Feb 1, 2010

Poverty Is...

I grew up in Orange County, CA. From there I moved to San Luis Obispo. I always had (more) than enough to eat, school supplies, and clothes that were not only warm but reasonably in style. I had never experienced poverty. Sure, I volunteered at the food bank, collected toiletries for the homeless, filled school backpacks with supplies and send toys overseas, but poverty was not part of my existence.

As a senior in high school, I went on a mission trip to Mexico to play with kids and build a house. My classmates were happily kicking around the soccer ball and drilling nails into a framework, but I remember watching all those kids running around barefoot in a field with rusty nails, and thinking that what they really needed was tetanus vaccinations. It was my first real glimpse into poverty, and gave me a sense of purpose for my future life as a physician.

Fast forward six years. I am now a third year medical student stationed in the central valley of California, my task to learn medicine while providing services to the underserved and poverty-stricken population here. What I've observed is a lot different than what I expected. I had thought that my time here would be a similar experience to that time in Mexico- working hard to provide something good for a family who would otherwise go without, and the people would recognize the service and be thankful. Instead what I've seen is two types of poverty. One is heartbreaking, one is frustrating.

Probably the worst representation of poverty that I've seen here is the car washes to raise money to bury a dead family member. The whole family sets up in a parking lot and depends on the money they raise to pay for the funeral. I can't imagine this grief; that you would be mourning your loved one while soaping a stranger's tires to earn money for a burial. Families of dying patients don't come to the hospital because they are picking fruit and will not make wages without a full day's work. Sometimes they die before their family gets there. Moms with babies, broken down on the side of the road. Parents that don't bring their kids to the doctor for fear of deportation. A man with six black widow bites on his back, from a day of grape picking (they fall out of the vineyards down the workers' shirts) who didn't come in for treatment until his shift was over. Families that share one apartment, one car, one social security number. This poverty is heartbreaking and deeply compels me to do the one thing I am able to do: provide compassionate and quality medicine.

And then there are the people that I tend to think of as selectively poor. A man who cannot "afford" his $4 prescription from Walmart, yet has a four pack per day smoking habit. People that demand that the doctor sign a disability form so they don't have to go back to work. Parents who use food stamps in front of me in line and then put their groceries in the back of their Cadillac Escalade with 26" spinner rims. A 17 year old with four kids whose frame of reference and way of life is to live on a government check. The woman at the clinic who is on MediCal, pays nothing for the $500 IUD I just put in her, and walks out chatting on her iPhone with a Coach bag slung over her shoulder.

I had expected my work here, even though I was in school, to be rewarding. And sometimes it is. But more often than not, I am confused by a population that drives a nicer car than I do to the swap meet on thursday morning, while I go to work. Some of my patients are appreciative of the care they have received, and motivated to make changes in their own health. Most of the time, however, the patients treat me like it is my duty and honor to serve them, and demand a lot in return for nothing. What I'm left with is a genuine desire to help those in need, with a disillusionment of needy people. I feel like my work here matters, but only to a few. I am tired of trying to make changes in people's health who only want Vicodin and a disability form signed by the doctor. I enjoyed working in practices where bills were paid by private insurance; where the patients asked thoughtful questions, were polite to me, and seemed committed to maintaining a healthy lifestyle.

I don't like myself for wanting to work with those above the poverty line. It seems like a failure, like I wasn't good enough of a person to reach out to those in need. But what I've experienced is that you give and give to people who are not invested in their own health and it is an unfulfilling experience for all involved. The truth is, public clinics have a hard time retaining doctors; they come for a few years (possibly for loan repayment) and then move on to a better life. I want to be a doctor who is excited about what I'm doing, who feels like my work has a purpose. I thought the greatest purpose of all would be in serving those who would otherwise not receive quality healthcare, but instead I'm left wondering what might be a better fit for me. In the end, all people need healthcare, everyone gets sick. It's just that some have better access to care than others. I am not content settling only in a comfortable practice with patients that pay their bills on time, but maybe there is a balance between this and the community health center. I'd love to have a practice that is a good fit for me and volunteer for Doctors Without Borders. Is this enough? I don't know. A comfortable, wrapped up ending to this post? There isn't one. Somewhere between my sense of morality, guilt, and desire for an enjoyable practice I'll have to figure out how and where I should practice medicine.


  1. I know what you mean. I routinely see patients who smoke, drink, smoke pot, are on disability and refuse to pay their copay or can't afford to get transportation to the appt. It just pisses me off. They are on medicaid, food stamps, disability, WIC, but have the money to smoke 2 packs a day and drink beer. It makes smoke come out of my ears. Oh and I have yet to have a patient quit smoking because they are pregnant. Selfish selfish selfish. Ok off my pedestal.

  2. Annie, you just voiced my exact frustrations and fears as a teacher. I teach a lot of the "socioeconomically disadvantaged" kids that qualify for free lunch at school and show up without paper or pencils to class, but they all own iPhones and wear designer clothes. Yes, I want to help them learn English and science and improve their outlook on the future. I want to show them that life isn't about poverty and unfairness and that they can empower themselves by learning. But when they get suspended for smoking pot on campus and they call me a F**king B**ch just for telling them to get to class on time I really wish that I taught the upper division elective science classes that only the "good" students take.

  3. I just wanted to comment that I have received so many emails and messages regarding this post- from people of all different professions. Teachers, dietitians, nurses, professors, other student doctors...all of these guys took the time to comment and say that the experiences I expressed seemed to be universal across all helping professions. I hesitated to post this because I worried about being judged, of being perceived as judgmental or uncaring. What I got was an outpouring of stories of patients and students alike who seem to have a sense of entitlement for their care. A friend in the allied health professions wrote that "the lack of desire [for patients] to be an active participant in their own care is totally frustrating." One story I got was about patients who received free bariatric surgery and nutrition counseling, and go on to gain back the weight. Other detailed frustrations are detailed in the above comments. Thanks to everyone who wrote and helped me realize that I am not alone in the struggle and confusion that I experience while working with the underserved.

  4. hey friend!

    i think that people are sinful, and people are selfish, no matter if they are rich or in poverty. don't let the selfish people color your view on poverty. or maybe it just shows you that it's not all black and white. people are flawed human beings. if you worked in a richer area, maybe it wouldn't be as dramatic or easy to see this truth, but it would be there.

    i am glad you are there for the man with the black widow bites, and the people having the car washes.

    pray for the selfish people, and serve them with Jesus' love too, because they need his grace and truth.

  5. I spent the day working with 6th grade teachers and their students in an under-served area of LA. Lots of kids really seemed to want to learn, but more than a few did not seem to care that much. It is always tough when you feel that you are more invested in a positive outcome than those for whom the outcome is intended. Casting pearls...always tricky.....

  6. It is always a joy to work with motivated people and very frustrating to work with people who expect to get better without effort. They may even blame you for a lack of progress. As an SLP, I don't see much of a pattern of who is motivated and who is not, and I seem to see a lot of both. Attitude and motivation seem very individual and sometimes hard to predict. But, then, receiving treatment for a disability is a very individual and personal experience. Working with kids is probably simpler. No one can work the system and gain from having a disability when they are eight.

  7. I am glad you posted this. It is important for each of us to understand our responsibility to each other in this world. I, too, help so many people who take for granted everything they can get. Everywhere we go, we see selfish people, and it is frustrating when we give all of ourselves to them, while they are angry because we did not give more.

    Today, America and the world have been reinvented. We have turned everything instant, easy, and uninvested. We don't look at the future and sacrifice for it. Instead, we do what we want now and hide from what comes next. That is why people expect someone to give them a quick-fix for their problems and then leave them alone. They get angry if they are expected to make a change.

    This becomes most obvious to doctors, lawyers, and other professionals, because they have learned discipline and given up a lot of quick desires for a valuable goal. It is difficult to understand how someone can not care about their future, but the truth is, they don't know how. As a professional and a medical student, so many days, you've woken up and said, "Okay, today I'd like to go to the beach. Oh, wait... I'm a medical student. I have to study." In contrast, most of your patients say, "Today is going to be hard. I need a cigarette!" If you tell them to quit smoking or their baby could have problems, they can't take ownership of those consequences. It WON'T happen to them, but the stress of thinking about it makes them need a cigarette.

    I would like to encourage you to keep pressing on and try to keep your heart from giving up on people. Remember that the work you do may not have a lasting effect on everyone you serve, but it will have an effect - even if you don't see it. You will also find that some of your patients will listen and may change, whether you know it or not. I think you would be surprised to find how many people you really affect. Keep treating your patients and hold onto the hope that the next one (or maybe this one) will actually hear you. If you only have a permanent effect on the people from your blog, who read your blog, or even just YOU, I think your time with "the least of these" was worth every second we are here!