Bitter Pill for Young Doctors

Slow and sick, the patients shuffle in.

With friends or grandparents or sisters, or no one at all, they slump into the plastic chairs and wait.

It’s a group you can find any afternoon outside the emergency room at Ventura County Medical Center.

On this day about 20 patients squirm on the hard seats, waiting for a triage nurse to sort through their cases--ranking them in order of urgency and arrival, and sending them back to the doctors.

The television drones. Babies cry. Men in dirty clothes slide off slippery chairs.

A 32-year-old mother of six is sitting near the counter. She has no car, no husband and a part-time job. Her sister took the afternoon off from work to drive her here from Oxnard. She has Medi-Cal and she needs her gall bladder removed.

There is 10-month-old Saidy. She has a raging fever and glassy eyes. Her mother speaks English but her father doesn’t. She has Medi-Cal, but they don’t.

There is a 48-year-old homeless schizophrenic woman struggling to get off the methamphetamines that have kept her strung out for the last year. She wants medical clearance to go to a detox center. She wants to straighten out her life, she says.

These are among the patients waiting for the 13 first-year residents at the medical center.

Day in, day out, the steady stream has taken its toll on the young residents--who arrived fresh to save the world last June.

“The pendulum starts out on one side--very idealistic,” says Dr. Lanyard Dial, head of the residency program at the county hospital. “It gets moved during the first year--to the more cynical, more frustrated side. During the second and third year it moves back. But it never moves back to where it started.”

Nine months into the program, the residents have grown to love the patients who suffer silently, and hate the patients who want nothing but fuel for a drug habit.

They have grown to love the system that helps the poor and the homeless, and hate the system that cannot care for the sick child of hard-working parents without health insurance.

As they enter the final quarter of their first year, they have encountered contradictory emotions that will plague them for the rest of their professional lives.

The patients have made them more jaded and more tired.

But they have also made them feel compassion and connection.

Ultimately, these patients will make them into doctors.

Getting to Know a Cast of Patients

First-year resident Steve Mills strides down the corridor and pokes his head into a sunny room.

It is here--in the intensive care unit and the telemetry section--that the doctors forge many of the strongest bonds with their patients. It is also here that residents pick up patients to fill their own fledgling family practices over the next three years.

Each will have about 150 patients by the time he or she finishes residency, a patient base that will help the doctors develop relationships over time and teach them to get to know the whole patient--the core philosophy of family medicine.

On this floor the young doctors visit each day, and monitor their patients’ medications and mental state. They also learn their character and idiosyncrasies.

“When you’re treating patients in the ER, it’s like a machine,” Mills says. “There’s an answer for every symptom. You don’t take account of anything--if the patient is stoic or emotional, low income or high, it’s all the same. But it’s nice to walk into the room, see your patient, and say, ‘How are you doing?’ ”

He walks over to a bed and says hello.

A 59-year-old man with a shock of greasy gray hair smiles as Mills enters. He is thin as a rail, lashed to the hospital bed with strips of gauze, wearing a diaper.

“Do you remember why you are here?” Mills asks.

The patient grins, but doesn’t respond.

“You were drinking, every day, for a long time,” Mills prompts. “You came into the ER. You had a seizure. You got so sick we had to keep you in the ICU for a week. Do you remember?”

A vacant grin.

“You’ve been here for five weeks. We’re looking for a place for you to live.”

The man smiles, and mumbles incoherently.

“I can’t get up,” he finally says.

“Right. We don’t want you to get up. You’ll fall and hurt yourself,” Mills says.

He has drunk so much, for so long, that his brain is addled and his body wasted. He finally collapsed here, on the hospital’s doorstep.

Cynicism and Optimism Coexist

The 7,200 patients who pass through Ventura County Medical Center each year are mostly minority and mostly poor.

About three-quarters are unemployed, on Medi-Cal or uninsured. Nearly one-third speak no English. A growing percentage are the county’s working poor--scraping by with nothing to spare.

Although there are no precise figures, doctors estimate that 30% to 40% of all the patients who pass through Ventura County Medical Center each year have drug- or alcohol-related illnesses. About 10% are seriously mentally ill.

They are a group with more than their share of human tragedy.

But Dial says the illnesses and problems of this population are good for residents’ training.

“Here they see more than they ever would serving a healthy, young population,” Dial says. “To that degree it is a privilege to serve these people. You’ll hear the residents say that.”

Still, Dial sometimes worries about the effect of seeing so much pain and suffering.

“The interns get a little jaundiced in the care of these people,” Dial says. “It takes awhile to see that a lot of the ravages that appear self-inflicted have a whole root and background in our society.”

Traces of that cynicism occasionally creep into Mills’ comments.

“So many patients come in, and the root problem is alcohol and drugs,” Mills says, matter of fact. “They’re here for a few weeks. We patch ‘em up. Send ‘em home. And then they’re back a few months later.”

Morning to night Mills is deluged with demands from patients asking for medication, medical excuses and attention.

For example, many patients come in asking to be cleared for disability payments. They are savvy. They know the system. They know how to fake illnesses. He has to be on guard--both for patients who know they are faking and those who aren’t even aware that they have concocted symptoms to get sympathy, or money, or a place to live.

Many patients have told him they are going to stop drinking.

Few do.

He tells of one patient who was riddled with abscesses from drug use.

“Help me. I’m going to get over this, doc,” he recalls her saying.

“I believe you,” he told her. “I know you’re strong. Come back in a year and show me.”

But she was back in a few weeks, with more abscesses.

“She was using again,” he says.

A nurse pops in to tell him another patient wants him to sign papers allowing her to receive disability payments.

He refuses.

But through the stench of alcohol, and despite the endless examples of abuse, Mills occasionally hits a patient who really makes him care. These are the patients who remind him that he got into family practice medicine to save lives and make a difference.

And for those few, he will carve out time from his 100-hour work week to ferret out extra treatment.

His next patient is one of the lucky ones--who charmed Mills with his earnestness, his desire to learn about his disease and his upbeat attitude.

He was a successful businessman until alcohol cost him his job, destroyed his marriage and cut him off from his family.

The only remnant of his former life is his Mercedes-Benz.

When Mills walks in, the man beams.

“It appears as though I will survive,” he says exuberantly. “He’s a miracle worker.”

He came in with atrial fibrillation, a condition that can be related to heavy alcohol use.

Homeless, alcoholic, malnourished, he needed medicine he could not get. The medicine he needed costs $200 to $300 a month.

Mills knew he could finagle several free samples of the very expensive medicine, but it wouldn’t last.

“In the end, it’s often up to you and your own initiative,” he says. “I could have left it and given him the next medication, which wasn’t as good but was covered.”

But Mills persisted, and with phone calls and extra hours he got his patient into a free drug program for compassionate use.

That is part of what residents learn during their training at the hospital, says registered nurse Maggie Gerk.

Indeed, the thicket of bureaucratic regulations is so complex, the hospital has special staff to determine patients’ eligibility.

The residents know that Medi-Cal, the state’s insurance program, takes care of patients who are incapacitated for a month and have children at home, are pregnant, or if they are disabled for a year by a problem that is not alcohol- or drug-related.

They know that those who work part time will not have health insurance through their job and will probably have to foot the bill themselves.

And they know that if all else fails and their patient is poor, could die and cannot get money any other way, he or she may be eligible for the hospital’s medically indigent adult program.

The residents also know where the free drug samples are stashed in the hospital. And they know how to enroll patients in programs they might not otherwise be eligible for.

“By the time they are third-years, they all know how to get what they want,” says Gerk, whose bookshelf is overflowing with dense forms explaining program after program--more than 52 through Medi-Cal alone.

“They are like little rats in a maze getting the cheese. They become very resourceful.”

Dealing With Everyone’s Realities

At 7:50 a.m. Dr. Jennifer Scott comes running out the front door of the hospital in yesterday’s clothes, her white doctor’s coat flapping behind her.

She’s post-call, which means she has been up all night. She just washed her hair in the sink, and she still has soap in her ears.

Dial is waiting for her in his Toyota Camry.

Scott is on the three-week community medicine rotation. In addition to her normal rotations and seeing her normal family practice patients, she will visit clinics in the community and learn more about the public health care system.

This morning Dial is taking her to the Livingston Memorial Visiting Nurse Assn., the oldest hospice program in Ventura.

As he navigates through the morning traffic, he explains the finances of the hospice system.

Medi-Cal pays Livingston $110 a day for care of terminally ill patients and visits to their homes. If the patients die in less than two weeks, Livingston loses money. If the patients die in two to three weeks, Livingston breaks even.

Scott looks disgusted at the bottom-line analysis of the dying.

At the nurses meeting, Dial signs 16 death certificates. Then the nurses talk about their patients, asking Dial what kind of care they should give.

Useful but tedious sessions with several insurance program administrators follow.

Back at the hospital, Scott curls up on the bed in the residents room to try to snatch some sleep.

This has been a tough year for Scott.

Her mother was hit by a car in France in the fall and still has not fully recovered. There were times when other doctors, and Scott herself, wondered if the emotional trauma, atop her already strenuous first-year residency schedule, would be too much to bear. She is making it, though.

But what she has seen this morning makes her mad.

It bothers her that the government is willing to spend hundreds of thousands of dollars for children who will probably die but will pay almost nothing for kids who are almost certainly going to live.

“I hate that the system is so dictated by money,” she says. “I wish we had a more equitable system for everybody.”

It upsets her that a child with a catastrophic illness may be eligible for hundreds of thousands of dollars in aid, but the child of a Mexican migrant worker--legal or undocumented--cannot get good antibiotics.

It frustrates her that some people consume so much by virtue of their own choices, such as substance abusers.

But for Scott, the most aggrieved of all are the working poor--too poor to afford health insurance but still not eligible for government assistance.

These are the sort of people she will treat when she returns to the tiny logging town of Burney, where she hopes to work someday.

“I hate it when I look down and see ‘self-pay,’ ” she says.

Still, she vows that financial concerns will not affect her approach to the patients, even though she knows she has to consider money with everyone she sees.

“It just takes tenacity,” she says, curling up on the bed. “And tenacity takes time.”

Dying Vicariously

In the emergency room, in the intensive care unit, in the family care clinic--all over the hospital the new doctors are coming into their own.

As they wade through a sea of patients, battling fatigue and cynicism, most of the residents have come across people who pierced their emotional armor.

These are the patients who haunt their dreams at night and dominate their discussions with other doctors during the day.

These are the ones who make them say what if, if only, why didn’t I just. . . .

These are the patients who teach them their own humanity.

For Dr. Mills, it’s a Latino kid who turned up in the emergency room eight months ago with shortness of breath. Last year he played basketball with his friends; this year he was dying of cancer.

He had no insurance and no doctor, so Mills took him into his practice.

“It’s challenging. I was there from the beginning. It’s like he’s you. I can relate to him,” Mills says.

Every treatment at the hospital failed the young man. Finally, his family took him to Mexico for alternative treatments. Several weeks ago he died.

He still bothers Mills.

“Can you imagine looking at a . . . kid and saying, ‘Prepare to die’?” Mills asks.

Dr. Christina Zaro found a special bond with a woman in her late 30s with chronic fatigue syndrome.

More-experienced doctors doubted anything was wrong.

But with this patient, Zaro was convinced that something was indeed wrong--despite a lack of detectable symptoms.

“So I told her maybe it’s nothing physical,” Zaro said. “Maybe it’s something emotional that is making you feel this way.”

The woman and her mother were so relieved to hear those simple words that the mother jumped up and hugged her.

“I’d never had anyone give me a hug before,” Zaro said shyly.

Like her colleagues, Zaro feels frustrated with the patients who refuse to take care of themselves. But she loves her patients’ stories and the privilege of being by their sides at some of the most intense, difficult moments of their lives.

“That’s the reason I got into medicine,” Zaro says with sudden passion, pounding her fist on a table. “I just love for people to spill their hearts out to me. In the deepest, darkest moments of people’s lives, this is where I want to be.”

Scott still thinks about a patient she lost the day before Christmas.

He was an old Mexican man, with a daughter who sat outside his door all day and all night.

The first night he met her, they sang the Mexican ballad “Celito Lindo” together as he lay in his hospital bed.

His daughter’s love for him reminded her of her own relationship with her mother.

“I loved his daughter and how much she loved him,” she says. “I just truly loved coming in to see this guy.”

One night, Scott was rushing to leave the hospital. She had a funny feeling about him, so she checked her favorite patient and he was fine.

“I came in the next morning and he had died in the night,” she says, tears coming to her eyes.

He taught her to trust her intuition, even when things look fine on the charts. And it taught her to see the love between family members.

She can’t sing “Celito Lindo” anymore.

She isn’t embarrassed about her sentimentality.

“Being sick sucks,” she says. “Going to the bathroom in front of everybody sucks. Getting a bill for $8,000 sucks. All these things suck, but at least I can sit and say, ‘You’re going to die, but I’m going to be here, and I’m going to care.’ ”

She pauses. “I’m a young doctor,” she says. “I don’t know everything. But I do care.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

About This Series

“Making of a Doctor: A Boot Camp for Family Medicine” follows young doctors through their first year of residency at the Ventura County Medical Center. Today’s installment, the third in a continuing series, looks at the patient population served by the residents at the county hospital, and the psychological and emotional toll on the residents.