In this age of medical miracles, consumers might think that the spectacular story of a mother carrying her own daughter's child and hence delivering her own grandchild might constitute the great moments in our practice. And these are great moments. But for me, the greatest challenges often don't take the form of the spectacular. Often the greatest challenges are meeting the needs of ordinary patients. Despite the media attention to miracles, most of us are struggling very hard to meet the needs of ordinary patients in a health care system that does not value ordinary care.
When I have a patient from a family which is dysfunctional, I have more than a single patient. I have a whole family to treat, regardless of my specialty. But our health care system chooses not to reward the time I spend with my patients to overcome the inadequacies of our miracle-lined health care system. Yet it is a kind of medicine I find personally very rewarding. And a kind of medicine which I know ultimately saves society millions of dollars.
A social worker called me and asked if I would see a former patient of mine who was again pregnant and not gaining any weight. The doctor she was seeing was unable to make any progress with her. This was a family who already had four children, and social services had placed one of the children in a foster home. They were trying to take the other three children away from the family.
The mother was a heavy smoker, she had not gained weight during her pregnancies, her babies were born early and had been too little, and she had failed to bond with some of them after birth. The mother now lived 75 miles from my office, but her husband did bring her in for me to see before she delivered this fifth child.
The first time I saw my patient and her husband, both were very unhappy with the situation. The husband had been extremely suspicious of me at the initial interview. And why shouldn't he be. Doctors are the persons who usually trigger the system which takes children away from parents. However, I was able to observe him in the waiting room with his children and he was at ease with them and treated them appropriately. I spent a good deal of time talking with the mother about cutting her smoking down so she would have a healthier baby. I observed the father each time she came, and he continuted to interact normally with his children.
The delivery was unremarkable. The mother was still smoking, but she had cut down and her baby was full term, normal weight, and healthy. However, after her delivery, the mother became severely depressed, which is what I had suspected had been occurring after her previous deliveries. With the severity of her depression, she was totally uninterested in her children, which contributed to her inability to bond with some of them.
I contacted the social worker who had referred her to me and we discussed the situation at length. It was my feeling that we could rely on the father to be the primary parent. He had overcome his initial suspicions of me and by now I had been able to observe the interactions with his children on several occasions. The social worker agreed with me, and she brought the family in for counseling. The mother went to work, and by doing shift work, each parent could be home to take care of the children, each accepting total responsibility for the children part of the day. The next time I saw my patient, she had overcome her depression problems and they had worked through a lot of the difficulties that had made the family dysfunctional. Once she overcame her depression and had some time away from home at work, she was able to successfully bond with her children.
Not long ago I got a frantic call from this woman on a Sunday evening. She was pregnant again and she had noticed a decrease in fetal movement. Again, she had not gained weight and she was smoking more. Her husband brought her to my office the next day, and we talked for several hours. Even though she had a considerable drive to come to my office, she kept her appointments, gained weight, and delivered a healthy baby.
Was this a miracle? Not by today's standards. Does our health care system recognize the value of this kind of intervention? No. I am unable to charge for the time I spend talking with her -- only for performing specific procedures. But I found my care of this patient very rewarding because I believe I have saved a family and improved the home environment for eight people. The long term effect of this kind of intervention could well span 50 to 80 years. At a savings to society of hundreds of thousands of dollars in social services, from prevention of child abuse to prison sentences.
A national health care system -- one based on everyday need instead of expensive miracles -- would reward doctors for providing this kind of relatively inexpensive but very effective intervention.
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