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Health Without Wealth

Dr. Cory writes about life in a free clinic.

By CORY FRANKLIN M.D.

The deed is everything, the glory naught.—Goethe
 
    It’s been a mixed blessing that in the last generation many of America’s academic medical centers, hospitals and clinics have evolved into a high-tech industry. While most deliver better care than ever before, as budgets commonly escalate into eight, nine and occasionally 10 figures, they’re forced to redefine their mission.  Unlike the past, today’s hospitals and clinics, both in the for-profit and the not-for-profit sector, depend on the market to survive. Consequently, while they still provide charitable care, their social service functions and local obligations have in many cases become subordinated to other imperatives such as the requirement to raise money and provide jobs for the community, as well as the need to cultivate political influence and community prestige. 
    It was not always this way. Before World War II, most hospitals and clinics were not expected to support themselves.  A century ago, when medicine was not so sophisticated, the wealthy often received care in their homes while the middle class and poor were often hospitalized for extended periods, sometimes for nonmedical reasons, and were not always expected to pay their bills. In the 1920s, only about one-half of patients actually paid for their services, with philanthropy and government making up the difference. The situation changed after the war when employers began to provide health insurance as a benefit to their employees. An acceleration occurred in the 1960s as the federal government ramped up spending in medical care with the Medicare program. Another impetus came in the 1980s when hospitals and clinics began turning to private financing for new construction and expansion.                   
    Today, there is one vestige of the earlier era: the free community clinic. Many of these clinics were set up in urban areas in the 1960s and ‘70s to provide free outpatient medical care to anyone, no questions asked. Staffed primarily by health care volunteers and a few salaried employees, they received whatever funding they could get from local governments, religious orders or philanthropic donations. They served the uninsured by providing medical care and social services, in some cases working in tandem with community hospitals and clinics. Many of these free clinics fell by the wayside, the victims of insufficient funding. (For an idea of the quintessential 1960s free clinic, rent the 1969 movie Change of Habit, no classic for sure, but a “guilty pleasure” starring Elvis Presley as a doctor working in a free clinic and Mary Tyler Moore as his nurse assistant who happens to be a nun.) Some of those early free clinics remained viable and even thrived as a new generation of clinics sprang up in the 80s and 90s with better funding and more staffing, but the same mission—to serve the poor and uninsured.
   I’ve had the opportunity to work in two free clinics at the bookends of my career. In the early ‘80s during my medical fellowship, I moonlighted at the Free Clinic of Cleveland. Established in 1970 as a telephone hotline, it is currently the second oldest and one of the largest free clinics in the United States. In one of those ironies of American medical care, it is located only a short distance from two of the country’s most wealthy and prestigious medical centers. Recently, upon retiring, my career has come full circle, and I now work at a free clinic, which provides medical, dental and eye care on the North Side of Chicago.           
    Medicine and medical care have changed remarkably in the past three decades; working in a hospital today is nothing like it was in 1980. But working at a free clinic remains remarkably unchanged—the experience, the challenges, the obstacles and difficulties and the need for money, volunteers, services and supplies.  
 
The Experience    
 
                                   
    The best thing about working at a free clinic is the sense of accomplishment and the spirit of camaraderie working with other people, nurses, pharmacists and secretaries, who are there for the same reasons as you. You are helping patients who really need help and usually have nowhere and no one else to turn to. There is genuine gratitude from patients for what everyone does for them, even in situations where their problems, medical or otherwise, are unsolvable with the resources at hand. Occasionally, a patient may grumble or complain—these are, after all, usually people who have had a rough go at life—but without question, the level of appreciation they show for everyone working in a free clinic is greater than in any other medical setting I ever worked.
    This, in turn, creates a special esprit de corps among those who work at the clinic that is probably akin to what those in the military experience—everyone working for a common purpose, subordinating their own interests to a common goal. The exhilaration is contagious. It is unusual to hear the staff complain. It was my impression working in many hospital and clinic environments that there was usually some staff member who resented something or someone and made no secret about it. You just don’t see that attitude often at a free clinic. A telling anecdote:  I remember when I initially started working at the Free Clinic of Cleveland, I happened to be assigned Monday nights. This was in the early 80s, the days when watching Monday Night Football with your friends was a ritual. It meant I couldn’t be there for the weekly party. At first, I was annoyed by the assignment and actually thought about giving up the idea of working there. But after a few weeks, so enjoyable was the experience in the clinic, I noticed I didn’t miss the football game or the party at all. It was therapeutic—for me.  
 
The Challenges    
 
                                      
    Anyone who works at a free clinic is likely to tell you their greatest challenge is how to take care of the patients. Every patient presents a unique set of difficult problems. A partial list of things you will see in the free clinic patient population include the following: they are poor, uninsured, unemployed, homeless, possess inadequate English skills, have no history of preventive medical care, have chronic health problems (especially diabetes and hypertension), psychiatric conditions, drug and/or alcohol problems and little or no family support. Patients with these problems present a challenge to even the most skilled practitioner and the first lesson you learn is that it is essential to remain nonjudgmental and maintain your equanimity.     
    There are inherent challenges in caring for these people. Many are quite sick and require a significant level of medical attention, nursing care and follow-up. Patients with multiple medical conditions require extensive testing and observation, which means they must come to the clinic frequently. Often this is not possible for them, especially if they have to travel a long way on public transportation. This is compounded because some don’t have telephones and a few don’t even have mailing addresses. Continuity of care is difficult. Another difficulty is that patients with multiple medical problems often need many medications. This further complicates management in patients who have trouble adhering to medication schedules or who experience debilitating drug side effects or interactions.         
    Lest anyone think the patient population is simply straight out of a Charles Dickens novel of poverty, there are a surprising number of unfortunate tales worthy of an O’Henry short story—middle and upper-class patients who show up after losing their job, being involved in a messy divorce or experiencing the death of a spouse. The free clinic population often includes widows who live alone and have no way of getting their medication. Occasionally there are patients who were once executives or worked at white-shoe law firms and received their medical care in the toniest clinics of the Upper WestSide of Manhattan, Chicago’s Gold Coast or West L.A. And yet their problems are often exactly the same as those of the homeless.         
    Ironically, the biggest difference between treating people at a free clinic and a regular clinic is that in a regular practice, you hate to see your relationship with a patient end when they come in and tell you they won’t be seeing you anymore, because they are moving, found a different doctor or have different insurance coverage. It’s a disappointment hearing that after forging a bond with someone over time. But in a free clinic, there is nothing better than hearing a patient you’ve forged a bond with say, “I liked having you as a doctor, but I found a job with health insurance and I won’t be coming back anymore. I’m sorry.” It’s like having a child graduate college and leave home—your disappointment in losing them is trivial compared to the pride and happiness you feel for them.   
     
The Obstacles     
                   
                     
    Resources, resources, resources. Every free clinic is in need of more resources. And the hardest thing to come by is often physician specialists. The complex medical problems these patients present require consultations with specialists with limited availability for this population. The patients’ common conditions create a constant need for general surgeons, orthopedists, gynecologists, cardiologists, gastroenterologists, urologists, endocrinologists, dermatologists and psychiatrists, among others. When these specialists are unavailable, there is often no alternative to sending the patient to a local emergency room—an expensive, inefficient approach.                        
    Another source of frustration is that because there are not many specialists available, not only do the patients miss their expertise, so do I. At the clinic I work at, I think I may have observed a pattern of a benign, but unusual liver condition in many of the patients who are Russian emigres. It should not affect their health in any way, but if it is an actual finding and not a coincidence, it suggests there may be a genetic predisposition in that population, something not described in the medical literature. It’s an interesting hypothesis, but one that is not likely to be tested simply because the resources and personnel are not available to do so. Little things like that make you miss the resources of the major medical center.
    Other resources are commonly in short supply—testing equipment, bandages and minor surgical instruments. Once I worked in a treatment room where someone had donated some medical textbooks that were available for reference. Unfortunately, a 1946 edition of Common Surgical Problems and a 1949 copy of Gynecology for the General Practitioner were of little help.
 
What A Free Clinic Needs

   Besides money, free clinics need volunteer services—nurses, doctors, psychiatrists, specialty practitioners, dentists, podiatrists, mental health workers and others including physical therapists, dieticians and health educators. Even the general public can provide volunteer services—sometimes occupational or legal advice may be of need. In clinics with large immigrant populations, translators are often in short supply. A free clinic is an excellent place for bilingual high school and college students to obtain entry-level volunteer experience.  
    Supplies are another area of need. A free clinic without access to medication is not a clinic. Many medications are expensive and hard to come by and patients need help getting on patient assistance programs. The large pharmaceutical companies should play a role in donating medications to keep free clinic pharmacies stocked. Medical professionals, medical schools and hospitals can donate unused medical supplies, equipment and educational materials. Here again, the general public can play a role, perhaps through the donation of a computer, a television set or simply magazines and reading materials for patients in the waiting room.
           
Philanthropy Works Both Way
 
             
   
    With an economy in distress, more families, in Chicago and elsewhere, will face unprecedented economic pressures. There is a realistic possibility the country will experience a surge in individuals without health insurance, jobs and, in some cases, even a place to live. Many people, perhaps a friend or neighbor, may be only ”one paycheck away.” Hospitals and private clinics, affected by the economic downturn themselves, may not be able to care for those living so precariously.  When these persons get sick, require counseling or simply need medication, they will go to free clinics. And this is how philanthropy works both ways. The general public needs the services of free clinics, and at the same time, money, volunteer services and supplies are part and parcel of what free clinics need most, the support of the general public.

Published: December 07, 2008
Issue: Winter 2008 - Annual Philanthropy Guide