says with the first smile of the day.
“Thank you,” says the interpreter. I tell the interpreter that I know what ‘gracias’ means. She interprets that too. Mom laughs and gives me a hug.
I walk back to my car late that night and sit for a second. I have a meeting the next morning with CIVHC to discuss data gathering and reporting. At the moment it all seems irrelevant. Can we measure the young girl’s sexual assault or the effects of her mother’s abandonment? Can we measure that father’s bigotry and entitlement? Can we measure my frustration with him? And how do you measure the depth of a mother’s love that would send her on a trip that could have ended in tragedy? I am lost.
A few days later I sit in a CIVHC board meeting listening to a discussion on mission and strategies, skeptical that we can really change the culture so that people could actually care about the person sitting next them in an ER waiting room, and not get up to find another seat. But when Jay Want, our board chair, mentions passion and telling a story, I get a little more hopeful.
Maybe by sharing a story, measuring more than just claims, listening to each other, giving caregivers some more money to talk to patients for longer than 15 minutes without sticking a needle in them or ordering a CT scan just to get paid more, we can help communities face their unique challenges. And maybe, just maybe we can help people feel more invested in their neighbors.
I am constantly reminded of some wonderful lyrics from Rage Against the Machine.
“It has to start somewhere. It has to start sometime. What better place than here? What better time than now?”
Lalit Bajaj is the research director for the section of emergency medicine as well as a practicing emergency medicine physician at the Children’s Hospital, Denver/University of Colorado. He co-chairs CIVHC’s Data and Transparency Advisory Group and the All-Payer Claims Database Advisory Committee.
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