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A few years ago,
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I was taking care of a woman who was a victim of violence.
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I wanted her to be seen in a clinic that specialized in trauma survivors.
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I made the appointment myself because, being the director of the department,
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I knew if I did it,
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she would get an appointment right away.
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The clinic was about an hour and a half away from where she lived.
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But she took down the address and agreed to go.
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Unfortunately, she didn't make it to the clinic.
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When I spoke to the psychiatrist, he explained to me
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that trauma survivors are often resistant
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to dealing with the difficult issues that they face
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and often miss appointments.
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For this reason,
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they don't generally allow the doctors to make appointments for the patients.
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They had made a special exception for me.
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When I spoke to my patient,
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she had a much simpler and less Freudian explanation
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of why she didn't go to that appointment:
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her ride didn't show.
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Now, some of you may be thinking,
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"Didn't she have some other way of getting to that clinic appointment?"
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Couldn't she have taken an Uber or called another friend?
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If you're thinking that,
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it's probably because you have resources.
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But she didn't have enough money for an Uber,
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and she didn't have another friend to call.
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But she did have me,
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and I was able to get her another appointment,
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which she kept without difficulty.
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She wasn't resistant,
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it's just that her ride didn't show.
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I wish I could say that this was an isolated incident,
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but I know from running the safety net systems
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in San Francisco, Los Angeles, and now New York City,
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that health care is built on a middle-class model
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that often doesn't meet the needs of low-income patients.
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That's one of the reasons why it's been so difficult
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for us to close the disparity in health care
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that exists along economic lines,
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despite the expansion of health insurance
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under the ACA, or Obamacare.
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Health care in the United States
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assumes that, besides getting across the large land expanse of Los Angeles,
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it also assumes that you can take off from work
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in the middle of the day to get care.
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One of the patients who came to my East Los Angeles clinic
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on a Thursday afternoon
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presented with partial blindness in both eyes.
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Very concerned, I said to him,
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"When did this develop?"
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He said, "Sunday."
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I said, "Sunday?
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Did you think of coming sooner to clinic?"
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And he said, "Well, I have to work in order to pay the rent."
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A second patient to that same clinic,
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a trucker,
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drove three days with a raging infection,
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only coming to see me after he had delivered his merchandise.
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Both patients' care was jeopardized by their delays in seeking care.
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Health care in the United States assumes that you speak English
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or can bring someone with you who can.
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In San Francisco, I took care of a patient on the inpatient service
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who was from West Africa and spoke a dialect so unusual
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that we could only find one translator on the telephonic line
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who could understand him.
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And that translator only worked one afternoon a week.
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Unfortunately, my patient needed translation services every day.
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Health care in the United States assumes that you are literate.
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I learned that a patient of mine who spoke English without accent
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was illiterate,
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when he asked me to please sign a social security disability form for him
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right away.
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The form needed to go to the office that same day,
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and I wasn't in clinic,
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so trying to help him out,
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knowing that he was the sole caretaker of his son,
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I said, "Well, bring the form to my administrative office.
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I'll sign it and I'll fax it in for you."
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He took the two buses to my office,
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dropped off the form,
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went back home to take care of his son ...
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I got to the office, and what did I find next to the big "X" on the form?
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The word "applicant."
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He needed to sign the form.
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And so now I had to have him take the two buses back to the office
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and sign the form so that we could then fax it in for him.
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It completely changed how I took care of him.
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I made sure that I always went over instructions verbally with him.
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It also made me think about all of the patients
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who receive reams and reams of paper
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spit out by our modern electronic health record systems,
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explaining their diagnoses and their treatments,
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and wondering how many people actually can understand
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what's on those pieces of paper.
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Health care in the United States assumes that you have a working telephone
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and an accurate address.
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The proliferation of inexpensive cell phones
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has actually helped quite a lot.
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But still, my patients run out of minutes,
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and their phones get disconnected.
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Low-income people often have to move around a lot by necessity.
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I remember reviewing a chart of a woman with an abnormality on her mammogram.
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That chart assiduously documents that three letters were sent to her home,
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asking her to please come in for follow-up.
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Of course, if the address isn't accurate,
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it doesn't much matter how many letters you send to that same address.
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Health care in the United States assumes that you have a steady supply of food.
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This is particularly an issue for diabetics.
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We give them medications that lower their blood sugar.
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On days when they don't have enough food,
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it puts them at risk for a life-threatening side effect
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of hypoglycemia, or low blood sugar.
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Health care in the United States assumes that you have a home
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with a refrigerator for your insulin,
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a bathroom where you can wash up,
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a bed where you can sleep
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without worrying about violence while you're resting.
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But what if you don't have that?
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What if you live on the street,
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you live under the freeway,
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you live in a congregant shelter,
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where every morning you have to leave at 7 or 8am?
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Where do you store your medicines?
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Where do you use the bathroom?
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How do you put your legs up if you have congestive heart failure?
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Is it any wonder that providing people with health insurance who are homeless
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does not erase the huge disparity
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between the homeless and the housed?
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Health care in the United States assumes that you prioritize your health care.
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But what about all of you?
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Let me assume for a moment that you're all taking a medication.
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Maybe it's for high blood pressure.
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Maybe it's for diabetes or depression.
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What if tonight you had a choice:
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you could have your medication but live on the street,
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or you could be housed in your home but not have your medication.
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Which would you choose?
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I know which one I would choose.
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This is just a graphic example of the kinds of choices
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that low-income patients have to make every day.
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So when my doctors shake their heads and say,
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"I don't know why that patient didn't keep his follow-up appointments,"
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"I don't know why she didn't go for that exam that I ordered,"
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I think, well, maybe her ride didn't show,
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or maybe he had to work.
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But also, maybe there was something more important that day
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than their high blood pressure or a screening colonoscopy.
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Maybe that patient was dealing with an abusive spouse
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or a daughter who is pregnant and drug-addicted
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or a son who was kicked out of school.
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Or even maybe they were riding their bicycle through an intersection
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and got hit by a truck,
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and now they're using a wheelchair and have very limited mobility.
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Obviously, these things also happen to middle-class people.
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But when they do,
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we have resources that enable us to deal with these problems.
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We also have the belief that we will live out our normal lifespans.
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That's not true for low-income people.
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They've seen their friends and relatives die young
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of accidents,
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of violence,
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of cancers that should have been diagnosed at an earlier stage.
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It can lead to a sense of hopelessness,
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that it doesn't really matter what you do.
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I know I've painted a bleak picture of the care of low-income patients.
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But I want you to know how rewarding I find it
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to work in a safety net system,
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and my deep belief is that we can make the system responsive
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to the needs of low-income patients.
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The starting point has to be to meet patients where they are,
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provide services without obstacles
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and provide patients what they need --
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not what we think they need.
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It's impossible for me to take good care of a patient
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who is homeless and living on the street.
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The right prescription for a homeless patient is housing.
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In Los Angeles,
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we housed 4,700 chronically homeless persons
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suffering from medical illness, mental illness, addiction.
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When we housed them, we found that overall health care costs,
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including the housing,
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decreased.
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That's because they had many fewer hospital visits,
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both in the emergency room and on the inpatient service.
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And we gave them back their dignity.
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No extra charge for that.
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For people who do not have a steady supply of food,
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especially those who are diabetic,
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safety net systems are experimenting with a variety of solutions,
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including food pantries at primary care clinics
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and distributing maps of community food banks and soup kitchens.
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And in New York City,
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we've hired a bunch of enrollers
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to get our patients into the supplemental nutrition program
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known as "food stamps" to most people.
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When patients and doctors don't understand each other,
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mistakes will occur.
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For non-English-speaking patients,
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translation is as important as a prescription pad.
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Perhaps more important.
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And, you know, it doesn't cost anything more
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to put all of the materials at the level of fourth-grade reading,
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so that everybody can understand what's being said.
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But more than anything else, I think low-income patients
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benefit from having a primary care doctor.
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Mind you, I think middle-class people also benefit
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from having somebody to quarterback their care.
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But when they don't, they have others who can advocate for them,
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who can get them that disability placard
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or make sure the disability application is completed.
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But low-income people really need a team of people who can help them
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to access the medical and non-medical services that they need.
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Also, many low-income people are disenfranchised
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from other community supports,
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and they really benefit from the care and continuity provided by primary care.
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A primary care doctor I particularly admire
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once told me how she believed that her relationship with a patient
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over a decade
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was the only healthy relationship that that patient had in her life.
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The good news is, you don't actually have to be a doctor
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to provide that special sauce of care and continuity.
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This was really brought home to me when one of my own long-term patients
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died at an outside hospital.
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I had to tell the other doctors and nurses in my clinic
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that he had passed.
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But I didn't know that in another part of our clinic,
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on a different floor,
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there was a registration clerk
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who had developed a very special relationship with my patient
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every time he came in for an appointment.
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When she learned three weeks later that he had died,
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she came and found me in my examining room,
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tears streaming down her cheeks,
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talking about my patient and the memories that she had of him,
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the kinds of discussions that they had had about their lives together.
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My patient had a hard life.
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He was by his own admission a gangbanger.
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He had spent a substantial amount of time in prison.
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He suffered from a very serious illness.
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He was a drug addict.
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But despite all that, he rarely missed a visit,
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and I like to believe that was because he knew at our clinic that he was loved.