it was dark and I was over

Today at clinic, a patient found out at the front desk that she didn't have insurance anymore. As a result, she no longer qualifies to come to our clinic. She had just been to the Emergency Department yesterday because she had a UTI and she had not been able to see a resident in clinic quickly enough (although, now that we know that she has lost her insurance, she would not have been seen by a resident anyway). She got antibiotics from the Emergency Department, but she wanted to be seen today because she was still having pain.

Also she has HIV.

Last time she was seen for her HIV, her CD4 count was great, which means her immune system was intact. She was on antiretroviral therapy, and it was working well. All we could do for her today was check her vital signs and make sure she wasn't dying in front of our faces, and tell her that she could go to the Emergency Department if she started to feel worse or developing worrisome symptoms.

If you follow this out to its logical conclusion, you have the dizzying, frustrating, enraging headache that is US healthcare. Patients without insurance do not get seen in the primary care setting. Preventative healthcare falls to the side in these patients, the most vulnerable ones, I might point out. As a result, they get sick and they come to the ER. Sometimes they aren't really sick and they come to the ER. But they come to the ER because they don't have a primary care physician to weigh in one way or another. This patient isn't acutely sick right now, so she probably won't get much out of a visit from the ER today. But thanks to losing her insurance, she won't be able to take her HIV meds, and her CD4 count will most likely plummet, and eventually, she will turn up in the ER with an opportunistic infection, having developed full blown AIDS. Good job, America.

As part of my residency, I rotate through the Emergency Department, and it also turns me into a rage monster, because again, a ton of the patients who turn up don't really need Emergency Services. They do not need a CT of their abdomen, seventeen labs and 12-hrs of monitoring, only to be sent away without explanation by a shrugging, tired ER doctor. They need a primary care physician.

But they're not likely to get one any time soon.

I'd like to complain some more, because there's an entire separate rant about how Internal Medicine programs pay pure lip service to encouraging residents towards primary care, while wholly supporting a system that actively kicks out the desire for anyone to do primary care. But I am tired. And frustrated that I contributed to the problem today because the system tied my hands behind my back.