Nov. 17, 2008

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Doctor as Advocate: Healing the Whole Patient

Graham Ramsay Ellen Rothman

“Obama winned! Obama winned!” cried my giddy 4-year-old as she streaked around the house. Her squealing 2-year-old sister chased after her, unsure of the cause for celebration and simply delighted to participate in the exuberance of the moment.

That morning, on my drive into the free clinic where I work in South Los Angeles, I had passed several polling stations, each with lines of voters stretching down the block. But at my clinic, which serves many of the uninsured and undocumented living in South L.A., the presence of the election was muted. I participated in the American Academy of Pediatrics “Prescription to Vote” program at our clinic, but in a day when I saw 30 patients, only one was eligible to vote, and she was so cowed by her poor English that she was not planning to participate.

In my community in South L.A., people are not disaffected. They are disempowered. My professional goal in this setting has been simple—to provide the best medical care possible in a system that does not seem to care much. I have been content to wage a private battle at the most basic level, my patient and I against the world.

Medicine used to be a profession of ideals. But it feels as though the last two decades have eroded the moral foundation. As I entered medical school in the early 1990s, the health maintenance organizations were transforming the landscape of medicine to trim the fat from the antiquated fee-for-service system. Efficiency became the primary concern of medical practices, governed by the business managers more than the clinicians.

Since then, the financial pressures have only intensified. At its worst, medicine has become a mass-production factory line designed to spit out a product—good health at a cut rate. Suspicious patients are no longer sure whether their doctor is allied with them or their insurer. The popular media are filled with examples of questionable relations between doctors and drug companies and reports of doctors over-ordering or under-ordering tests to cheat patients or bilk insurers. A niche of boutique medical practices has drawn fed-up physicians and wealthy patients from the rat race of modern medicine. What happened to the doctor as healer? What happened to the doctor as human? It has been a disillusioning time to be in medicine.

The delivery of medical care at my clinic is chaotic, disorganized, and lacking in vision. Patients wait sometimes for hours, and the care is often great, but sometimes not. Yet there is an unwavering commitment to community health. My clinic has been a leader in bringing together different organizations in South L.A. to create green space, to improve access to healthy food, to fight the slum lords. I find this combination of care and activism appealing.

But as I have begun to explore the liberal politics of South L.A., I discovered some very uncomfortable positions. When Martin Luther King Hospital closed, opponents argued that South L.A. needed care—any care—rather than that the community deserved the best care. Protesters reacted with outrage when legislation passed making it illegal to sleep on the streets, but outrage against people having to sleep on the streets at all was lost. Physicians for Social Responsibility sites as its primary issues toxic pollutants, nuclear weapons, and global warming. But with 15 percent of Americans lacking insurance and basic healthcare, are these really our most important social concerns as physicians?

Even as I cherished my role as a doctor, I felt that Medicine failed me. I looked to find my own path and tried to forget about the larger world. My choice of, first, the Indian Health Service and then South L.A. was nothing but escapist. Until this year’s presidential elections.

Obama’s mission put eloquent voice to the need for our nation to look out for those who have less. A good pediatrician worries not just about vaccines and growth charts, but also about schools and food and economic stability and family support. Most pediatricians don’t even get to see those uninsured children who lack even the most basic resources to walk through the clinic door. Without these fundamentals, health and well-being are impossible to achieve. Obama recognizes this interdependence and demonstrated his willingness to serve as a national advocate for the fundamentals. For me, this has translated into a powerful sense of identification, since I feel that in some small way, I, too, am an advocate.

It is unlikely that Obama’s politics will change the care offered by my practice, locally known as a clinic of last resort. None of the proposed healthcare reform plans suggest expanding services for the undocumented. But in Obama, I see a national leader who can restore social integrity to our country. I see someone who can speak for the people.

Macy and I were out of the house well before 7 a.m. on election day, and we waited for over an hour to vote. Together, we inked our selection: Obama. How powerful to teach Macy, as she ran cheering through the house that evening, that her ballot contributed to Obama’s win, that his victory was also, in part, her victory. The two defining experiences of my life have been becoming a physician and becoming a mother. That one small moment in the voting booth distilled the hopes and ideals of each.

—Ellen Rothman

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Copyright 2008 by the President and Fellows of Harvard College