but it's out of my control

This one is going to be discombobulated.

The patient with sickle cell lies uncomfortably in the hospital bed, rubbing her pregnant belly. She's been worried all week; this is not her first pregnancy, not by a lot, but there has been more bad news than happy ones during her pregnancies. Sickle cell patients are at a higher risk for miscarriages, preeclampsia, all kinds of pregnancy related complications. She is having a pain crisis. 

The nurse changed her benadryl dosing halfway through her hospitalization, convinced she was seeking a 'benadryl high.'

I talk to the interns about the importance of treating sickle cell patients with consistency and fairness. I talk about how they have real pain. I talk about the patients who have been perceived as 'crying wolf' who subsequently died of acute chest syndrome or a myocardial infarction. I talk about how sickle cell patients live a decade longer in the UK compared to the US; I ask the interns why that is. They come up with creative suggestions, ones that those with much more training have tried to use as explanations, about biological differences. But it's pretty much established that the reason that they live longer is that they have healthcare and an infrastructure that knows it benefits the system to treat these patients properly.

But I watch the nurse complain to the intern about the benadryl request, and I wonder how long before the interns unlearn everything I've just tried to teach them.

We walk into the room, where the patient rubs her belly. Her partner is lying in bed beside her, the two of them barely contained in the uncomfortable hospital bed. The fellow starts speaking straight to the patient, completely ignoring her partner, who the fellow has never met. I gently interject and introduce myself to the man, and he responds immediately, politely introducing himself too. The fellow awkwardly recovers.

Walking back to the rest of our patients, a hodgepodge of chronically and acutely ill patients, I think about inequity and disparities. And how it's not enough to say you try to treat every patient the same, because the fact of the matter is we just don't. There are inherent biases. Things the nurses teach you, things the residents might have taught you during training, little silent cues, and there's society at large. Every time a sickle cell patient is on my service, I am haunted by the statistics about their outcomes. I think of the patient rubbing her belly- African-American woman with sickle cell patient. I think of the maternal mortality rates in the US, and we call OB one more time and make them check on the patient.

But I worry that it's still not enough.

The best thing we did at our institution that helped control sickle cell related pain was the work of an African-American nurse who took it on as her cause to treat these patients humanely and to improve their pain. She championed an initiative to reserve a set number of chairs in our infusion center for IV pain medications for these patients, so that they could call in with a pain crisis, come in and get the needed IV opioids without waiting for several hours in a crowded ED, getting scowls and skepticism from nurses and doctors who don't fully understand their disease, and having to argue about the dosage they need.

That nurse really singlehandedly reduced the number of hospitalizations due to sickle cell at our hospital, though initially her plan was thought to be unrealistic. Sickle cell patients come to the hospital and don't leave until you make it uncomfortable for them, one resident said to me when I was a trainee. That was the perception, that was the theory. That was utter bullsh*t, that was grounded in inherent biases, systemic racism, and a lack of education.

***

We round in the morning, and it is starting to exhaust me, which always happens around this point, the 10th day of a 14-day hospital stretch. Mostly I am exhausted by what I can't do. There are five patients on our service right now who don't really need to be in the hospital. One had been living in Morocco with her husband, and returned home to California after getting out of an abusive relationship, only to find out she had an aggressive lymphoma that was eating away at her hip. But since she just moved back to the US, her health insurance is still being processed. So here she sits. Another was diagnosed with acute leukemia and didn't have health insurance. He would die if we didn't give him chemotherapy. He'll die if we let him leave the hospital since, if he walks out of the hospital, he can't receive therapy in the clinic (which normally would be the treatment). So here he sits. Another has the kind of mental health issues that are not severe enough to warrant inpatient mental health treatment (because the state has made so many cuts to mental health care, inpatient centers have had to narrow down criteria for admitting patients to only the most sick, dangerous patients), but not mild enough to allow him to be discharged safely. Here he wanders the hallways. One lives five hours away in a rural area- I regularly receive emails from desperate recruiters trying to get me to take a job as an oncologist in this particular rural area. There are clinics, but no providers, especially since we've made it harder for foreign physicians to stay in the US. The last patient will not be accepted to a nursing facility and no one in his immediate or extended family can care for him at home, especially because we as a nation do not provide enough financial and ancillary support to caregivers.

Of all the types of care you can get, a night in the hospital is the most expensive.

So yes, the system can handle single-payer insurance.

***

Call me corny, I don't care. But if you ask me which movie has stuck with me the longest this past year, it's Spiderman: Into the Spiderverse, which is now available to stream on Netflix. I watch the superhero movies, at least some of them, but mostly for mindless entertainment. Even the ones people claim are great (i.e. Bat-Bale-man era stuff), I find pretty problematic if you look too closely at its politics. No such problems with this movie. The spirit of everything good about New York is also infused into every second of this movie. The soundtrack is pretty good too.