Beyond Assumptions About Access and Affordability
I am writing in response to Kristen Massey’s response to Jonathan R.C. Green’s letter regarding health care access and cost [Clinician Reviews. 2010;20(3):5; see also Clinician Reviews. 2010;20(1):2]. I live and work in New York City, and I have worked in federally funded clinics as well as private clinics. This “access” to quality medical care at no or low cost is questionable. I have yet to see a patient who does not have the ability to pay get any free medical care. For those who can pay a little, that little is too much for them.
Unless Ms. Massey has had to face utilizing these services, which she states are so affordable “in almost every community across the country,” it’s impossible for her to make that assumption. I have learned to see some things as just advertisement. The examples that Ms. Massey shares regarding the fee schedule of $45: Does that include if someone needs to see a specialist? I have had many patients who were seen for primary care but needed a cardiologist, and there was nothing we could do for them. Some people do not qualify for Medicaid, but are still considered poor.
This is a great country, but for millions, medical care is not “quality,” or even available. Try walking in the shoes of these people before making these assumptions.
Diana Wint, RN, MSN, FNP, New York, NY
Kristen Massey’s statement that “In almost every community across the country, one can easily find free or low-cost health care clinics” is the most incredibly naive statement I have ever heard from a nurse!
She draws this conclusion by sampling one community, which she calls the “town” of Evansville, Indiana. With a population of 118,000, Evansville is clearly a big city to most of us. It takes a fairly large city to be able to provide low-cost clinics. Rural communities count themselves lucky to have any resident health care providers.
Massey clearly doesn’t understand what it is to be the working poor, where people are constantly shuffling which bill they can put off paying so that the electricity won’t be turned off and they can put food on the table. I suggest she call up a rural public health nurse and follow her on her rounds and see just how much free and low-cost health care is out there!
Helen Wootton, RN, MSN, FNP, Moscow, ID
Ask the Derm Guru
Thank you for the interesting DermaDiagnosis case in the March issue (Clinician Reviews. 2010;20:3). It is a great and intriguing article that prompted two questions for the department editor, Joe R. Monroe, MPAS, PA-C:
1. Have you ever seen topical calcineurin inhibitors used on the actual eyelids or lid margins?
2. Why is oral tetracycline advisable for this condition instead of doxycycline?
Thank you for your help and interesting advice.
Lisa Ross, RN, FNP, Redding, CA
Lisa, here are the answers to your questions:
1. Topical calcineurin inhibitors, such as tacrolimus or pimecrolimus, are perfectly good alternatives for treatment of eyelid dermatoses. I freely admit that I use the topical steroid preparation mostly because it works so well that I’ve never had a reason to change. I would never give them to a patient whom I thought I couldn’t trust to use them correctly.
2. Doxycycline would be a completely acceptable alternative to tetracycline from a therapeutic standpoint. But for this particular condition, tetracycline works quite well, is less expensive than doxycycline, and, taken properly, causes less stomach upset, in my experience. I have patients take tetracycline with food (as long as it is not calcium-rich), which helps to avoid gastrointestinal complaints while still ensuring absorption.
Joe R. Monroe, PA-C, MPAS, Oklahoma City
A Few More Words About Haiti
I would like to present a different perspective on what was happening on the ground in Haiti during the first weeks following the earthquake. I was there with DMAT CA-6, arriving in Port-au-Prince three days after the earthquake.
In her editorial on Haiti (Clinician Reviews. 2010;20:cover, 18-20), Marie-Eileen Onieal stated, “In the US, relief efforts are coordinated through the White House, yet the bottleneck at the US-controlled Haitian airport seemed a contradiction to coordination.” The US took full control of the airport three days after the earthquake, following utter chaos at the airport and near mid-air collisions in the airspace around the airport. The overflow of planes was diverted to other airports.
At take-off, the pilot of our plane explained that in recent flights to Haiti he had been forced to circle for two hours waiting for his chance to land. He had seven hours’ worth of fuel on board. The flight down was 2.5 hours, and he needed fuel for his return trip; there is no jet fuel available at the Haitian airport. Our pilot told us that if he had to circle for close to two hours, he would have to bring us back to the US and try another time. Yes, there was a bottleneck. But that was the reality of the airstrip.