Saturday, June 28, 2008


NewFNP's patients are coming in sicker. Totally anecdotal, of course, but what on newFNP isn't? She doesn't have anyone who has scratched a hole in her skull and exposed her brain, as Atul Gawande writes about in this week's New Yorker, but she has just had people come in that, truthfully, should be seen by internal medicine or psychiatry or, in this case, oncology, surgery and radiology.

This young, single mother of three first noticed the small bump on her upper arm, beneath the surface of the skin, about a year ago. The demands of single parenthood and her low-paying/no-insurance-providing job had kept her out of medical care. When asked to describe the size of the initially noticed lesion, she drew a circle 4mm in diameter.  When newFNP measured the mass in clinic, it was 12.5 cm by 15 cm.

It was firm.  Not firm firm, but softly firm and disturbingly firm.  Soft tissue sarcoma firm.  Oh shit firm.

NewFNP saw and felt the mass and instantly flashed back to her recent patient with two huge malignant masses.  She wrote the urgent referrals to her county system, but she knows that this young woman will need to go through the emergency department in order to get the CT and biopsy that she needs.

NewFNP is sick of this.  She is deeply frustrated by having nowhere to turn for her patients who need more care than newFNP's clinic provides.  She is frustrated that her major metropolitan area's community clinic association has so few resources for the community clinics.   And she is frustrated that she is so busy on a day to day basis that she cannot create her own backroads system of referrals.

Our patients wait.  They wait until their symptoms are unbearable.  They wait until they borrow someone's glucose monitor and see "HI" and then they wait some more before they come in, wondering if their 30-pound weight loss and dry mouth and frequent trips to the john could be caused by diabetes.  They wait until their likely rhabdomyosarcoma is visible from across the room.

In writing this, newFNP realizes that this is only half true.  There are the other group of patients who present for every URI, hangnail, bruise and stomach ache that they experience.  NewFNP sort of wishes that these worried well would come in less and the very needy new diabetics and cancer patients and HIV/AIDS patients would come in sooner -- when newFNP and her colleagues could actually help them.


Anonymous said...

I know....I saw an uninsured woman with hpv positive metastatic squamous cell cervical carcinoma....she had never had a pap in her life. Ironically, paps are FREE for her in California, and she could have had one (with free gyn follow up) any time in the last thirty years. A truly preventable case in theory.

she never knew the woman's health visits would be free! No one EVER told her she should get a pap.

Anonymous said...

I am sure it may not make you feel any better! But we have the same situation in New Zealand where the health care system is much different,the secondary care system is free and there is better access to PHC. Unfortunately for our Maori and Polynesion (and other ethnic populations) the access issues are also around cultural appropriateness of services,and all those other socioeconomical issues that are evident the world over.Communication is the key on every level in the health system

Rick said...

Here's the American healthcare crisis; except now it's being brought to light by the people it's affecting: providers and patients.