By Nia Zalamea, MD
Three years into my private practice, I met a gentleman (we can call him “Mr. B”) who was a father of two, husband and contractor. He came to me with a complaint of rectal bleeding, and we determined the next step was to perform a colonoscopy. On the day of his colonoscopy, we noted a fairly large mass in his sigmoid colon, with near obstruction. His wife was outside in the waiting room and his two children were away at college, in their first year of studies.
I sat next to Mrs. B and began, “Mrs. B, we have discovered the source of your husband’s bleeding…” As I spoke, she broke down in tears, worried about what would happen to their livelihood. A lifelong farmer, she had always stayed at home tending to the animals, while her husband went out to help build homes and businesses.
Mr. B had no insurance through his employers, as he worked multiple part-time jobs. During calving and hay season, some money did come in to the farm from selling the excess hay and calves. Aside from this, the family had no financial support. As Mr. B’s wife sat beside his stretcher, she begged him to not tell the children, afraid that they would leave school. Their son and daughter were two of the few family members able to seek a college education.
We scheduled the gentleman for surgery a few days later. Despite their parents’ best efforts, the children found out, and came home. While their father was undergoing surgery, the son and daughter were pooling their financial resources and preparing things at home so their mother wouldn’t have to.
As Mr. B went on to undergo a colectomy and almost a year of chemotherapy, our staff tried to help him, through financial assistance programs and case management. At first, he tried to work between treatments. Before long, however, the treatments took a toll on his stamina, and he had to stop working. The family ended up having to sell the farm to make ends meet. Ultimately, the two children never returned to school. They had to forego pursing a higher education in order to work full-time to support their family. The economic impact of colon cancer was such that two generations of the family had to fight to avoid bankruptcy.
This story is the reality of private practice. As providers, we sometimes have little support to offer when we deliver a life-changing diagnosis. We are able to provide state-of-the-art surgical and medical care, yet we lack the resources or training to restore our patients’ livelihood afterwards. Is this really the “best practice?”
The “best practice” should be one that turns medical care into a conduit through which we can improve a patient’s quality of life. Sometimes, a patient must be made “weaker” or “more vulnerable” through surgical procedures or treatments before he or she is able to reap the benefits of wellness. But without the gains on the other side of care, are the losses worth it?
Today, I practice in a nonprofit, faith-based setting for the poor. At the Church Health Center in Memphis, my patients and I have more resources than I could have ever dreamed of in my private practice. We are financially centered in a different way than in my private practice: we talk about the true cost of care, such as the loss of wages when a patient needs an operation, and the cost savings of a good outcome. I am able to prescribe smoking cessation classes after discussing the impacts of tobacco use on hernia operations. If the patient will be on a lifting restriction, I can prescribe appointments with our exercise and movement specialists for a post-operative exercise program, to ensure continued fitness in preparation for a return to the workforce. With extensive social work, and more importantly, an open and honest discussion about finances, we are all able to understand and anticipate together the losses that may accompany a surgical procedure for an hourly wage employee.
In addition, the Center provides a safe place in which to discuss the impact of health on spirituality. For many of my patients, their faith community is a more important support network than their family. Partnering with pastors and faith community members to rally support for the person in question becomes a team effort in which we all are focused on helping to boost that person back to life.
As physicians, I believe we have a responsibility to change what we do for our patients. Rather than allow colon cancer to signal the end of higher education for an entire generation, or the end of a family business, we must invest time and energy into providing resources that enable the patient and family to return to life as soon as possible. Otherwise, we only provide gains for those patients who can afford the losses. Best practices are defined not only by delivering peer-accepted, guideline- supported care: it is more important to ensure that the recipients of that care are prepared to reap the benefits.
Nia Zalamea is a General Surgeon at the Church Health Center and cares for the working uninsured people of Memphis. She has a background in overseas mission work and a passion for faith and health, and received The Gold Foundation’s Leonard Tow Humanism in Medicine award in 2004.
