Preventive Care vs Preventive Care

For a community health center, our clinic is able to provide our patients with some pretty extensive and impressive resources.  We have multiple in house interpreters, a nutritionist, a behavioral health specialists, a social worker, and a specific nurse dedicated to educating and helping to keep track of our OB patients.  I am grateful daily for these resources.  It is the key to providing good, comprehensive care to my patients. 

But more often than I'd like, I end up feeling like our patients are still falling through cracks somewhere, somehow.  Last week I had this distinct sentiment as I saw a 50 something year old woman for her annual gynecology exam.  This particular patient had qualified for another critical program our clinic provides, which allows women with no insurance and low income to get pap smears, mammograms, and colon cancer screening at no cost. 

This patient was added to my schedule the same day of the appointment.  Generally, these visits are not squeeze-in appropriate since it is preventive care.  But, my patient was scheduled to get her mammogram the following day, and in order for it to be covered under this particular program, she needed to see the doctor and have her full gyn exam prior to the mammogram.

My medical assistant hustled through the copious paperwork involved with these program qualifiers, presented me with the intake sheet containing the patient's vital signs, and declared:

"The front desk said that they are sorry for adding her on so late, and that you should not address any other health concerns with her today, since we squeezed her in.  They also told that to the patient."

"Umm... ok..." was my skeptical reply, having been around the block a few times with patients and having generally found it difficult to adhere to that practical-sounding though ridiculous rule.

Here is the conversation between me and my medical assistant that followed:
Skeptical and incredulous Dr: Wait... is this really her blood pressure?!  (219/99)

Well-intentioned and hard-working medical assistant: Yes, but the front desk says you can't talk to her about any medical issues today.

Skeptical and even more incredulous doctor: Well, if I don't talk to her about her blood pressure and she has a stroke today, and I'm on the witness stand being asked the question "Dr., why didn't you address the patient's blood pressure that day?" and I reply "because the front desk told me not to" I'm still in big trouble.

I plodded into the room, clutching her vital signs in my hand, desperately hoping it was a typo (Nope, rechecked on both arms!).  Via interpreter, I commence the "preventive" visit.  I tell the patient that I know she is here for a pap smear but that I need to ask her about her blood pressure.  Did she take her blood pressure medication today (already skeptical about this since I had deduced that the patient had not been in clinic since 2011 and had not refilled her bp medication in many months)?  She assures me that she usually takes it daily (unclear how as it had not been dispensed or prescribed in months) but that today she didn't due to a horrible, uncharacteristic headache that she woke up with.

[insert dramatic, foreboding music here]

Was she experiencing any chest pain or shortness of breath?  No, but about 30 minutes ago she started having blurred vision which she has never had before.

[inhale, exhale]

I explain to her that her blood pressure is very worrisome, and that she quite possibly may have a stroke as a result of it, and that she needs immediate attention in the hospital.  I explain this while doing the pap smear.  I know, I know, I'm crazy.  But listen.  The woman wanted her pap smear. And her mammogram the following day (though I figured she might miss that one due to being admitted in the hospital but I didn't want to break too much bad news in one day).  And I had some time to spare with all the interpreting going on.  And you know I like to be efficient.

After the exam was over, and the necessity of a trip to the ER fully explained, I stepped out to let her get dressed and call a family member.  I called the local ER to give them a heads up about her arrival.  She, of course, refused ambulance transfer due to cost ("You better document the hell out of that" was the thoughtful advice given to me by the ER doc with whom I discussed the case.).  But the patient promised that her husband was coming to take her straight there.  I reiterated how important it was, and why such high blood pressure with her other symptoms is so dangerous.  She talked for awhile with the interpreter who then said to me "she wants to know how the pap smear went."

The patient left with her husband and I finished my afternoon clinic, all the while feeling like I was running against a wind machine. 

Spoiler alert: Her pap smear was normal.  She did not show up at the ER, and has no showed for 2 appointments with me. And has blamed lack of insurance and cost of care.

There's preventive care.  And then there's preventive care.  Yes, it is important that patients have access to important cancer screening preventive care services.  But what about other critical medical services?  Will she die of cervical cancer?  Unlikely.  Will she have a stroke or heart attack?  More likely.  Wouldn't it be nice if she had basic medical coverage so she could afford to see me and get her blood pressure medications?  Instead of walking around with her very treatable, untreated hypertension, like a ticking time bomb, moments away from partial paralysis and a big, expensive hospitalization for stroke?