WEBVTT

00:00:00.655 --> 00:00:02.278
A few years ago,

00:00:02.302 --> 00:00:06.025
I was taking care of a woman
who was a victim of violence.

00:00:06.654 --> 00:00:11.826
I wanted her to be seen in a clinic
that specialized in trauma survivors.

00:00:12.431 --> 00:00:17.271
I made the appointment myself because,
being the director of the department,

00:00:17.295 --> 00:00:18.757
I knew if I did it,

00:00:18.781 --> 00:00:21.197
she would get an appointment right away.

00:00:21.886 --> 00:00:25.799
The clinic was about an hour and a half
away from where she lived.

00:00:25.823 --> 00:00:29.254
But she took down the address
and agreed to go.

NOTE Paragraph

00:00:30.794 --> 00:00:34.247
Unfortunately, she didn't
make it to the clinic.

00:00:35.339 --> 00:00:39.633
When I spoke to the psychiatrist,
he explained to me

00:00:39.657 --> 00:00:43.023
that trauma survivors are often resistant

00:00:43.047 --> 00:00:45.874
to dealing with the difficult
issues that they face

00:00:45.898 --> 00:00:47.781
and often miss appointments.

00:00:48.298 --> 00:00:49.480
For this reason,

00:00:49.504 --> 00:00:54.361
they don't generally allow the doctors
to make appointments for the patients.

00:00:54.892 --> 00:00:57.550
They had made a special exception for me.

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

00:01:00.562 --> 00:01:04.607
she had a much simpler
and less Freudian explanation

00:01:04.631 --> 00:01:06.961
of why she didn't go to that appointment:

00:01:07.714 --> 00:01:09.236
her ride didn't show.

NOTE Paragraph

00:01:10.996 --> 00:01:13.143
Now, some of you may be thinking,

00:01:13.167 --> 00:01:16.885
"Didn't she have some other way
of getting to that clinic appointment?"

00:01:17.347 --> 00:01:21.602
Couldn't she have taken an Uber
or called another friend?

00:01:22.327 --> 00:01:23.767
If you're thinking that,

00:01:23.791 --> 00:01:26.795
it's probably because you have resources.

00:01:27.385 --> 00:01:30.514
But she didn't have
enough money for an Uber,

00:01:30.538 --> 00:01:33.183
and she didn't have
another friend to call.

00:01:33.858 --> 00:01:35.570
But she did have me,

00:01:35.594 --> 00:01:38.599
and I was able to get her
another appointment,

00:01:38.623 --> 00:01:40.953
which she kept without difficulty.

00:01:41.650 --> 00:01:43.337
She wasn't resistant,

00:01:43.361 --> 00:01:45.201
it's just that her ride didn't show.

NOTE Paragraph

00:01:46.669 --> 00:01:50.588
I wish I could say that this
was an isolated incident,

00:01:50.612 --> 00:01:53.638
but I know from running
the safety net systems

00:01:53.662 --> 00:01:58.247
in San Francisco, Los Angeles,
and now New York City,

00:01:59.181 --> 00:02:02.779
that health care is built
on a middle-class model

00:02:02.803 --> 00:02:07.086
that often doesn't meet the needs
of low-income patients.

00:02:07.807 --> 00:02:11.842
That's one of the reasons
why it's been so difficult

00:02:11.866 --> 00:02:15.509
for us to close the disparity
in health care

00:02:15.533 --> 00:02:18.929
that exists along economic lines,

00:02:18.953 --> 00:02:22.600
despite the expansion of health insurance

00:02:22.624 --> 00:02:25.991
under the ACA, or Obamacare.

NOTE Paragraph

00:02:26.908 --> 00:02:29.241
Health care in the United States

00:02:29.265 --> 00:02:36.206
assumes that, besides getting across
the large land expanse of Los Angeles,

00:02:37.390 --> 00:02:40.222
it also assumes that you
can take off from work

00:02:40.246 --> 00:02:42.706
in the middle of the day to get care.

00:02:43.434 --> 00:02:47.714
One of the patients who came
to my East Los Angeles clinic

00:02:47.738 --> 00:02:49.960
on a Thursday afternoon

00:02:49.984 --> 00:02:54.754
presented with partial
blindness in both eyes.

00:02:55.449 --> 00:02:57.570
Very concerned, I said to him,

00:02:57.594 --> 00:02:59.172
"When did this develop?"

00:02:59.952 --> 00:03:01.584
He said, "Sunday."

00:03:02.457 --> 00:03:03.928
I said, "Sunday?

00:03:03.952 --> 00:03:06.806
Did you think of coming sooner to clinic?"

00:03:07.326 --> 00:03:10.513
And he said, "Well, I have to work
in order to pay the rent."

NOTE Paragraph

00:03:11.598 --> 00:03:14.261
A second patient to that same clinic,

00:03:14.285 --> 00:03:15.734
a trucker,

00:03:15.758 --> 00:03:19.455
drove three days with a raging infection,

00:03:19.479 --> 00:03:23.797
only coming to see me
after he had delivered his merchandise.

00:03:24.487 --> 00:03:30.829
Both patients' care was jeopardized
by their delays in seeking care.

NOTE Paragraph

00:03:31.839 --> 00:03:35.448
Health care in the United States
assumes that you speak English

00:03:35.472 --> 00:03:38.596
or can bring someone with you who can.

00:03:39.160 --> 00:03:44.005
In San Francisco, I took care of a patient
on the inpatient service

00:03:44.029 --> 00:03:49.159
who was from West Africa
and spoke a dialect so unusual

00:03:49.183 --> 00:03:54.741
that we could only find one translator
on the telephonic line

00:03:54.765 --> 00:03:56.584
who could understand him.

00:03:56.608 --> 00:03:59.796
And that translator only worked
one afternoon a week.

00:04:00.695 --> 00:04:05.428
Unfortunately, my patient needed
translation services every day.

NOTE Paragraph

00:04:06.526 --> 00:04:09.948
Health care in the United States
assumes that you are literate.

00:04:10.476 --> 00:04:15.693
I learned that a patient of mine
who spoke English without accent

00:04:15.717 --> 00:04:17.225
was illiterate,

00:04:17.249 --> 00:04:22.934
when he asked me to please sign
a social security disability form for him

00:04:22.958 --> 00:04:24.274
right away.

00:04:24.298 --> 00:04:27.591
The form needed to go
to the office that same day,

00:04:27.615 --> 00:04:29.502
and I wasn't in clinic,

00:04:29.526 --> 00:04:31.104
so trying to help him out,

00:04:31.128 --> 00:04:34.885
knowing that he was
the sole caretaker of his son,

00:04:34.909 --> 00:04:39.130
I said, "Well, bring the form
to my administrative office.

00:04:39.154 --> 00:04:42.060
I'll sign it and I'll fax it in for you."

00:04:42.084 --> 00:04:44.579
He took the two buses to my office,

00:04:44.603 --> 00:04:46.759
dropped off the form,

00:04:46.783 --> 00:04:49.149
went back home to take care of his son ...

00:04:49.173 --> 00:04:54.597
I got to the office, and what did I find
next to the big "X" on the form?

00:04:54.621 --> 00:04:56.053
The word "applicant."

00:04:57.561 --> 00:04:59.225
He needed to sign the form.

00:05:00.255 --> 00:05:03.707
And so now I had to have him
take the two buses back to the office

00:05:03.731 --> 00:05:08.556
and sign the form so that
we could then fax it in for him.

00:05:08.580 --> 00:05:10.748
It completely changed
how I took care of him.

00:05:10.772 --> 00:05:15.731
I made sure that I always went over
instructions verbally with him.

00:05:17.096 --> 00:05:19.946
It also made me think about
all of the patients

00:05:19.970 --> 00:05:23.271
who receive reams and reams of paper

00:05:23.295 --> 00:05:27.348
spit out by our modern
electronic health record systems,

00:05:27.372 --> 00:05:30.005
explaining their diagnoses
and their treatments,

00:05:30.029 --> 00:05:32.951
and wondering how many people
actually can understand

00:05:32.975 --> 00:05:35.170
what's on those pieces of paper.

NOTE Paragraph

00:05:35.954 --> 00:05:40.555
Health care in the United States assumes
that you have a working telephone

00:05:40.579 --> 00:05:42.186
and an accurate address.

00:05:42.781 --> 00:05:46.132
The proliferation
of inexpensive cell phones

00:05:46.156 --> 00:05:48.011
has actually helped quite a lot.

00:05:48.377 --> 00:05:51.383
But still, my patients run out of minutes,

00:05:51.407 --> 00:05:53.655
and their phones get disconnected.

NOTE Paragraph

00:05:54.918 --> 00:05:59.341
Low-income people often have
to move around a lot by necessity.

00:05:59.365 --> 00:06:05.396
I remember reviewing a chart of a woman
with an abnormality on her mammogram.

00:06:05.850 --> 00:06:11.335
That chart assiduously documents
that three letters were sent to her home,

00:06:11.359 --> 00:06:14.418
asking her to please
come in for follow-up.

00:06:15.127 --> 00:06:17.373
Of course, if the address isn't accurate,

00:06:17.397 --> 00:06:21.818
it doesn't much matter how many letters
you send to that same address.

NOTE Paragraph

00:06:23.397 --> 00:06:28.414
Health care in the United States assumes
that you have a steady supply of food.

00:06:29.035 --> 00:06:32.183
This is particularly
an issue for diabetics.

00:06:32.591 --> 00:06:35.783
We give them medications
that lower their blood sugar.

00:06:36.388 --> 00:06:38.994
On days when they don't have enough food,

00:06:39.018 --> 00:06:42.787
it puts them at risk
for a life-threatening side effect

00:06:42.811 --> 00:06:45.786
of hypoglycemia, or low blood sugar.

NOTE Paragraph

00:06:46.935 --> 00:06:50.189
Health care in the United States
assumes that you have a home

00:06:50.213 --> 00:06:52.690
with a refrigerator for your insulin,

00:06:52.714 --> 00:06:55.353
a bathroom where you can wash up,

00:06:55.377 --> 00:06:57.379
a bed where you can sleep

00:06:57.403 --> 00:07:01.692
without worrying about violence
while you're resting.

00:07:02.385 --> 00:07:04.058
But what if you don't have that?

00:07:04.692 --> 00:07:06.928
What if you live on the street,

00:07:06.952 --> 00:07:09.205
you live under the freeway,

00:07:09.229 --> 00:07:11.520
you live in a congregant shelter,

00:07:11.544 --> 00:07:15.469
where every morning
you have to leave at 7 or 8am?

00:07:16.029 --> 00:07:18.103
Where do you store your medicines?

00:07:20.851 --> 00:07:22.617
Where do you use the bathroom?

00:07:24.209 --> 00:07:28.389
How do you put your legs up
if you have congestive heart failure?

00:07:29.056 --> 00:07:35.369
Is it any wonder that providing people
with health insurance who are homeless

00:07:35.393 --> 00:07:38.425
does not erase the huge disparity

00:07:38.449 --> 00:07:40.825
between the homeless and the housed?

NOTE Paragraph

00:07:41.862 --> 00:07:47.427
Health care in the United States assumes
that you prioritize your health care.

00:07:47.974 --> 00:07:49.657
But what about all of you?

00:07:50.467 --> 00:07:54.717
Let me assume for a moment
that you're all taking a medication.

00:07:54.741 --> 00:07:56.974
Maybe it's for high blood pressure.

00:07:56.998 --> 00:08:00.186
Maybe it's for diabetes or depression.

00:08:01.272 --> 00:08:03.713
What if tonight you had a choice:

00:08:04.626 --> 00:08:09.182
you could have your medication
but live on the street,

00:08:10.507 --> 00:08:15.910
or you could be housed in your home
but not have your medication.

00:08:17.879 --> 00:08:19.376
Which would you choose?

00:08:21.289 --> 00:08:23.086
I know which one I would choose.

NOTE Paragraph

00:08:24.538 --> 00:08:28.634
This is just a graphic example
of the kinds of choices

00:08:28.658 --> 00:08:31.770
that low-income patients
have to make every day.

00:08:32.418 --> 00:08:35.344
So when my doctors
shake their heads and say,

00:08:35.368 --> 00:08:39.955
"I don't know why that patient
didn't keep his follow-up appointments,"

00:08:40.549 --> 00:08:45.442
"I don't know why she didn't go
for that exam that I ordered,"

00:08:45.466 --> 00:08:49.147
I think, well, maybe her ride didn't show,

00:08:49.171 --> 00:08:50.940
or maybe he had to work.

00:08:51.509 --> 00:08:57.366
But also, maybe there was something
more important that day

00:08:57.390 --> 00:09:01.207
than their high blood pressure
or a screening colonoscopy.

00:09:01.873 --> 00:09:05.274
Maybe that patient was dealing
with an abusive spouse

00:09:06.252 --> 00:09:10.120
or a daughter who is pregnant
and drug-addicted

00:09:10.144 --> 00:09:13.393
or a son who was kicked out of school.

00:09:13.872 --> 00:09:19.292
Or even maybe they were riding
their bicycle through an intersection

00:09:19.316 --> 00:09:21.475
and got hit by a truck,

00:09:21.499 --> 00:09:25.957
and now they're using a wheelchair
and have very limited mobility.

NOTE Paragraph

00:09:27.619 --> 00:09:31.177
Obviously, these things also happen
to middle-class people.

00:09:32.161 --> 00:09:33.925
But when they do,

00:09:33.949 --> 00:09:38.332
we have resources that enable us
to deal with these problems.

00:09:38.838 --> 00:09:44.065
We also have the belief that we
will live out our normal lifespans.

00:09:44.678 --> 00:09:46.959
That's not true for low-income people.

00:09:47.578 --> 00:09:51.706
They've seen their friends
and relatives die young

00:09:51.730 --> 00:09:53.139
of accidents,

00:09:53.163 --> 00:09:54.360
of violence,

00:09:54.384 --> 00:09:58.691
of cancers that should have
been diagnosed at an earlier stage.

00:09:59.206 --> 00:10:01.923
It can lead to a sense of hopelessness,

00:10:01.947 --> 00:10:04.231
that it doesn't really matter what you do.

NOTE Paragraph

00:10:06.128 --> 00:10:11.244
I know I've painted a bleak picture
of the care of low-income patients.

00:10:11.268 --> 00:10:14.301
But I want you to know
how rewarding I find it

00:10:14.325 --> 00:10:16.783
to work in a safety net system,

00:10:16.807 --> 00:10:21.160
and my deep belief is that we can
make the system responsive

00:10:21.184 --> 00:10:23.543
to the needs of low-income patients.

00:10:24.935 --> 00:10:29.051
The starting point has to be
to meet patients where they are,

00:10:29.075 --> 00:10:31.900
provide services without obstacles

00:10:32.678 --> 00:10:35.504
and provide patients what they need --

00:10:36.257 --> 00:10:38.109
not what we think they need.

NOTE Paragraph

00:10:39.625 --> 00:10:43.508
It's impossible for me
to take good care of a patient

00:10:43.532 --> 00:10:45.925
who is homeless and living on the street.

00:10:46.933 --> 00:10:51.443
The right prescription
for a homeless patient is housing.

00:10:52.474 --> 00:10:54.288
In Los Angeles,

00:10:54.312 --> 00:11:00.342
we housed 4,700 chronically
homeless persons

00:11:00.366 --> 00:11:05.004
suffering from medical illness,
mental illness, addiction.

00:11:06.060 --> 00:11:10.675
When we housed them, we found
that overall health care costs,

00:11:10.699 --> 00:11:12.586
including the housing,

00:11:12.610 --> 00:11:13.767
decreased.

00:11:14.220 --> 00:11:18.695
That's because they had
many fewer hospital visits,

00:11:18.719 --> 00:11:23.115
both in the emergency room
and on the inpatient service.

00:11:24.106 --> 00:11:26.710
And we gave them back their dignity.

00:11:27.374 --> 00:11:29.192
No extra charge for that.

NOTE Paragraph

00:11:30.652 --> 00:11:35.273
For people who do not have
a steady supply of food,

00:11:35.297 --> 00:11:38.960
especially those who are diabetic,

00:11:38.984 --> 00:11:44.393
safety net systems are experimenting
with a variety of solutions,

00:11:44.417 --> 00:11:48.551
including food pantries
at primary care clinics

00:11:48.575 --> 00:11:53.314
and distributing maps of community
food banks and soup kitchens.

00:11:53.835 --> 00:11:55.657
And in New York City,

00:11:55.681 --> 00:11:58.240
we've hired a bunch of enrollers

00:11:58.264 --> 00:12:03.481
to get our patients into
the supplemental nutrition program

00:12:03.505 --> 00:12:06.878
known as "food stamps" to most people.

NOTE Paragraph

00:12:08.671 --> 00:12:12.308
When patients and doctors
don't understand each other,

00:12:12.332 --> 00:12:14.101
mistakes will occur.

00:12:14.717 --> 00:12:16.665
For non-English-speaking patients,

00:12:16.689 --> 00:12:20.528
translation is as important
as a prescription pad.

00:12:21.208 --> 00:12:22.698
Perhaps more important.

00:12:23.274 --> 00:12:26.143
And, you know, it doesn't
cost anything more

00:12:26.167 --> 00:12:30.984
to put all of the materials
at the level of fourth-grade reading,

00:12:31.008 --> 00:12:35.105
so that everybody can understand
what's being said.

NOTE Paragraph

00:12:35.935 --> 00:12:39.342
But more than anything else,
I think low-income patients

00:12:39.366 --> 00:12:43.125
benefit from having a primary care doctor.

00:12:43.680 --> 00:12:46.306
Mind you, I think middle-class
people also benefit

00:12:46.330 --> 00:12:49.124
from having somebody
to quarterback their care.

00:12:49.631 --> 00:12:52.762
But when they don't, they have others
who can advocate for them,

00:12:52.786 --> 00:12:56.142
who can get them that disability placard

00:12:56.166 --> 00:13:00.202
or make sure the disability
application is completed.

00:13:00.739 --> 00:13:06.041
But low-income people really need
a team of people who can help them

00:13:06.065 --> 00:13:10.735
to access the medical and non-medical
services that they need.

00:13:11.226 --> 00:13:14.529
Also, many low-income people
are disenfranchised

00:13:14.553 --> 00:13:16.945
from other community supports,

00:13:16.969 --> 00:13:22.983
and they really benefit from the care
and continuity provided by primary care.

00:13:23.615 --> 00:13:26.480
A primary care doctor
I particularly admire

00:13:26.504 --> 00:13:31.578
once told me how she believed
that her relationship with a patient

00:13:31.602 --> 00:13:33.089
over a decade

00:13:33.113 --> 00:13:37.452
was the only healthy relationship
that that patient had in her life.

NOTE Paragraph

00:13:38.793 --> 00:13:42.727
The good news is, you don't
actually have to be a doctor

00:13:42.751 --> 00:13:47.357
to provide that special sauce
of care and continuity.

00:13:47.713 --> 00:13:51.933
This was really brought home to me
when one of my own long-term patients

00:13:51.957 --> 00:13:54.538
died at an outside hospital.

00:13:54.887 --> 00:13:58.624
I had to tell the other doctors
and nurses in my clinic

00:13:58.648 --> 00:14:00.026
that he had passed.

00:14:00.465 --> 00:14:04.474
But I didn't know that
in another part of our clinic,

00:14:04.498 --> 00:14:06.522
on a different floor,

00:14:06.546 --> 00:14:09.069
there was a registration clerk

00:14:09.093 --> 00:14:13.108
who had developed a very special
relationship with my patient

00:14:13.132 --> 00:14:16.126
every time he came in for an appointment.

00:14:16.849 --> 00:14:20.535
When she learned three weeks later
that he had died,

00:14:20.559 --> 00:14:23.299
she came and found me
in my examining room,

00:14:23.323 --> 00:14:26.250
tears streaming down her cheeks,

00:14:26.274 --> 00:14:31.875
talking about my patient
and the memories that she had of him,

00:14:31.899 --> 00:14:35.973
the kinds of discussions that they had had
about their lives together.

00:14:38.072 --> 00:14:39.943
My patient had a hard life.

00:14:40.705 --> 00:14:43.781
He was by his own admission a gangbanger.

00:14:44.234 --> 00:14:47.851
He had spent a substantial
amount of time in prison.

00:14:48.893 --> 00:14:51.699
He suffered from a very serious illness.

00:14:52.318 --> 00:14:53.843
He was a drug addict.

00:14:54.530 --> 00:14:57.628
But despite all that,
he rarely missed a visit,

00:14:58.692 --> 00:15:04.173
and I like to believe that was because
he knew at our clinic that he was loved.

NOTE Paragraph

00:15:05.793 --> 00:15:11.154
When our health care systems have the same
commitment to low-income patients

00:15:11.178 --> 00:15:13.075
that that man had to us,

00:15:13.099 --> 00:15:14.638
two things will happen.

00:15:15.638 --> 00:15:20.443
First, the system will be responsive
to the needs of low-income people.

00:15:20.467 --> 00:15:24.438
It will speak their language,
it will meet their schedules,

00:15:24.462 --> 00:15:26.380
it will fulfill their needs.

00:15:27.169 --> 00:15:31.114
Second, we will be providing
the kind of care

00:15:31.138 --> 00:15:33.938
that we went into this profession to do --

00:15:33.962 --> 00:15:36.771
not just checking the boxes,

00:15:36.795 --> 00:15:40.150
but really taking care of those we serve.

NOTE Paragraph

00:15:41.404 --> 00:15:42.642
Thank you.

NOTE Paragraph

00:15:42.666 --> 00:15:46.888
(Applause)