0:00:00.830,0:00:02.515
A few years ago,

0:00:02.515,0:00:06.490
I was taking care of a woman[br]who was a victim of violence.

0:00:06.718,0:00:12.616
I wanted her to be seen in a clinic[br]that specialized in trauma survivors.

0:00:12.836,0:00:18.006
I made the appointment myself because,[br]being the director of the department,

0:00:18.006,0:00:19.708
I knew if I did it,

0:00:19.708,0:00:21.928
she would get an appointment right away.

0:00:22.148,0:00:26.040
The clinic was about an hour and a half[br]away from where she lived,

0:00:26.040,0:00:29.758
but she took down the address[br]and agreed to go.

0:00:30.736,0:00:35.339
Unfortunately, she didn't[br]make it to the clinic.

0:00:35.339,0:00:37.933
When I spoke to the psychiatrist,

0:00:37.933,0:00:40.200
he explained to me

0:00:40.200,0:00:43.285
that trauma survivors are often resistant

0:00:43.285,0:00:46.554
to dealing with the difficult[br]issues that they face,

0:00:46.554,0:00:48.759
and often miss appointments.

0:00:48.759,0:00:49.934
For this reason,

0:00:49.934,0:00:54.596
they don't generally allow the doctors[br]to make appointments for the patients.

0:00:55.163,0:00:58.189
They had made a special exception for me.

0:00:58.569,0:01:00.721
When I spoke to my patient,

0:01:00.721,0:01:04.679
she had a much simpler[br]and less Freudian explanation

0:01:04.679,0:01:07.794
of why she didn't go to that appointment:

0:01:08.024,0:01:10.256
her ride didn't show.

0:01:11.068,0:01:13.558
Now, some of you may be thinking,

0:01:13.558,0:01:17.641
"Didn't she have some other way[br]of getting to that clinic appointment?"

0:01:17.641,0:01:19.942
Couldn't she have taken an Uber

0:01:19.942,0:01:22.295
or called another friend?

0:01:22.582,0:01:24.429
If you're thinking that,

0:01:24.429,0:01:27.457
it's probably because you have resources.

0:01:27.457,0:01:30.864
But she didn't have[br]enough money for an Uber,

0:01:30.864,0:01:34.065
she didn't have another friend to call.

0:01:34.065,0:01:35.877
But she did have me, and I was able[br]to get her another appointment,

0:01:35.877,0:01:41.715
which she kept without difficulty.

0:01:41.968,0:01:45.788
She wasn't resistant,[br]it's just her ride didn't show.

0:01:46.868,0:01:50.885
I wish I could say that this[br]was an isolated incident,

0:01:50.885,0:01:53.934
but I know from running[br]the safety net systems

0:01:53.934,0:01:59.443
in San Francisco, Los Angeles,[br]and now New York City,

0:01:59.443,0:02:03.002
that health care is built[br]on a middle class model

0:02:03.002,0:02:07.509
that often doesn't meet the needs[br]of low-income patients.

0:02:08.014,0:02:11.878
That's one of the reasons why[br]it's been so difficult

0:02:12.143,0:02:15.809
for us to close[br]the disparity in health care

0:02:15.809,0:02:19.228
that exists along economy lines

0:02:19.228,0:02:22.839
despite the expansion of health insurance

0:02:22.839,0:02:26.206
under the ACA, or ObamaCare.

0:02:27.044,0:02:29.759
Health care in the United States

0:02:29.759,0:02:33.435
assumes that, besides getting across[br]the large land expanse of Los Angeles,

0:02:33.435,0:02:40.843
it also assumes that you[br]can take off from work

0:02:40.843,0:02:43.689
in the middle of the day to get care.

0:02:43.689,0:02:47.992
One of the patients who came[br]to my East Los Angeles clinic

0:02:47.992,0:02:50.237
on a Thursday afternoon

0:02:50.237,0:02:53.451
presented with partial blindness

0:02:53.451,0:02:55.672
in both eyes.

0:02:55.672,0:02:57.816
Very concerned, I said to him,

0:02:57.816,0:03:00.136
"When did this develop?"

0:03:00.136,0:03:02.117
He said, "Sunday."

0:03:02.584,0:03:04.694
I said, "Sunday?

0:03:04.694,0:03:07.572
Did you think of coming sooner to clinic?"

0:03:07.572,0:03:11.718
And he said, "Well, I have to work[br]in order to pay the rent."

0:03:11.718,0:03:15.967
A second patient to that same clinic,

0:03:15.967,0:03:16.821
a trucker,

0:03:16.821,0:03:19.765
drove three days with a raging infection,

0:03:19.765,0:03:24.411
only coming to see me[br]after he had delivered his merchandise.

0:03:24.647,0:03:31.967
Both patients' care was jeopardized[br]by their delays in seeking care.

0:03:31.967,0:03:35.609
Health care in the United States[br]assumes that you speak English

0:03:35.809,0:03:39.060
or can bring someone with you who can.

0:03:39.343,0:03:44.211
In San Francisco, I took care of a patient[br]on the inpatient service

0:03:44.211,0:03:46.412
who was from West Africa

0:03:46.412,0:03:49.363
and spoke a dialect so unusual

0:03:49.363,0:03:54.944
that we could only find one translator[br]on the telephonic line

0:03:54.944,0:03:56.975
who could understand him,

0:03:56.975,0:04:00.163
and that translator only worked[br]one afternoon a week.

0:04:00.934,0:04:05.667
Unfortunately, my patient[br]needed translation services every day.

0:04:06.614,0:04:10.060
Health care in the United States[br]assumes that you are literate.

0:04:10.060,0:04:13.203
I learned that a patient of mine[br]who spoke English without accent

0:04:13.203,0:04:17.498
was illiterate

0:04:17.498,0:04:20.569
when he asked me to please sign[br]a social security disability form

0:04:20.569,0:04:24.439
for him right away.

0:04:24.659,0:04:27.854
The form need to go[br]to the office that same day,

0:04:27.854,0:04:29.685
and I wasn't in clinic,

0:04:29.685,0:04:31.409
so trying to help him out,

0:04:31.409,0:04:35.068
knowing that he was[br]the sole caretaker of his son,

0:04:35.068,0:04:39.403
I said, "Well, bring the form[br]to my administrative office.

0:04:39.403,0:04:42.243
I'll sign it and I'll fax it in for you."

0:04:42.243,0:04:44.858
He took the two buses to my office,

0:04:44.858,0:04:46.783
dropped off the form,

0:04:46.783,0:04:49.418
went back home to take care of his son,

0:04:49.418,0:04:54.839
I got to the office, and what did I find[br]next to the big "X" on the form?

0:04:54.839,0:04:56.567
The word "applicant."

0:04:56.567,0:04:59.076
He needed to sign the form.

0:05:00.382,0:05:04.093
And so now I had to have him[br]take the two buses back to the office

0:05:04.093,0:05:08.600
and sign the form so that[br]we could then fax it in for him.

0:05:08.795,0:05:11.070
It completely changed[br]how I took care of him.

0:05:11.070,0:05:16.327
I made sure that I always went over[br]instructions verbally with him.

0:05:16.327,0:05:20.977
It also made me think about[br]all of the patients

0:05:20.977,0:05:23.295
who receive reams and reams of paper

0:05:23.295,0:05:27.196
spit out by our modern[br]electronic health record systems

0:05:27.196,0:05:30.220
explaining their diagnoses[br]and their treatments,

0:05:30.220,0:05:34.065
and wondering how many people actually

0:05:34.065,0:05:36.263
can understand what's on[br]those pieces of paper.

0:05:36.263,0:05:40.830
Health care in the United States assumes[br]that you have a working telephone

0:05:40.830,0:05:42.829
and an accurate address.

0:05:42.829,0:05:46.543
The proliferation[br]of inexpensive cell phones

0:05:46.543,0:05:48.591
has actually helped quite a lot,

0:05:48.591,0:05:51.065
but still my patients run out of minutes

0:05:51.065,0:05:54.597
and their phones get disconnected.

0:05:55.054,0:05:59.812
Low-income people often have[br]to move around a lot by necessity.

0:05:59.812,0:06:06.017
I remember reviewing a chart of a woman[br]with an abnormality on her mammogram.

0:06:06.017,0:06:08.957
That chart assiduously documents[br]that three letters were sent to her home

0:06:08.957,0:06:15.223
asking her to please come in for followup.

0:06:15.223,0:06:17.746
Of course, if the address isn't accurate,

0:06:17.746,0:06:22.389
it doesn't much matter how many letters[br]you send to that same address.

0:06:23.333,0:06:28.971
Health care in the United States assumes[br]that you have a steady supply of food.

0:06:29.234,0:06:32.790
This is particularly[br]an issue for diabetics.

0:06:32.790,0:06:36.714
We give them medications[br]that lower their blood sugar.

0:06:36.714,0:06:39.185
On days when they don't have enough food,

0:06:39.185,0:06:42.977
it puts them at risk[br]for a life-threatening side effect

0:06:42.977,0:06:47.039
of hypoglycemia, or low blood sugar.

0:06:47.213,0:06:50.490
Health care in the United States assumes[br]that you have a home

0:06:50.490,0:06:52.921
with a refrigerator for your insulin,

0:06:52.921,0:06:55.616
a bathroom where you can wash up,

0:06:55.616,0:07:00.099
a bed where you can sleep[br]without worrying about violence

0:07:00.099,0:07:02.596
while you are resting.

0:07:02.823,0:07:04.971
But what if you don't have that?

0:07:04.971,0:07:07.221
What if you live on the streets,

0:07:07.221,0:07:09.123
you live under the freeway,

0:07:09.123,0:07:11.900
you live in a congregant shelter

0:07:11.900,0:07:15.895
where every morning[br]you have to leave at 7 or 8 am?

0:07:16.260,0:07:19.875
Where do you store your medicines?

0:07:21.098,0:07:23.496
Where do you use the bathroom?

0:07:24.368,0:07:28.860
How do you put your legs up[br]if you have congestive heart failure?

0:07:29.303,0:07:34.118
Is it any wonder that providing people[br]with health insurance who are homeless

0:07:34.118,0:07:38.712
does not erase the huge disparity

0:07:38.712,0:07:40.825
between the homeless and the housed?

0:07:42.061,0:07:47.472
Health care in the United States assumes[br]that you prioritize your health care,

0:07:48.221,0:07:50.534
but what about all of you?

0:07:50.534,0:07:55.033
Let me assume for a moment[br]that you're all taking a medication.

0:07:55.033,0:07:57.533
Maybe it's for high blood pressure.

0:07:57.533,0:08:01.534
Maybe it's for diabetes or depression.

0:08:01.534,0:08:05.158
What if tonight you had a choice:

0:08:05.158,0:08:08.207
you could have your medication[br]but live on the street,

0:08:08.207,0:08:16.151
or you could be housed in your home[br]but not have your medication?

0:08:18.142,0:08:21.155
Which would you choose?

0:08:21.155,0:08:23.767
I know which one I would choose.

0:08:24.721,0:08:28.882
This is just a graphic example[br]of the kinds of choices

0:08:28.882,0:08:32.419
that low-income patients[br]have to make every day.

0:08:32.419,0:08:35.559
So when my doctors[br]shake their heads and say,

0:08:35.559,0:08:40.819
"I don't know why that patient[br]didn't keep his followup appointments,"

0:08:40.819,0:08:45.696
"I don't know why she didn't go[br]for that exam that I ordered,"

0:08:45.696,0:08:49.306
I think, well, maybe her ride didn't show,

0:08:49.306,0:08:51.771
or maybe he had to work.

0:08:51.771,0:08:57.651
But also, maybe there was something[br]more important that day

0:08:57.651,0:09:01.859
than their high blood pressure[br]or a screening colonoscopy.

0:09:02.103,0:09:06.411
Maybe that patient was dealing[br]with an abusive spouse

0:09:06.411,0:09:10.357
or a daughter who is pregnant[br]and drug-addicted,

0:09:10.357,0:09:14.084
or a son who was kicked out of school,

0:09:14.084,0:09:19.647
or even maybe they were riding[br]their bicycle through an intersection

0:09:19.647,0:09:21.829
and got hit by a truck,

0:09:21.829,0:09:26.394
and now they're using a wheelchair[br]and have very limited mobility.

0:09:27.881,0:09:32.119
Obviously, these things also happen[br]to middle class people,

0:09:32.119,0:09:34.146
but when they do,

0:09:34.146,0:09:39.075
we have resources that enable us[br]to deal with these problems.

0:09:39.275,0:09:44.257
We also have the belief that we[br]will live out our normal lifespans.

0:09:44.916,0:09:47.857
That's not true for low-income people.

0:09:47.857,0:09:52.039
They've seen their friends and relatives[br]die young of accidents, of violence,

0:09:52.039,0:09:59.524
of cancers that should have[br]been diagnosed at an earlier stage.

0:09:59.524,0:10:02.225
It can lead to a sense of hopelessness,

0:10:02.225,0:10:05.357
that it doesn't really matter what you do.

0:10:06.414,0:10:11.316
I know I've painted a bleak picture[br]of the care of low-income patients,

0:10:11.316,0:10:14.476
but I want you to know[br]how rewarding I find it

0:10:14.476,0:10:17.038
to work in a safety net system

0:10:17.038,0:10:21.414
and my deep belief that we[br]can make the system responsive

0:10:21.414,0:10:23.560
to the needs of low-income patients.

0:10:25.166,0:10:29.305
The starting point has to be[br]to meet patients where they are,

0:10:29.305,0:10:32.957
provide services without obstacles,

0:10:32.957,0:10:36.638
and provide patients what they need,

0:10:36.638,0:10:39.061
not what we think they need.

0:10:39.824,0:10:43.730
It's impossible for me[br]to take good care of a patient

0:10:43.730,0:10:46.466
who is homeless and living on the street.

0:10:46.466,0:10:50.590
The right prescription[br]for a homeless patient is housing.

0:10:50.590,0:10:52.790
In Los Angeles, we have 4,700[br]chronically homeless persons

0:10:52.790,0:11:01.096
suffering from medical illness,

0:11:01.096,0:11:05.434
mental illness, addiction.

0:11:05.434,0:11:10.939
When we house them, we found[br]that overall health care costs,

0:11:10.939,0:11:12.810
including the housing, decreased.

0:11:12.810,0:11:19.057
That's because they had[br]many fewer hospital visits,

0:11:19.057,0:11:23.347
both in the emergency room[br]and on the inpatient service.

0:11:24.329,0:11:27.629
And we gave them back their dignity.

0:11:27.629,0:11:29.857
No extra charge for that.

0:11:30.652,0:11:35.526
For people who do not have[br]a steady supply of food,

0:11:35.526,0:11:39.205
especially those who are diabetic,

0:11:39.205,0:11:44.464
safety net systems are experimenting[br]with a variety of solutions,

0:11:44.464,0:11:48.849
including food pantries[br]at primary care clinics,

0:11:48.849,0:11:52.207
distributing maps of community[br]food banks and soup kitchens.

0:11:52.207,0:11:55.999
And in New York City,

0:11:55.999,0:11:58.554
we've hired a bunch of enrollers

0:11:58.554,0:12:00.419
to get our patients

0:12:00.419,0:12:07.629
into the supplemental nutrition program[br]known as food stamps to most people.

0:12:08.942,0:12:12.949
When patients and doctors[br]don't understand each other,

0:12:12.949,0:12:14.893
mistakes will occur.

0:12:14.893,0:12:19.472
For non-English-speaking patients,[br]translation is as important

0:12:19.472,0:12:21.444
as a prescription pad,[br]perhaps more important.

0:12:21.444,0:12:23.483
And, you know, it doesn't[br]cost anything more

0:12:23.483,0:12:31.297
to put all of the materials[br]at the level of fourth-grade reading

0:12:31.297,0:12:36.230
so that everybody can understand[br]what's being said.

0:12:36.230,0:12:39.660
But more than anything else,[br]I think low-income patients

0:12:39.660,0:12:43.839
benefit from having a primary care doctor.

0:12:43.839,0:12:47.881
Mind you, I think middle class people[br]also benefit from having somebody

0:12:47.881,0:12:49.933
to quarterback their care,

0:12:49.933,0:12:53.017
but when they don't, they have others[br]who can advocate for them,

0:12:53.017,0:12:56.492
who can get them that disability placard,

0:12:56.492,0:13:00.775
or make sure the disability[br]application is completed.

0:13:01.033,0:13:06.216
But low-income people really need[br]a team of people who can help them

0:13:06.216,0:13:12.012
to access the medical and non-medical[br]services that they need.

0:13:12.012,0:13:14.784
Also, many low-income people[br]are disenfranchised

0:13:14.784,0:13:17.268
from other community supports,

0:13:17.268,0:13:23.507
and they really benefit from the care[br]and continuity provided by primary care.

0:13:23.822,0:13:26.928
A primary care doctor[br]I particularly admire

0:13:26.928,0:13:31.056
once told me how she believed[br]that her relationship with a patient

0:13:31.056,0:13:35.779
over a decade was the only [br]healthy relationship

0:13:35.779,0:13:37.846
that that patient had in her life.

0:13:39.000,0:13:42.895
The good news is, you don't[br]actually have to be a doctor

0:13:42.895,0:13:47.134
to provide that special sauce[br]of care and continuity.

0:13:47.928,0:13:52.286
This was really brought home to me[br]when one of my own long-term patients

0:13:52.286,0:13:55.078
died at an outside hospital.

0:13:55.078,0:13:58.838
I had to tell the other doctors[br]and nurses in my clinic

0:13:58.838,0:14:00.481
that he had passed.

0:14:00.735,0:14:04.617
But I didn't know that[br]in another part of our clinic,

0:14:04.617,0:14:06.478
on a different floor,

0:14:06.478,0:14:09.258
there was a registration clerk

0:14:09.258,0:14:12.253
who had developed[br]a very special relationship

0:14:12.253,0:14:16.914
with my patient every time[br]he came in for an appointment.

0:14:16.914,0:14:20.827
When she learned three weeks later[br]that he had died,

0:14:20.827,0:14:26.423
she came and found me[br]in my examining room,

0:14:26.423,0:14:27.892
tears streaming down her cheeks,

0:14:27.892,0:14:28.905
talking about my patient

0:14:28.905,0:14:32.020
and the memories that she had of him,

0:14:32.233,0:14:36.307
the kinds of discussions that they had had[br]about their lives together.

0:14:38.318,0:14:40.389
My patient had a hard life.

0:14:40.389,0:14:44.353
He was by his own admission a gangbanger.

0:14:44.353,0:14:49.520
He had spent substantial[br]amount of time in prison.

0:14:49.520,0:14:52.557
He suffered from a very serious illness.

0:14:52.557,0:14:54.808
He was a drug addict.

0:14:54.808,0:14:58.403
But despite all that,[br]he rarely missed a visit,

0:14:58.403,0:15:01.291
and I like to believe that was because[br]he knew at our clinic that he was loved.

0:15:01.291,0:15:03.134
When our health care systems have the same[br]commitment to low-income patients

0:15:03.134,0:15:13.267
that that man had to us,

0:15:13.267,0:15:14.939
two things will happen.

0:15:14.939,0:15:20.901
First, the system will be responsive[br]to the needs of low-income people.

0:15:20.901,0:15:24.575
It will speak their language,[br]it will meet their schedules,

0:15:24.575,0:15:27.296
it will fulfill their needs.

0:15:27.296,0:15:32.316
Second, we will be providing[br]the kind of care

0:15:32.316,0:15:34.304
that we went into this profession to do,

0:15:34.304,0:15:37.065
not just checking the boxes

0:15:37.065,0:15:40.420
but really taking care of those we serve.

0:15:41.619,0:15:44.945
Thank you.

0:15:44.945,0:15:47.260
(Applause)