The Rochester Review, University of Rochester, Rochester, New York, USA
Children who live in poverty experience health and illness in different ways than do more fortunate children," says Julius Goepp, director of pediatric emergency medicine at the Medical Center's Strong Memorial Hospital.
"We need to do a better job of teaching our young physicians and other health care providers the 'art part' of dealing with people in poverty," says Dr. Julius Goepp (above), the Medical Center's director of pediatric emergency medicine. The corollary, he adds, is that "health care providers are often unaware of this different experience, and the resulting conflict in point of view contributes to the pervasive misunderstandings and frustrations experienced by both care givers and those they serve."
When Goepp was a young pediatrician working in the inner-city areas of Boston and Baltimore, he often wondered why so many of the local residents habitually turned to the nearest emergency room for obviously non-acute cases like bumps and bruises, sore throats, and other minor infections. Later, when he became an attending physician, other new doctors went to him with the same question.
" 'Why are all these people coming to the E.R. with minor problems?' That's what you hear over and over again," he says.
Even though E.R. personnel exist to handle life-threatening, urgent situations, some 40 percent of the patients they see are non-urgent cases that could have been taken care of in a doctor's office.
The emergency department, Goepp says, is the place where most of the nation's more than 20 million children covered by Medicaid get their medical care. Too often, he says, the parents who bring them there are viewed by doctors and fellow clinicians as "abusers" of the health care system, taking up precious resources when they should know better.
"Everyone is frustrated when people show up in the E.R. with illnesses that are not serious," says Goepp. "It's only with maturity and understanding that you begin to realize that more often than not there are good reasons why this happens."
Goepp rattles off a long list of scenarios that can affect the health of poor children, from the inability of their parents to afford a healthy diet, to lack of electricity to run medical appliances like nebulizers for asthma, to prescriptions being pilfered by drug-addicted neighbors.
Similar problems send people to the E.R. when others would consult their primary physician: no insurance, lack of transportation (ambulance rides are free, i.e., paid for by the system), no money to fill the prescription that would have prevented the illness from becoming acute, weird working hours. Any of these might be the culprit.
Consider, says Goepp, the mother who brings her 6-year-old son into the emergency room at 3 a.m. because he has ringworm of the scalp--a small, local infection that he's had for several days. The mother wants him treated immediately and takes him to the closest E.R.
Often this woman would be immediately labeled by the triage nurse and the doctor as an abuser of the E.R., and they'd wonder why she'd roused her son out of bed at that hour for a routine exam," says Goepp.
But, he suggests, there might be logical reasons why the woman is acting in this way. "She might work the late shift at a nursing home and doesn't get off work until 11:30 p.m. Then it takes her four bus rides to get home by 2 a.m., and there waiting for her is a note from the child's teacher saying that her son can't get back into school until he is looked at by a doctor. If mom gets public assistance that is tied directly to her child's attendance at school, the situation now becomes an economic emergency.
"In her eyes, she is being a good mother by bringing him to the hospital immediately, yet she's met there by people who castigate her for that decision. They think she is either inconsiderate or stupid--an abuser of the health care system.
"It's that attitude--that the poor act in an irrational fashion--that I hope to change. The poor act according to a set of rules that are very rational in the world they live in. Those of us who take care of their health have an obligation to learn what those rules are."
Even though most doctors are trained in large cities where they are expected to treat a great many people in poverty, Goepp says they receive little or no help in learning how to work with them effectively. Thus they become frustrated and angry when patients act in ways that seem inappropriate. In addition, he says, physicians often fail to see the incredible strength and resilience of people who live without the advantages most of us accept without a second thought. Preparing doctors to deal with such patients would not only benefit the patients, but would also help the physicians by easing burnout.
"We need to do a better job of teaching our young physicians and other health care providers the 'art part' of dealing with people in poverty," he says.
As his contribution toward solving the problem, Goepp is editing a comprehensive textbook on children's health care in urban America. A volume that calls upon the disparate expertise of professionals in many different fields, it will, he hopes, begin to affect doctors' attitudes.
As a preliminary step, he obtained funding from the Bureau of Maternal and Child Health and Georgetown University's National Center for Education in Maternal and Child Health for a national conference to consider the complex issues to be covered. Held in Washington, D.C., in the spring, the gathering drew an eclectic group of some 50 physicians, educators, law-enforcement officers, community organizers, clergy, and others to discuss issues and solutions in what he calls a "trans-disciplinary approach" to the problem.
Doctors do a great job of teaching medicine, economists do a great job describing poverty, and law enforcement officials can discuss the consequences of poverty," he says. "Each of these groups is interested in children and poverty, but they don't talk to each other regularly. Through future colloquia and the eventual publication of the textbook, we're hoping to begin and to sustain just such a dialogue."
Tom Rickey is senior science editor for the Office of University Public Relations. His most recent article for Rochester Review, on Nobel Prizewinner Steven Chu '70, appeared in the Spring-Summer 1998 issue.
Copyright 1998, University of Rochester
