Dr. Reisman is assistant professor, Department of Internal Medicine, Yale University School of Medicine and VA Connecticut Healthcare System, New Haven, Connecticut.
Mrs. F., an indigent 70-year-old widowed grandmother, required four different medications to manage her soaring blood pressure. The monthly total was $300, almost half her income. Her anxiety about the cost of the drugs further elevated her blood pressure. She admitted to me that she tried to save money by skimping on doses. Drug samples helped, but they were not enough. As her blood pressure rose, I pleaded with her to take the proper doses, though she was not financially able to do this. She was dating a younger man and was considering getting married. “If I get married,” Mrs. F. told me, “I'll invite you to the wedding.” Instead, I attended her funeral. She died from a stroke, which should have been preventable.
Cases like this are the bread and butter of the first-year medical student course, Professional Responsibility and Ethics, for which I am a discussion leader. An uninsured patient cannot afford medications, tests, or appointment fees. We go through the list of possibilities, from giving medication samples to asking for free care, but the group eventually agrees that the best option is to advocate for a change in the system.
Students, and many physicians, find the concept of advocacy inspiring but nebulous. Do we charter a bus to Washington, DC? Do we meet with our congressional representatives? Do we send letter after letter to the president? This type of advocacy would take a significant amount of time and effort, both of which are in short supply for any medical student or physician. I propose a simpler, quicker means of advocacy: storytelling. Storytelling is an integral part of the practice of medicine. We share stories about our patients to vent our frustrations with the system, to hope for empathy, to remember a patient who suffered. Taking this one step further can pave the road for advocacy. Wait, or don't wait, for a news story that makes you remember a particular patient. Write down the patient's story with the briefest of commentaries. Get people outside of the medical center to learn about your patient's story. Send it to a local paper, a national paper, a student publication, a radio station, or a Web site.
About six months after Mrs. F.'s death, I read a New York Times cover story about the effects of rising medication costs on the elderly. I thought about Mrs. F. and described the story in a letter to the editor. When the letter appeared, thousands of people—including legislators and philanthropists—must have read it. Several people wrote to me and invited me to join local advocacy groups. One woman had suggestions about where patients might obtain discounted or free medications. A conservative Florida radio show host asked me to discuss Mrs. F.'s story on his talk show. Perhaps hundreds of conservative Floridians (an audience I might otherwise not have reached) listened; perhaps their perspectives were tweaked by the story of one patient's devastating experience of inequities in our health care system.
Putting into print the stories that disturb and unsettle us can bring these stories out of the medical center and into the public's eye. This is armchair advocacy—and it works.
Anna B. Reisman, MD