Yesterday I met for 2 hours with the "smoking cessation counselor" at the free clinic and found out that that position was being eliminated for financial reasons. The counselor and I talked about her experiences at the clinic and how they mirrored those she experienced in her teaching at an urban charter school, as well as dealing with a familly member whose child has asthma. She reflected that exhortations to "being strong" failed to improve people's lives when the parent lacked life and parenting skills, was seriously depressed, did not or could not bond with their child, used illicit drugs, smoked cigrettes, set their needs above those of their child.
Access to health care was not the primary problem. What appeared to be the problem was the inability to utilize health care: ie, not taking medications, disregarding what was recommended, suspicious of other's motivations, concealing information which made the parent appear to be "bad"; almost as if the parent was aware of what was the right thing to do, but had failed to do what was correct. The counselor described situations that were dysfunctional, and, basically, they appeared to me to be situations where the parent had to change their own behavior to improve their child's health. The child with asthma, because it is a chronic and life long condition, (one does not outgrow it), had medications that were to be given every day whether the child appeared to need them or not. The parent of the child confided to this relative, that she would tell the health care provider that she was giving the medications regularly and that they were not working, when infact, the parent would stop the medications as soon as she believed the child was better. Because the child would have another asthma attack, some of which are very frightening to observe, the parent would take the child into the health care provider for an unscheduled office visit and obtain treatment. After several of these unscheduled office visits, or emergency room visits or even hospitalizations, the health care provider contacted the pharmacy where the parent had said that the prescriptions were filled, and found that either the prescriptions were not filled at all, or were never refilled as recommended. Once the parent was confronted, the parent took the child to another health care facility lamenting how the previous doctor did not know what they were doing. And so the cycle would start again. Each time the parent would keep the child out of school to keep the child from getting sick, or when sick; changing schools; going to a charter school because the public school system "did not know what they were doing"; asking relatives for money so that the parent could move to a warm climate for the sake of the child's health (which of course is a falicy since asthma is just as common and difficult to treat when you don't take one's asthma medications in Hawaii as it is in Minnesota and people who move from cold environments to warm ones do not get better until they actually begin taking their medications every day as prescribed). The counselor reflected how the patients served by the free clinic, those children whom she tried to teach at the charter school, and her own relative were so similar and that one intervention such as smoking cessation, without the other components like health care and its educational component, drug rehabilitation, psychological therapy, parenting and life skills instructions, and a change in how one viewed the health care establishment were all necessary before there was a discernable impact on the child's health.
In my 30 years of practice, these are the difficult to treat patients and require a team approach. Hopefully with a comprehensive approach, the parent will buy into the need for change in their lives, and will make the changes in their own behavior for the benefit of their child; they understand that they must view the child and his/her needs and safety as a parental priority, and not focused upon themselves.I hope a comprehensive approach to the treatment of the child with asthma can be provided when KK and I are at the clinic; otherwise, this will be just another revolving door and dissatisfaction on everyone's part.
What do you think?
1 comment:
Dad, this rings very true to me. Latching on to one solution to complex problems like these often fails. Unfortunately, a lot of the issues that you mentioned with the parent who didn't give their child the medication they were prescribed are confounded by other factors. For example, conflicting advice from different doctors, doctors who don't acknowledge their uncertainty, religious beliefs, racism, classism, mistrust of corporate medicine, inability to afford medication, etc. In my experience, these factors often combine together to create enough uncertainty in the minds of patients that they feel they need to figure things out for themselves.
I see one of the major challenges that health care providers face in treating poor people in the US and elsewhere is establishing trust. On top of the inflated costs of medical treatment, there are reports of serious mistakes in large vaccinations in Africa, for example, in which needles were reused since sufficient needles were not provided, and a relatively large percentage of patients ended up contracting HIV and Hep. A. Combine these reports with America's history of using smallpox to commit genocide against the native Americans, and our legacy of racist and unequal treatment of African Americans and other minorities, many people begin to mistrust the medical establishment altogether.
I'm not exactly sure how to address this mistrust, but I do believe that it is a hugh problem.
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