Hello from Norwalk, CT

It's a quiet late Friday afternoon at the Norwalk Community Health Center and finally I am contributing to the fellow's blog. Apologies for my absence so far, it's been a busy summer and early autumn.

In about an hour and a half my 15th week at the health center will be coming to an end. In that time I have become fairly comfortable in my role here, along with the other P55 fellow, Julia. So far our work has been mostly administrative: We have worked on various quality improvement projects and have chipped in to help compile data for various government public health departments on the health center's clinical performance in a number of areas. We have also worked to contact and communicate with patients about their ongoing healthcare needs, helping them to schedule appointments with specialists and find their way through the complex, disorganized, and often frustrating healthcare landscape they face. At the end of the month, we will play a small clinical role for the first time by acting as quasi-medical assistants in a pilot of the use of knowledge supplementing software for managing diabetic patients.

What patient contact I have had so far has been fairly astonishing. Many of the health center's patients are socioeconomically disadvantaged, and I've found that while some of these patients are quite knowledgeable of their conditions and involved in their own care, others are sometimes almost entirely ignorant of the diseases that afflict them and their implications. This is not to say that these patients are always irresponsible. Some of them are very tenacious in finding out where it is the doctors want them to go and what it is they want them to do without really conceptually understanding why they are doing all these things. Nevertheless, the lack of basic medical knowledge that I have seen has in some cases rivaled or even surpassed that which I saw in rural West Africa, which I never would have imagined before.

The other notable aspect of my interaction with patients so far has been the prodigious difficulty I have seen some of them face in simply accessing any kind of specialty care. Patients with Medicaid or no insurance are able to access high-quality primary care at the health center because the health center qualifies for adequate compensation from Medicaid (somewhere around 120 dollars per visit), and because the health center offers a sliding fee scale for the uninsured such that they pay out of pocket for care only as much as they are able to according to some financial formula. However, virtually no independent specialists are compensated reasonably by Medicaid (their compensation per visit can be as low as 15 dollars, which simply doesn't begin to cover all the costs of a visit), and thus almost all do not accept Medicaid patients. Meanwhile, sliding fee scale patients are left to face high specialist visit costs by themselves, and are almost always unable to afford these visits to private providers.

The only option for Medicaid and uninsured patients is then to go to "specialty clinics" run by area hospitals where specialists donate their time and skills for little or no compensation. However, demand for these appointments is far greater than capacity, and the waiting list for an appointment can range from 3 months to more than half a year, depending on the specialty. Some effort is made to accommodate patients with emergency referrals first, but most of these patients must suffer long waits to be seen, and even then it is uncertain they will be able to afford the remedies they may need to solve their problems.

This is not the time or place to discuss healthcare reform, and, to be fair, the health center's Medicare patients (for people over 65) are able to receive very generous care from any specialist, but the inequality in access and care for those who do not qualify for Medicare is nothing short of a national disgrace. This fellowship has put us in the middle of issues that I had previously only read about distantly, and it has certainly been a more worldly sort of education that we have been receiving here so far than most of what we've had in the past.

Personally, I have spent a lot of time travelling on the weekends this summer and early autumn, and am now beginning to settle down for the next few months to study for the MCAT. Norwalk is a lovely town, almost like Princeton on the beach in some parts, but it can't compete with the magnificence of nearby New York City as a weekend hangout. I have been able to find a group to play pickup soccer with in Stamford, a few miles down the road, but other than these weekly excursions and my MCAT studying I have no scheduled extra-office activities for now. Once that MCAT is done that will certainly change.

Anyway, hope to be able to contribute more regularly to this blog from here on out.