WEBVTT

00:00:00.830 --> 00:00:02.515
A few years ago,

00:00:02.515 --> 00:00:06.490
I was taking care of a woman
who was a victim of violence.

00:00:06.718 --> 00:00:12.616
I wanted her to be seen in a clinic
that specialized in trauma survivors.

00:00:12.836 --> 00:00:18.006
I made the appointment myself because,
being the director of the department,

00:00:18.006 --> 00:00:19.708
I knew if I did it,

00:00:19.708 --> 00:00:21.928
she would get an appointment right away.

00:00:22.148 --> 00:00:26.040
The clinic was about an hour and a half
away from where she lived,

00:00:26.040 --> 00:00:29.758
but she took down the address
and agreed to go.

NOTE Paragraph

00:00:30.736 --> 00:00:35.339
Unfortunately, she didn't
make it to the clinic.

00:00:35.339 --> 00:00:37.933
When I spoke to the psychiatrist,

00:00:37.933 --> 00:00:40.200
he explained to me

00:00:40.200 --> 00:00:43.285
that trauma survivors are often resistant

00:00:43.285 --> 00:00:46.554
to dealing with the difficult
issues that they face,

00:00:46.554 --> 00:00:48.759
and often miss appointments.

00:00:48.759 --> 00:00:49.934
For this reason,

00:00:49.934 --> 00:00:54.596
they don't generally allow the doctors
to make appointments for the patients.

00:00:55.163 --> 00:00:58.189
They had made a special exception for me.

NOTE Paragraph

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

00:01:00.721 --> 00:01:04.679
she had a much simpler
and less Freudian explanation

00:01:04.679 --> 00:01:07.794
of why she didn't go to that appointment:

00:01:08.024 --> 00:01:10.256
her ride didn't show.

NOTE Paragraph

00:01:11.068 --> 00:01:13.558
Now, some of you may be thinking,

00:01:13.558 --> 00:01:17.641
"Didn't she have some other way
of getting to that clinic appointment?"

00:01:17.641 --> 00:01:19.942
Couldn't she have taken an Uber

00:01:19.942 --> 00:01:22.295
or called another friend?

00:01:22.582 --> 00:01:24.429
If you're thinking that,

00:01:24.429 --> 00:01:27.457
it's probably because you have resources.

00:01:27.457 --> 00:01:30.864
But she didn't have
enough money for an Uber,

00:01:30.864 --> 00:01:34.065
she didn't have another friend to call.

00:01:34.065 --> 00:01:35.877
But she did have me, and I was able
to get her another appointment,

00:01:35.877 --> 00:01:41.715
which she kept without difficulty.

00:01:41.968 --> 00:01:45.788
She wasn't resistant,
it's just her ride didn't show.

NOTE Paragraph

00:01:46.868 --> 00:01:50.885
I wish I could say that this
was an isolated incident,

00:01:50.885 --> 00:01:53.934
but I know from running
the safety net systems

00:01:53.934 --> 00:01:59.443
in San Francisco, Los Angeles,
and now New York City,

00:01:59.443 --> 00:02:03.002
that health care is built
on a middle class model

00:02:03.002 --> 00:02:07.509
that often doesn't meet the needs
of low-income patients.

00:02:08.014 --> 00:02:11.878
That's one of the reasons why
it's been so difficult

00:02:12.143 --> 00:02:15.809
for us to close
the disparity in health care

00:02:15.809 --> 00:02:19.228
that exists along economy lines

00:02:19.228 --> 00:02:22.839
despite the expansion of health insurance

00:02:22.839 --> 00:02:26.206
under the ACA, or ObamaCare.

NOTE Paragraph

00:02:27.044 --> 00:02:29.759
Health care in the United States

00:02:29.759 --> 00:02:33.435
assumes that, besides getting across
the large land expanse of Los Angeles,

00:02:33.435 --> 00:02:40.843
it also assumes that you
can take off from work

00:02:40.843 --> 00:02:43.689
in the middle of the day to get care.

NOTE Paragraph

00:02:43.689 --> 00:02:47.992
One of the patients who came
to my East Los Angeles clinic

00:02:47.992 --> 00:02:50.237
on a Thursday afternoon

00:02:50.237 --> 00:02:53.451
presented with partial blindness

00:02:53.451 --> 00:02:55.672
in both eyes.

00:02:55.672 --> 00:02:57.816
Very concerned, I said to him,

00:02:57.816 --> 00:03:00.136
"When did this develop?"

00:03:00.136 --> 00:03:02.117
He said, "Sunday."

00:03:02.584 --> 00:03:04.694
I said, "Sunday?

00:03:04.694 --> 00:03:07.572
Did you think of coming sooner to clinic?"

00:03:07.572 --> 00:03:11.718
And he said, "Well, I have to work
in order to pay the rent."

NOTE Paragraph

00:03:11.718 --> 00:03:15.967
A second patient to that same clinic,

00:03:15.967 --> 00:03:16.821
a trucker,

00:03:16.821 --> 00:03:19.765
drove three days with a raging infection,

00:03:19.765 --> 00:03:24.411
only coming to see me
after he had delivered his merchandise.

00:03:24.647 --> 00:03:31.967
Both patients' care was jeopardized
by their delays in seeking care.

NOTE Paragraph

00:03:31.967 --> 00:03:35.609
Health care in the United States
assumes that you speak English

00:03:35.809 --> 00:03:39.060
or can bring someone with you who can.

00:03:39.343 --> 00:03:44.211
In San Francisco, I took care of a patient
on the inpatient service

00:03:44.211 --> 00:03:46.412
who was from West Africa

00:03:46.412 --> 00:03:49.363
and spoke a dialect so unusual

00:03:49.363 --> 00:03:54.944
that we could only find one translator
on the telephonic line

00:03:54.944 --> 00:03:56.975
who could understand him,

00:03:56.975 --> 00:04:00.163
and that translator only worked
one afternoon a week.

00:04:00.934 --> 00:04:05.667
Unfortunately, my patient
needed translation services every day.

NOTE Paragraph

00:04:06.614 --> 00:04:10.060
Health care in the United States
assumes that you are literate.

00:04:10.060 --> 00:04:13.203
I learned that a patient of mine
who spoke English without accent

00:04:13.203 --> 00:04:17.498
was illiterate

00:04:17.498 --> 00:04:20.569
when he asked me to please sign
a social security disability form

00:04:20.569 --> 00:04:24.439
for him right away.

00:04:24.659 --> 00:04:27.854
The form need to go
to the office that same day,

00:04:27.854 --> 00:04:29.685
and I wasn't in clinic,

00:04:29.685 --> 00:04:31.409
so trying to help him out,

00:04:31.409 --> 00:04:35.068
knowing that he was
the sole caretaker of his son,

00:04:35.068 --> 00:04:39.403
I said, "Well, bring the form
to my administrative office.

00:04:39.403 --> 00:04:42.243
I'll sign it and I'll fax it in for you."

00:04:42.243 --> 00:04:44.858
He took the two buses to my office,

00:04:44.858 --> 00:04:46.783
dropped off the form,

00:04:46.783 --> 00:04:49.418
went back home to take care of his son,

00:04:49.418 --> 00:04:54.839
I got to the office, and what did I find
next to the big "X" on the form?

00:04:54.839 --> 00:04:56.567
The word "applicant."

00:04:56.567 --> 00:04:59.076
He needed to sign the form.

00:05:00.382 --> 00:05:04.093
And so now I had to have him
take the two buses back to the office

00:05:04.093 --> 00:05:08.600
and sign the form so that
we could then fax it in for him.

00:05:08.795 --> 00:05:11.070
It completely changed
how I took care of him.

00:05:11.070 --> 00:05:16.327
I made sure that I always went over
instructions verbally with him.

00:05:16.327 --> 00:05:20.977
It also made me think about
all of the patients

00:05:20.977 --> 00:05:23.295
who receive reams and reams of paper

00:05:23.295 --> 00:05:27.196
spit out by our modern
electronic health record systems

00:05:27.196 --> 00:05:30.220
explaining their diagnoses
and their treatments,

00:05:30.220 --> 00:05:34.065
and wondering how many people actually

00:05:34.065 --> 00:05:36.263
can understand what's on
those pieces of paper.

NOTE Paragraph

00:05:36.263 --> 00:05:40.830
Health care in the United States assumes
that you have a working telephone

00:05:40.830 --> 00:05:42.829
and an accurate address.

00:05:42.829 --> 00:05:46.543
The proliferation
of inexpensive cell phones

00:05:46.543 --> 00:05:48.591
has actually helped quite a lot,

00:05:48.591 --> 00:05:51.065
but still my patients run out of minutes

00:05:51.065 --> 00:05:54.597
and their phones get disconnected.

NOTE Paragraph

00:05:55.054 --> 00:05:59.812
Low-income people often have
to move around a lot by necessity.

00:05:59.812 --> 00:06:06.017
I remember reviewing a chart of a woman
with an abnormality on her mammogram.

00:06:06.017 --> 00:06:08.957
That chart assiduously documents
that three letters were sent to her home

00:06:08.957 --> 00:06:15.223
asking her to please come in for followup.

00:06:15.223 --> 00:06:17.746
Of course, if the address isn't accurate,

00:06:17.746 --> 00:06:22.389
it doesn't much matter how many letters
you send to that same address.

NOTE Paragraph

00:06:23.333 --> 00:06:28.971
Health care in the United States assumes
that you have a steady supply of food.

00:06:29.234 --> 00:06:32.790
This is particularly
an issue for diabetics.

00:06:32.790 --> 00:06:36.714
We give them medications
that lower their blood sugar.

00:06:36.714 --> 00:06:39.185
On days when they don't have enough food,

00:06:39.185 --> 00:06:42.977
it puts them at risk
for a life-threatening side effect

00:06:42.977 --> 00:06:47.039
of hypoglycemia, or low blood sugar.

NOTE Paragraph

00:06:47.213 --> 00:06:50.490
Health care in the United States assumes
that you have a home

00:06:50.490 --> 00:06:52.921
with a refrigerator for your insulin,

00:06:52.921 --> 00:06:55.616
a bathroom where you can wash up,

00:06:55.616 --> 00:07:00.099
a bed where you can sleep
without worrying about violence

00:07:00.099 --> 00:07:02.596
while you are resting.

00:07:02.823 --> 00:07:04.971
But what if you don't have that?

00:07:04.971 --> 00:07:07.221
What if you live on the streets,

00:07:07.221 --> 00:07:09.123
you live under the freeway,

00:07:09.123 --> 00:07:11.900
you live in a congregant shelter

00:07:11.900 --> 00:07:15.895
where every morning
you have to leave at 7 or 8 am?

00:07:16.260 --> 00:07:19.875
Where do you store your medicines?

00:07:21.098 --> 00:07:23.496
Where do you use the bathroom?

00:07:24.368 --> 00:07:28.860
How do you put your legs up
if you have congestive heart failure?

00:07:29.303 --> 00:07:34.118
Is it any wonder that providing people
with health insurance who are homeless

00:07:34.118 --> 00:07:38.712
does not erase the huge disparity

00:07:38.712 --> 00:07:40.825
between the homeless and the housed?

NOTE Paragraph

00:07:42.061 --> 00:07:47.472
Health care in the United States assumes
that you prioritize your health care,

00:07:48.221 --> 00:07:50.534
but what about all of you?

00:07:50.534 --> 00:07:55.033
Let me assume for a moment
that you're all taking a medication.

00:07:55.033 --> 00:07:57.533
Maybe it's for high blood pressure.

00:07:57.533 --> 00:08:01.534
Maybe it's for diabetes or depression.

00:08:01.534 --> 00:08:05.158
What if tonight you had a choice:

00:08:05.158 --> 00:08:08.207
you could have your medication
but live on the street,

00:08:08.207 --> 00:08:16.151
or you could be housed in your home
but not have your medication?

00:08:18.142 --> 00:08:21.155
Which would you choose?

00:08:21.155 --> 00:08:23.767
I know which one I would choose.

00:08:24.721 --> 00:08:28.882
This is just a graphic example
of the kinds of choices

00:08:28.882 --> 00:08:32.419
that low-income patients
have to make every day.

00:08:32.419 --> 00:08:35.559
So when my doctors
shake their heads and say,

00:08:35.559 --> 00:08:40.819
"I don't know why that patient
didn't keep his followup appointments,"

00:08:40.819 --> 00:08:45.696
"I don't know why she didn't go
for that exam that I ordered,"

00:08:45.696 --> 00:08:49.306
I think, well, maybe her ride didn't show,

00:08:49.306 --> 00:08:51.771
or maybe he had to work.

00:08:51.771 --> 00:08:57.651
But also, maybe there was something
more important that day

00:08:57.651 --> 00:09:01.859
than their high blood pressure
or a screening colonoscopy.

00:09:02.103 --> 00:09:06.411
Maybe that patient was dealing
with an abusive spouse

00:09:06.411 --> 00:09:10.357
or a daughter who is pregnant
and drug-addicted,

00:09:10.357 --> 00:09:14.084
or a son who was kicked out of school,

00:09:14.084 --> 00:09:19.647
or even maybe they were riding
their bicycle through an intersection

00:09:19.647 --> 00:09:21.829
and got hit by a truck,

00:09:21.829 --> 00:09:26.394
and now they're using a wheelchair
and have very limited mobility.

00:09:27.881 --> 00:09:32.119
Obviously, these things also happen
to middle class people,

00:09:32.119 --> 00:09:34.146
but when they do,

00:09:34.146 --> 00:09:39.075
we have resources that enable us
to deal with these problems.

00:09:39.275 --> 00:09:44.257
We also have the belief that we
will live out our normal lifespans.

00:09:44.916 --> 00:09:47.857
That's not true for low-income people.

00:09:47.857 --> 00:09:52.039
They've seen their friends and relatives
die young of accidents, of violence,

00:09:52.039 --> 00:09:59.524
of cancers that should have
been diagnosed at an earlier stage.

00:09:59.524 --> 00:10:02.225
It can lead to a sense of hopelessness,

00:10:02.225 --> 00:10:05.357
that it doesn't really matter what you do.

NOTE Paragraph

00:10:06.414 --> 00:10:11.316
I know I've painted a bleak picture
of the care of low-income patients,

00:10:11.316 --> 00:10:14.476
but I want you to know
how rewarding I find it

00:10:14.476 --> 00:10:17.038
to work in a safety net system

00:10:17.038 --> 00:10:21.414
and my deep belief that we
can make the system responsive

00:10:21.414 --> 00:10:23.560
to the needs of low-income patients.

00:10:25.166 --> 00:10:29.305
The starting point has to be
to meet patients where they are,

00:10:29.305 --> 00:10:32.957
provide services without obstacles,

00:10:32.957 --> 00:10:36.638
and provide patients what they need,

00:10:36.638 --> 00:10:39.061
not what we think they need.

NOTE Paragraph

00:10:39.824 --> 00:10:43.730
It's impossible for me
to take good care of a patient

00:10:43.730 --> 00:10:46.466
who is homeless and living on the street.

00:10:46.466 --> 00:10:50.590
The right prescription
for a homeless patient is housing.

00:10:50.590 --> 00:10:52.790
In Los Angeles, we have 4,700
chronically homeless persons

00:10:52.790 --> 00:11:01.096
suffering from medical illness,

00:11:01.096 --> 00:11:05.434
mental illness, addiction.

00:11:05.434 --> 00:11:10.939
When we house them, we found
that overall health care costs,

00:11:10.939 --> 00:11:12.810
including the housing, decreased.

00:11:12.810 --> 00:11:19.057
That's because they had
many fewer hospital visits,

00:11:19.057 --> 00:11:23.347
both in the emergency room
and on the inpatient service.

00:11:24.329 --> 00:11:27.629
And we gave them back their dignity.

00:11:27.629 --> 00:11:29.857
No extra charge for that.

NOTE Paragraph

00:11:30.652 --> 00:11:35.526
For people who do not have
a steady supply of food,

00:11:35.526 --> 00:11:39.205
especially those who are diabetic,

00:11:39.205 --> 00:11:44.464
safety net systems are experimenting
with a variety of solutions,

00:11:44.464 --> 00:11:48.849
including food pantries
at primary care clinics,

00:11:48.849 --> 00:11:52.207
distributing maps of community
food banks and soup kitchens.

00:11:52.207 --> 00:11:55.999
And in New York City,

00:11:55.999 --> 00:11:58.554
we've hired a bunch of enrollers

00:11:58.554 --> 00:12:00.419
to get our patients

00:12:00.419 --> 00:12:07.629
into the supplemental nutrition program
known as food stamps to most people.

NOTE Paragraph

00:12:08.942 --> 00:12:12.949
When patients and doctors
don't understand each other,

00:12:12.949 --> 00:12:14.893
mistakes will occur.

00:12:14.893 --> 00:12:19.472
For non-English-speaking patients,
translation is as important

00:12:19.472 --> 00:12:21.444
as a prescription pad,
perhaps more important.

00:12:21.444 --> 00:12:23.483
And, you know, it doesn't
cost anything more

00:12:23.483 --> 00:12:31.297
to put all of the materials
at the level of fourth-grade reading

00:12:31.297 --> 00:12:36.230
so that everybody can understand
what's being said.

NOTE Paragraph

00:12:36.230 --> 00:12:39.660
But more than anything else,
I think low-income patients

00:12:39.660 --> 00:12:43.839
benefit from having a primary care doctor.

00:12:43.839 --> 00:12:47.881
Mind you, I think middle class people
also benefit from having somebody

00:12:47.881 --> 00:12:49.933
to quarterback their care,

00:12:49.933 --> 00:12:53.017
but when they don't, they have others
who can advocate for them,

00:12:53.017 --> 00:12:56.492
who can get them that disability placard,

00:12:56.492 --> 00:13:00.775
or make sure the disability
application is completed.

00:13:01.033 --> 00:13:06.216
But low-income people really need
a team of people who can help them

00:13:06.216 --> 00:13:12.012
to access the medical and non-medical
services that they need.

00:13:12.012 --> 00:13:14.784
Also, many low-income people
are disenfranchised

00:13:14.784 --> 00:13:17.268
from other community supports,

00:13:17.268 --> 00:13:23.507
and they really benefit from the care
and continuity provided by primary care.

00:13:23.822 --> 00:13:26.928
A primary care doctor
I particularly admire

00:13:26.928 --> 00:13:31.056
once told me how she believed
that her relationship with a patient

00:13:31.056 --> 00:13:35.779
over a decade was the only 
healthy relationship

00:13:35.779 --> 00:13:37.846
that that patient had in her life.

NOTE Paragraph

00:13:39.000 --> 00:13:42.895
The good news is, you don't
actually have to be a doctor

00:13:42.895 --> 00:13:47.134
to provide that special sauce
of care and continuity.

00:13:47.928 --> 00:13:52.286
This was really brought home to me
when one of my own long-term patients

00:13:52.286 --> 00:13:55.078
died at an outside hospital.

00:13:55.078 --> 00:13:58.838
I had to tell the other doctors
and nurses in my clinic

00:13:58.838 --> 00:14:00.481
that he had passed.

00:14:00.735 --> 00:14:04.617
But I didn't know that
in another part of our clinic,

00:14:04.617 --> 00:14:06.478
on a different floor,

00:14:06.478 --> 00:14:09.258
there was a registration clerk

00:14:09.258 --> 00:14:12.253
who had developed
a very special relationship

00:14:12.253 --> 00:14:16.914
with my patient every time
he came in for an appointment.

00:14:16.914 --> 00:14:20.827
When she learned three weeks later
that he had died,

00:14:20.827 --> 00:14:26.423
she came and found me
in my examining room,

00:14:26.423 --> 00:14:27.892
tears streaming down her cheeks,

00:14:27.892 --> 00:14:28.905
talking about my patient

00:14:28.905 --> 00:14:32.020
and the memories that she had of him,

00:14:32.233 --> 00:14:36.307
the kinds of discussions that they had had
about their lives together.

00:14:38.318 --> 00:14:40.389
My patient had a hard life.

00:14:40.389 --> 00:14:44.353
He was by his own admission a gangbanger.

00:14:44.353 --> 00:14:49.520
He had spent substantial
amount of time in prison.

00:14:49.520 --> 00:14:52.557
He suffered from a very serious illness.

00:14:52.557 --> 00:14:54.808
He was a drug addict.

00:14:54.808 --> 00:14:58.403
But despite all that,
he rarely missed a visit,

00:14:58.403 --> 00:15:01.291
and I like to believe that was because
he knew at our clinic that he was loved.

NOTE Paragraph

00:15:01.291 --> 00:15:03.134
When our health care systems have the same
commitment to low-income patients

00:15:03.134 --> 00:15:13.267
that that man had to us,

00:15:13.267 --> 00:15:14.939
two things will happen.

00:15:14.939 --> 00:15:20.901
First, the system will be responsive
to the needs of low-income people.

00:15:20.901 --> 00:15:24.575
It will speak their language,
it will meet their schedules,

00:15:24.575 --> 00:15:27.296
it will fulfill their needs.

00:15:27.296 --> 00:15:32.316
Second, we will be providing
the kind of care

00:15:32.316 --> 00:15:34.304
that we went into this profession to do,

00:15:34.304 --> 00:15:37.065
not just checking the boxes

00:15:37.065 --> 00:15:40.420
but really taking care of those we serve.

NOTE Paragraph

00:15:41.619 --> 00:15:44.945
Thank you.

NOTE Paragraph

00:15:44.945 --> 00:15:47.260
(Applause)