0:00:00.655,0:00:02.278
A few years ago,

0:00:02.302,0:00:06.025
I was taking care of a woman[br]who was a victim of violence.

0:00:06.654,0:00:11.826
I wanted her to be seen in a clinic[br]that specialized in trauma survivors.

0:00:12.431,0:00:17.271
I made the appointment myself because,[br]being the director of the department,

0:00:17.295,0:00:18.757
I knew if I did it,

0:00:18.781,0:00:21.197
she would get an appointment right away.

0:00:21.886,0:00:25.799
The clinic was about an hour and a half[br]away from where she lived.

0:00:25.823,0:00:29.254
But she took down the address[br]and agreed to go.

0:00:30.794,0:00:34.247
Unfortunately, she didn't[br]make it to the clinic.

0:00:35.339,0:00:39.633
When I spoke to the psychiatrist,[br]he explained to me

0:00:39.657,0:00:43.023
that trauma survivors are often resistant

0:00:43.047,0:00:45.874
to dealing with the difficult[br]issues that they face

0:00:45.898,0:00:47.781
and often miss appointments.

0:00:48.298,0:00:49.480
For this reason,

0:00:49.504,0:00:54.361
they don't generally allow the doctors[br]to make appointments for the patients.

0:00:54.892,0:00:57.550
They had made a special exception for me.

0:00:58.409,0:01:00.538
When I spoke to my patient,

0:01:00.562,0:01:04.607
she had a much simpler[br]and less Freudian explanation

0:01:04.631,0:01:06.961
of why she didn't go to that appointment:

0:01:07.714,0:01:09.236
her ride didn't show.

0:01:10.996,0:01:13.143
Now, some of you may be thinking,

0:01:13.167,0:01:16.885
"Didn't she have some other way[br]of getting to that clinic appointment?"

0:01:17.347,0:01:21.602
Couldn't she have taken an Uber[br]or called another friend?

0:01:22.327,0:01:23.767
If you're thinking that,

0:01:23.791,0:01:26.795
it's probably because you have resources.

0:01:27.385,0:01:30.514
But she didn't have[br]enough money for an Uber,

0:01:30.538,0:01:33.183
and she didn't have[br]another friend to call.

0:01:33.858,0:01:35.570
But she did have me,

0:01:35.594,0:01:38.599
and I was able to get her[br]another appointment,

0:01:38.623,0:01:40.953
which she kept without difficulty.

0:01:41.650,0:01:43.337
She wasn't resistant,

0:01:43.361,0:01:45.201
it's just that her ride didn't show.

0:01:46.669,0:01:50.588
I wish I could say that this[br]was an isolated incident,

0:01:50.612,0:01:53.638
but I know from running[br]the safety net systems

0:01:53.662,0:01:58.247
in San Francisco, Los Angeles,[br]and now New York City,

0:01:59.181,0:02:02.779
that health care is built[br]on a middle-class model

0:02:02.803,0:02:07.086
that often doesn't meet the needs[br]of low-income patients.

0:02:07.807,0:02:11.842
That's one of the reasons[br]why it's been so difficult

0:02:11.866,0:02:15.509
for us to close the disparity[br]in health care

0:02:15.533,0:02:18.929
that exists along economic lines,

0:02:18.953,0:02:22.600
despite the expansion of health insurance

0:02:22.624,0:02:25.991
under the ACA, or Obamacare.

0:02:26.908,0:02:29.241
Health care in the United States

0:02:29.265,0:02:36.206
assumes that, besides getting across[br]the large land expanse of Los Angeles,

0:02:37.390,0:02:40.222
it also assumes that you[br]can take off from work

0:02:40.246,0:02:42.706
in the middle of the day to get care.

0:02:43.434,0:02:47.714
One of the patients who came[br]to my East Los Angeles clinic

0:02:47.738,0:02:49.960
on a Thursday afternoon

0:02:49.984,0:02:54.754
presented with partial[br]blindness in both eyes.

0:02:55.449,0:02:57.570
Very concerned, I said to him,

0:02:57.594,0:02:59.172
"When did this develop?"

0:02:59.952,0:03:01.584
He said, "Sunday."

0:03:02.457,0:03:03.928
I said, "Sunday?

0:03:03.952,0:03:06.806
Did you think of coming sooner to clinic?"

0:03:07.326,0:03:10.513
And he said, "Well, I have to work[br]in order to pay the rent."

0:03:11.598,0:03:14.261
A second patient to that same clinic,

0:03:14.285,0:03:15.734
a trucker,

0:03:15.758,0:03:19.455
drove three days with a raging infection,

0:03:19.479,0:03:23.797
only coming to see me[br]after he had delivered his merchandise.

0:03:24.487,0:03:30.829
Both patients' care was jeopardized[br]by their delays in seeking care.

0:03:31.839,0:03:35.448
Health care in the United States[br]assumes that you speak English

0:03:35.472,0:03:38.596
or can bring someone with you who can.

0:03:39.160,0:03:44.005
In San Francisco, I took care of a patient[br]on the inpatient service

0:03:44.029,0:03:49.159
who was from West Africa[br]and spoke a dialect so unusual

0:03:49.183,0:03:54.741
that we could only find one translator[br]on the telephonic line

0:03:54.765,0:03:56.584
who could understand him.

0:03:56.608,0:03:59.796
And that translator only worked[br]one afternoon a week.

0:04:00.695,0:04:05.428
Unfortunately, my patient needed[br]translation services every day.

0:04:06.526,0:04:09.948
Health care in the United States[br]assumes that you are literate.

0:04:10.476,0:04:15.693
I learned that a patient of mine[br]who spoke English without accent

0:04:15.717,0:04:17.225
was illiterate,

0:04:17.249,0:04:22.934
when he asked me to please sign[br]a social security disability form for him

0:04:22.958,0:04:24.274
right away.

0:04:24.298,0:04:27.591
The form needed to go[br]to the office that same day,

0:04:27.615,0:04:29.502
and I wasn't in clinic,

0:04:29.526,0:04:31.104
so trying to help him out,

0:04:31.128,0:04:34.885
knowing that he was[br]the sole caretaker of his son,

0:04:34.909,0:04:39.130
I said, "Well, bring the form[br]to my administrative office.

0:04:39.154,0:04:42.060
I'll sign it and I'll fax it in for you."

0:04:42.084,0:04:44.579
He took the two buses to my office,

0:04:44.603,0:04:46.759
dropped off the form,

0:04:46.783,0:04:49.149
went back home to take care of his son ...

0:04:49.173,0:04:54.597
I got to the office, and what did I find[br]next to the big "X" on the form?

0:04:54.621,0:04:56.053
The word "applicant."

0:04:57.561,0:04:59.225
He needed to sign the form.

0:05:00.255,0:05:03.707
And so now I had to have him[br]take the two buses back to the office

0:05:03.731,0:05:08.556
and sign the form so that[br]we could then fax it in for him.

0:05:08.580,0:05:10.748
It completely changed[br]how I took care of him.

0:05:10.772,0:05:15.731
I made sure that I always went over[br]instructions verbally with him.

0:05:17.096,0:05:19.946
It also made me think about[br]all of the patients

0:05:19.970,0:05:23.271
who receive reams and reams of paper

0:05:23.295,0:05:27.348
spit out by our modern[br]electronic health record systems,

0:05:27.372,0:05:30.005
explaining their diagnoses[br]and their treatments,

0:05:30.029,0:05:32.951
and wondering how many people[br]actually can understand

0:05:32.975,0:05:35.170
what's on those pieces of paper.

0:05:35.954,0:05:40.555
Health care in the United States assumes[br]that you have a working telephone

0:05:40.579,0:05:42.186
and an accurate address.

0:05:42.781,0:05:46.132
The proliferation[br]of inexpensive cell phones

0:05:46.156,0:05:48.011
has actually helped quite a lot.

0:05:48.377,0:05:51.383
But still, my patients run out of minutes,

0:05:51.407,0:05:53.655
and their phones get disconnected.

0:05:54.918,0:05:59.341
Low-income people often have[br]to move around a lot by necessity.

0:05:59.365,0:06:05.396
I remember reviewing a chart of a woman[br]with an abnormality on her mammogram.

0:06:05.850,0:06:11.335
That chart assiduously documents[br]that three letters were sent to her home,

0:06:11.359,0:06:14.418
asking her to please[br]come in for follow-up.

0:06:15.127,0:06:17.373
Of course, if the address isn't accurate,

0:06:17.397,0:06:21.818
it doesn't much matter how many letters[br]you send to that same address.

0:06:23.397,0:06:28.414
Health care in the United States assumes[br]that you have a steady supply of food.

0:06:29.035,0:06:32.183
This is particularly[br]an issue for diabetics.

0:06:32.591,0:06:35.783
We give them medications[br]that lower their blood sugar.

0:06:36.388,0:06:38.994
On days when they don't have enough food,

0:06:39.018,0:06:42.787
it puts them at risk[br]for a life-threatening side effect

0:06:42.811,0:06:45.786
of hypoglycemia, or low blood sugar.

0:06:46.935,0:06:50.189
Health care in the United States[br]assumes that you have a home

0:06:50.213,0:06:52.690
with a refrigerator for your insulin,

0:06:52.714,0:06:55.353
a bathroom where you can wash up,

0:06:55.377,0:06:57.379
a bed where you can sleep

0:06:57.403,0:07:01.692
without worrying about violence[br]while you're resting.

0:07:02.385,0:07:04.058
But what if you don't have that?

0:07:04.692,0:07:06.928
What if you live on the street,

0:07:06.952,0:07:09.205
you live under the freeway,

0:07:09.229,0:07:11.520
you live in a congregant shelter,

0:07:11.544,0:07:15.469
where every morning[br]you have to leave at 7 or 8am?

0:07:16.029,0:07:18.103
Where do you store your medicines?

0:07:20.851,0:07:22.617
Where do you use the bathroom?

0:07:24.209,0:07:28.389
How do you put your legs up[br]if you have congestive heart failure?

0:07:29.056,0:07:35.369
Is it any wonder that providing people[br]with health insurance who are homeless

0:07:35.393,0:07:38.425
does not erase the huge disparity

0:07:38.449,0:07:40.825
between the homeless and the housed?

0:07:41.862,0:07:47.427
Health care in the United States assumes[br]that you prioritize your health care.

0:07:47.974,0:07:49.657
But what about all of you?

0:07:50.467,0:07:54.717
Let me assume for a moment[br]that you're all taking a medication.

0:07:54.741,0:07:56.974
Maybe it's for high blood pressure.

0:07:56.998,0:08:00.186
Maybe it's for diabetes or depression.

0:08:01.272,0:08:03.713
What if tonight you had a choice:

0:08:04.626,0:08:09.182
you could have your medication[br]but live on the street,

0:08:10.507,0:08:15.910
or you could be housed in your home[br]but not have your medication.

0:08:17.879,0:08:19.376
Which would you choose?

0:08:21.289,0:08:23.086
I know which one I would choose.

0:08:24.538,0:08:28.634
This is just a graphic example[br]of the kinds of choices

0:08:28.658,0:08:31.770
that low-income patients[br]have to make every day.

0:08:32.418,0:08:35.344
So when my doctors[br]shake their heads and say,

0:08:35.368,0:08:39.955
"I don't know why that patient[br]didn't keep his follow-up appointments,"

0:08:40.549,0:08:45.442
"I don't know why she didn't go[br]for that exam that I ordered,"

0:08:45.466,0:08:49.147
I think, well, maybe her ride didn't show,

0:08:49.171,0:08:50.940
or maybe he had to work.

0:08:51.509,0:08:57.366
But also, maybe there was something[br]more important that day

0:08:57.390,0:09:01.207
than their high blood pressure[br]or a screening colonoscopy.

0:09:01.873,0:09:05.274
Maybe that patient was dealing[br]with an abusive spouse

0:09:06.252,0:09:10.120
or a daughter who is pregnant[br]and drug-addicted

0:09:10.144,0:09:13.393
or a son who was kicked out of school.

0:09:13.872,0:09:19.292
Or even maybe they were riding[br]their bicycle through an intersection

0:09:19.316,0:09:21.475
and got hit by a truck,

0:09:21.499,0:09:25.957
and now they're using a wheelchair[br]and have very limited mobility.

0:09:27.619,0:09:31.177
Obviously, these things also happen[br]to middle-class people.

0:09:32.161,0:09:33.925
But when they do,

0:09:33.949,0:09:38.332
we have resources that enable us[br]to deal with these problems.

0:09:38.838,0:09:44.065
We also have the belief that we[br]will live out our normal lifespans.

0:09:44.678,0:09:46.959
That's not true for low-income people.

0:09:47.578,0:09:51.706
They've seen their friends[br]and relatives die young

0:09:51.730,0:09:53.139
of accidents,

0:09:53.163,0:09:54.360
of violence,

0:09:54.384,0:09:58.691
of cancers that should have[br]been diagnosed at an earlier stage.

0:09:59.206,0:10:01.923
It can lead to a sense of hopelessness,

0:10:01.947,0:10:04.231
that it doesn't really matter what you do.

0:10:06.128,0:10:11.244
I know I've painted a bleak picture[br]of the care of low-income patients.

0:10:11.268,0:10:14.301
But I want you to know[br]how rewarding I find it

0:10:14.325,0:10:16.783
to work in a safety net system,

0:10:16.807,0:10:21.160
and my deep belief is that we can[br]make the system responsive

0:10:21.184,0:10:23.543
to the needs of low-income patients.

0:10:24.935,0:10:29.051
The starting point has to be[br]to meet patients where they are,

0:10:29.075,0:10:31.900
provide services without obstacles

0:10:32.678,0:10:35.504
and provide patients what they need --

0:10:36.257,0:10:38.109
not what we think they need.

0:10:39.625,0:10:43.508
It's impossible for me[br]to take good care of a patient

0:10:43.532,0:10:45.925
who is homeless and living on the street.

0:10:46.933,0:10:51.443
The right prescription[br]for a homeless patient is housing.

0:10:52.474,0:10:54.288
In Los Angeles,

0:10:54.312,0:11:00.342
we housed 4,700 chronically[br]homeless persons

0:11:00.366,0:11:05.004
suffering from medical illness,[br]mental illness, addiction.

0:11:06.060,0:11:10.675
When we housed them, we found[br]that overall health care costs,

0:11:10.699,0:11:12.586
including the housing,

0:11:12.610,0:11:13.767
decreased.

0:11:14.220,0:11:18.695
That's because they had[br]many fewer hospital visits,

0:11:18.719,0:11:23.115
both in the emergency room[br]and on the inpatient service.

0:11:24.106,0:11:26.710
And we gave them back their dignity.

0:11:27.374,0:11:29.192
No extra charge for that.

0:11:30.652,0:11:35.273
For people who do not have[br]a steady supply of food,

0:11:35.297,0:11:38.960
especially those who are diabetic,

0:11:38.984,0:11:44.393
safety net systems are experimenting[br]with a variety of solutions,

0:11:44.417,0:11:48.551
including food pantries[br]at primary care clinics

0:11:48.575,0:11:53.314
and distributing maps of community[br]food banks and soup kitchens.

0:11:53.835,0:11:55.657
And in New York City,

0:11:55.681,0:11:58.240
we've hired a bunch of enrollers

0:11:58.264,0:12:03.481
to get our patients into[br]the supplemental nutrition program

0:12:03.505,0:12:06.878
known as "food stamps" to most people.

0:12:08.671,0:12:12.308
When patients and doctors[br]don't understand each other,

0:12:12.332,0:12:14.101
mistakes will occur.

0:12:14.717,0:12:16.665
For non-English-speaking patients,

0:12:16.689,0:12:20.528
translation is as important[br]as a prescription pad.

0:12:21.208,0:12:22.698
Perhaps more important.

0:12:23.274,0:12:26.143
And, you know, it doesn't[br]cost anything more

0:12:26.167,0:12:30.984
to put all of the materials[br]at the level of fourth-grade reading,

0:12:31.008,0:12:35.105
so that everybody can understand[br]what's being said.

0:12:35.935,0:12:39.342
But more than anything else,[br]I think low-income patients

0:12:39.366,0:12:43.125
benefit from having a primary care doctor.

0:12:43.680,0:12:46.306
Mind you, I think middle-class[br]people also benefit

0:12:46.330,0:12:49.124
from having somebody[br]to quarterback their care.

0:12:49.631,0:12:52.762
But when they don't, they have others[br]who can advocate for them,

0:12:52.786,0:12:56.142
who can get them that disability placard

0:12:56.166,0:13:00.202
or make sure the disability[br]application is completed.

0:13:00.739,0:13:06.041
But low-income people really need[br]a team of people who can help them

0:13:06.065,0:13:10.735
to access the medical and non-medical[br]services that they need.

0:13:11.226,0:13:14.529
Also, many low-income people[br]are disenfranchised

0:13:14.553,0:13:16.945
from other community supports,

0:13:16.969,0:13:22.983
and they really benefit from the care[br]and continuity provided by primary care.

0:13:23.615,0:13:26.480
A primary care doctor[br]I particularly admire

0:13:26.504,0:13:31.578
once told me how she believed[br]that her relationship with a patient

0:13:31.602,0:13:33.089
over a decade

0:13:33.113,0:13:37.452
was the only healthy relationship[br]that that patient had in her life.

0:13:38.793,0:13:42.727
The good news is, you don't[br]actually have to be a doctor

0:13:42.751,0:13:47.357
to provide that special sauce[br]of care and continuity.

0:13:47.713,0:13:51.933
This was really brought home to me[br]when one of my own long-term patients

0:13:51.957,0:13:54.538
died at an outside hospital.

0:13:54.887,0:13:58.624
I had to tell the other doctors[br]and nurses in my clinic

0:13:58.648,0:14:00.026
that he had passed.

0:14:00.465,0:14:04.474
But I didn't know that[br]in another part of our clinic,

0:14:04.498,0:14:06.522
on a different floor,

0:14:06.546,0:14:09.069
there was a registration clerk

0:14:09.093,0:14:13.108
who had developed a very special[br]relationship with my patient

0:14:13.132,0:14:16.126
every time he came in for an appointment.

0:14:16.849,0:14:20.535
When she learned three weeks later[br]that he had died,

0:14:20.559,0:14:23.299
she came and found me[br]in my examining room,

0:14:23.323,0:14:26.250
tears streaming down her cheeks,

0:14:26.274,0:14:31.875
talking about my patient[br]and the memories that she had of him,

0:14:31.899,0:14:35.973
the kinds of discussions that they had had[br]about their lives together.

0:14:38.072,0:14:39.943
My patient had a hard life.

0:14:40.705,0:14:43.781
He was by his own admission a gangbanger.

0:14:44.234,0:14:47.851
He had spent a substantial[br]amount of time in prison.

0:14:48.893,0:14:51.699
He suffered from a very serious illness.

0:14:52.318,0:14:53.843
He was a drug addict.

0:14:54.530,0:14:57.628
But despite all that,[br]he rarely missed a visit,

0:14:58.692,0:15:04.173
and I like to believe that was because[br]he knew at our clinic that he was loved.

0:15:05.793,0:15:11.154
When our health care systems have the same[br]commitment to low-income patients

0:15:11.178,0:15:13.075
that that man had to us,

0:15:13.099,0:15:14.638
two things will happen.

0:15:15.638,0:15:20.443
First, the system will be responsive[br]to the needs of low-income people.

0:15:20.467,0:15:24.438
It will speak their language,[br]it will meet their schedules,

0:15:24.462,0:15:26.380
it will fulfill their needs.

0:15:27.169,0:15:31.114
Second, we will be providing[br]the kind of care

0:15:31.138,0:15:33.938
that we went into this profession to do --

0:15:33.962,0:15:36.771
not just checking the boxes,

0:15:36.795,0:15:40.150
but really taking care of those we serve.

0:15:41.404,0:15:42.642
Thank you.

0:15:42.666,0:15:46.888
(Applause)