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Learning to Take Steps Forward

Kuo, Scott

doi: 10.1097/ACM.0b013e31816bf093
Other Features: Teaching and Learning Moments

Dr. Kuo is an intern in internal medicine, Cooper University Hospital, Camden, New Jersey.

Continuity of care is a principle that many medical school curricula have incorporated, including my alma mater, Robert Wood Johnson Medical School. The Adult Health Outreach Project (HOP) is a student-run clinic that allows third-year medical students to provide free health care to patients with no medical insurance. My patient, Nancy, whom I treated over the course of one year, was a relatively healthy woman; however, she did complain about worsening knee pain for the past two years. My experiences with Nancy illuminated clinical pathways, ethical dilemmas, and challenges that will shape my practice of medicine.

On our first visit, I decided that she needed an MRI of her knees. I suspected that she had severe osteoarthritis; however, I had to make sure there wasn’t any concurrent damage to her ligaments. MRI results confirmed extensive bilateral knee damage. Knee replacements were needed and an orthopedic appointment was scheduled. After obtaining a bilateral knee series, I went to see the orthopedist. I learned that a total knee replacement cost about $10,000 so I was hoping for any help that he could provide. I told him about the Adult HOP clinic, and that this patient could not pay for the surgery. After reviewing the x-rays, without hesitation he scheduled the operation in three months.

During the meeting with the orthopedist, the intersection of medical student learning and cost containment became apparent. If the x-ray showed advanced degenerative disease, the only thing the MRI would add was the finer details. Here, I learned a critical lesson: a $30 dollar x-ray was sometimes sufficient to diagnose the patient.

Two main issues remained: the surgical clearance and the postoperative care. The surgical dental clearance was problematic. My patient needed extensive dental work and the dentist was incredibly overbooked. This was the first time I had to personally visit a provider to advocate for a patient’s situation, and the dentist agreed to fit Nancy into the schedule. Furthermore, Nancy’s postoperative rehabilitation was complicated by her lack of insurance. Unable to pay for the normal inpatient rehabilitation, Nancy would be sent home immediately following her hospital stay. In order to compensate for this alteration in her care, I had to learn the basics of physical therapy from the PMR physicians so that I could provide physical therapy at my patient’s home.

Shortly after the surgery, I was on vacation with my roommate when Nancy called me about disability paperwork. My roommate was in disbelief that I gave my number to a patient; we debated the division between doctor and patient. Since HOP doesn’t have an on-call service, we stay connected through cell phones. I understood my friend’s concerns, but I had decided that the patient comes first.

Treating Nancy taught me many lessons in medical knowledge and patient management. The contextual learning related to engaging complex delivery systems, each with their own forbidding mountain of paperwork and socioeconomic issues, educated me in ways no textbook or lecture could.

With the combined efforts of the orthopedist, the hospital, and the HOP clinic, we were able to perform something exceptional—with limited resources and large costs, we obtained bilateral knee replacements for an uninsured patient. Recently, I spoke with Nancy. She was climbing stairs, and her pain was considerably reduced. I did not share with Nancy that she helped me climb important stairs as well. Yet through it all, I was able to take part in the continuum of my patient’s health care. I served my patient and community while learning lessons that transcend individual clerkship boundaries.

In accordance with HIPPA, an alias was used to hide the patient’s name.

Scott Kuo

Dr. Kuo is an intern in internal medicine, Cooper University Hospital, Camden, New Jersey.

© 2008 Association of American Medical Colleges