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an online version of the magazine Fall 2009
Learning Curve

My Own Health Care Debate

By Daniel Munoz, M.D. '04


Learning Curve
Illustration by Sherrill Cooper

As one of four assistant chiefs of service for the Department of Medicine, I have cared for hundreds of patients, made thousands of clinical decisions, all while trying to teach something to the Osler medical house staff. Each day offers a dozen compelling stories.

Yet, what strikes me about the chief resident experience thus far is no one particular patient, no one particular encounter, but rather how the sum of the encounters has challenged some of my deep personal and political views.

With every passing day, it seems the debate about national health care reform becomes more raw. Angry town hall meetings have quenched the media’s thirst for evocative clips of ordinary citizens threatened by any systemic overhaul. Juxtaposed to the anger and fear is the equally impassioned argument that access to affordable health care is a moral, societal obligation we have to every American.

A detailed list of reasons for disagreement about health care reform could fill this whole magazine. But I sense there is an overarching theme to the debate, an underlying philosophical division between reasonable advocates of reform and reasonable opponents of reform: Should we all be willing to contribute (with tax money, blood, sweat, and tears) to the cause of ensuring everyone is included in the system?

In this job, as I shuttle from patient to patient, there are days that I cannot make up my mind.

Mr. F has a terrible life. A longtime addict of heroin and of prescription narcotics (which he buys on street corners, rather than at Rite Aid), Mr. F spends a good deal of his unemployed time shuttling between local ERs looking for his next fix. His cries of pain are answered with intravenous narcotics and admissions to the hospital. Twice in July, he was admitted to my service. Twice, we exhaustively searched for organic causes of his pain. Twice, we came up empty. One of my jobs is to first always assume that the diagnostic failure is mine. But, it’s hard not to be discouraged when I hear him joking on his cell phone while eating fast food brought to him by a buddy, only to grip his abdomen in agony as he sees me enter his room. When confronted, he curses, he threatens staff, and he leaves.

Ms. T, on the other hand, is a delight. And for a 47-year-old mother of four, she stays admirably active. She works as a housekeeper, riding the bus every day from East Baltimore to Roland Park to scrub kitchen floors and iron laundry. Twice a week she volunteers as a drug counselor at an inner city recovery house, pouring her soul into helping addicts get clean and stay clean. She does this despite diabetes, high blood pressure, and congestive heart failure. By the end of her work day, her legs ache to the point where walking is difficult. The next morning, she does it all again. Her wages go to bus fare, school supplies, and food/clothing for her family. Without health insurance, filling her medicines is prohibitively expensive. Eventually her symptoms escalate to the point of trumping her pride, and she forces herself to the hospital. Getting her better is easy (and enormously gratifying as I’ve never met someone who says “thank you” as sweetly as she). Keeping her well is not.

Are these extreme examples, chosen to make a point? Yes. But they are also real examples.

When Mr. F is in the hospital, I agonize over his consumption of resources and our energies. I worry about his corrosive effect on the attitudes of impressionable doctors-in-training. And I shudder at the thought of taxpayer money making it easier for this man to order off the narcotic menu at any hospital or pharmacy in the area.

When Ms. T is in the hospital, I hate how conflicting it is for me to discharge her, knowing how hard it is for her to afford her medicines on a tight family budget. She plays by the rules, works as hard as our medical residents, and yet struggles to maintain her health. If my annual check to the IRS could be shunted directly to her pharmacy bill, I would be a happy camper.

How do I reconcile these two views? What kind of national approach do they suggest? I’m not sure. But it raises a question with which I will continue to struggle. Which is more important: excluding the Mr. Fs or including the Ms. Ts?

There is one final wrinkle to this story. Why does Ms. T volunteer at a recovery house? Fifteen years ago, she herself was an addict rescued by a taxpayer-funded drug treatment program. Had society not offered her a helping hand, she might have never developed into the beautiful human being she is today.

So for now, I’ll keep struggling with what the right answer is. I’ll keep challenging my own views every day. And I’ll keep trying to make inroads with Mr. F. *


— Daniel Munoz is a second-year cardiology fellow.
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