Viewpoint: Transcending Differences

As a retired family physician who treated patients in lower income neighborhoods for years, I was greatly interested in reading the reprint of Dr. Joan Thomas’s 1969 article, “Medical Problems of the Ghetto” (FJ, January 2013).

I attended medical school in Chicago from 1965-1970. Through an American Friends Service Committee program called PREP and through a summer health project funded by the War on Poverty, we became intimately involved with many families on the west side of Chicago in a community called East Garfield Park. All of this occurred through a house owned by the AFSC called Project House. This community was primarily a low-income black community.

In 1970, my wife and I moved to York, Pa., following riots there in 1969. I began my internship in medicine at York Hospital. For my alternative service, I became the physician for the Community Health Center in York City and the rural communities of York County. The establishment of this health center was a grassroots effort stemming from the riots in 1969. I continued to work at the Health Center through 1976, when my partner and I set up a practice in the city of York.

At this time there were few physicians. They typically saw a very large number of low income patients in a short period of time in order to maintain their income at the level they wished. We did not do this at our health centers or in our private practice. The health center was initially funded with private and foundation monies and some fees for service through Medicaid and private payments, but when my partner and I went into private practice, it was a struggle to generate adequate income; we were able to do this eventually by performing medical services in a variety of settings for which we were paid.

I feel much frustration in the comments of Dr. Thomas—justifiably so. Many of our patients were poor and young. There was some degree of suspiciousness of dealing with white medical structure that had been uncaring. Over time, trust between the patients, staff and doctors improved. I think this is primarily why we hired staff from the community to work in the health centers; they knew the patients well.

We were fortunate that we had a good relationship with physicians at our local hospital who, for the most part, gave equal care to all patients. Our referral process went well, although the only resource to specialty care was through “clinics” at the hospital where patients did not receive appointments but had to wait in a queue at the beginning of the clinic time. Specialty physicians in the community donated their time at these clinics.

Many patients did not have health insurance or were on Medicaid. The reimbursement was very poor and inconsistent for all medical specialties to the point that many doctors did not make an attempt to bill for their services.

If you were hospitalized, you were put on the medical or surgical ward where you were cared for by the doctors in training who were supervised by the attending physicians. This was not an ideal situation for quality of care and follow-up on discharge from the hospital, but it was an improvement over what existed before 1970, and more frequently than I wish to admit, the physicians in training did not have proper training in cultural sensitivity.

Payment for hospital services for low-income patients has always been insufficient but that is primarily because we as a nation are not willing to tax ourselves well enough to support these kinds of services for the low income. About $1,000 of an individual’s private health insurance annual premium goes to pay for unreimbursed or under-reimbursed health care given through non-profit hospitals. It has been my lifelong experience that co-payments by patients, whether low income or not, have not led to an abuse of the medical system through over-utilization.

Since the 1960s and 1970s, the way in which medical care is offered to low income patients has improved to some degree depending on where you live in the U.S. The major problems that remain, and have been so for quite some time, are availability of health care insurance, access to a primary care provider, ability to pay for medications, and transportation to health care offices. Hopefully the Affordable Health Care Act will address many of these problems.

In York, we have been very fortunate that the medical community as a whole has assumed responsibility for improving access to and quality of care for low income patients regardless of ethnicity. It has been a cooperative effort that is not ideal, but is far better than it was 40 years ago. Many recent graduating physicians are employed by health systems for a variety of reasons, but one of the primary reasons is that the physician can provide equal care to all individuals regardless of their ability to pay because they are salaried by the health system that employs them.

The spiritual guidance that I have tried to follow is that I do my best to listen to my patients; I do not rush them through the visit; I try to be aware of their personal, social and financial problems as I attempt to care for their medical problems; and I do my best to treat them as an equal person even though I have a great deal of specialized knowledge.

I think we can attempt to transcend the differences between those in the healthcare profession and our patients, whether they are poor or not and regardless of their cultural or ethnic background, by deciding that we will stand shoulder-to-shoulder and walk hand-in-hand with them in attempting to correct the inadequacies of our healthcare system. In other words, we will be their advocates, and by being our patient’s advocates, we will speak out about the inadequacies in our healthcare system and for those solutions that will improve accessibility and quality of care for all of our patients.

Ken Woerthwein

York, Pa.