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Thursday Aug 07, 2014

Reality Check: Residents Aren't Prepared to Deal With Patients' Financial, Coverage Limits

In medical school, our patient encounters typically consisted of completing a history -- including talking with patients about any concerns or issues that led them to seek care -- doing a physical exam, and developing a diagnosis and treatment plan with the resident and attending.

In the real world, it turns out, it's not that simple. I recently began the first year of family medicine residency, and I quickly realized that some important steps were left out of the learning process. As students, we were not often exposed to what happened next for patients. We missed the part where the physician talked with the patient about his or her insurance, what it covered and what it did not.

 This week I'm attending the AAFP's National Conference in Kansas City, Mo., which offers students and residents opportunities to learn about clinical skills, leadership and more. One thing students don't learn in medical school is how to manage patients who lack the means to pay for needed treatment.

I recently saw a patient, a woman in her mid-30s, who came in for a checkup. In addition to her chronic conditions, including hypertension and diabetes, she complained of joint pain in her knees and hips. After taking her history and talking with her about her discomfort, I wanted to have her tested for rheumatoid arthritis.

Her first question was, "How much will that cost?" The patient had private insurance, but her plan left a lot to be desired. It covered office visits and some medications, but it did not cover labs.

The patient, a single mom who also was supporting her mother, informed me that she already was paying off a large lab bill from a previous visit. She needed to repeat labs related to the medications for her chronic conditions, but she couldn't pay for those, let alone for a blood test for rheumatoid arthritis.

I could have ordered the labs, but there wasn't any point in doing so because she told me it would have to wait. It's not that she would have been noncompliant, she simply couldn't afford to do what needed to be done. From her perspective, doing the labs would have meant asking the people she supports to sacrifice something else.

I asked her to come back in two months so that we could reassess her situation -- both physically and financially. For now, she plans to continue treating her joint pain with OTC medications.

This situation is hard for me to get used to. I can't do what I want to do -- what I've been trained to do -- to help some of my patients. Instead, I have to consider a patient's medical, social and financial situation and work within those limitations.

Medical students should have more exposure to this part of the process so they are more aware of the reality that awaits them. What do you do -- or what can you do -- when your patients' financial or coverage limitations are barriers to needed care?

Tate Hinkle, M.D., is the student member of the AAFP Board of Directors.

Comments:

Although some medical students and residents may not be prepared to deal with patients who are unable to pay for their treatments due to social or economic obstacles, it isn't the medical school or even the residencies that are to blame. It is the medical student and the resident who should take his or her learning about the real world into their own hands. Medical school won't be able to sit you down in a lecture room and teach you about how to treat and handle situations that involve financial and social obstacles. If you are interested in learning about such situations in the real world, the real world is all around you. Learn and explore your community. Go shopping where your patients shop, attend community activities, learn about recourses available, become friends with community health workers. There may be a person or place that is already dealing with these challenges, where you can learn. If not, be that person. If there isn't a place that offers care to underserved individuals, create one. If we truly want to help our patient, we shouldn't expect these tools to be given to us in a binder. Most medical schools and residencies have connections to volunteer clinics or rural rotations. Seek out opportunities to learn or create them.

Posted by Raquel Cisneros MD on August 09, 2014 at 08:18 PM CDT #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.