The last straw: A reminder of what happens when patients lack access to care

It was 2:30 p.m. on a Tuesday during our family medicine placement at a local clinic. Having completed a few weeks of the placement, we were deep into the daily routine: history, physical, present the patient case to the preceptor, repeat.

Mr Smith was a new patient to the clinic. His build was rotund, but he had a slender pair of arms and legs. His calloused hands and unkempt facial hair reflected a life of physical labor that had taken its toll over the years. According to his chart, he had recently started an office job. Slumped over in a chair in the corner of the exam room, he seemed reserved, apprehensive, and disinclined to talk to us. We tried to put him at ease with a few opening remarks and questions, and soon, after relaxing, he admitted that he had been neglectful of his health. He couldn’t remember how long it had been since he’d seen a doctor. When asked what brought him in that day he delivered a jumbled account that we pieced together into enough of a clear story about one overriding health concern dating 10 years prior.

He was diagnosed with type 2 diabetes in 2010. He was started on a medication, the name of which he couldn’t remember, but it was too expensive for him to take long-term. He stopped taking it 2 months after being prescribed this medication.

“I have four kids,” he told us, his voice thick with concern. “I felt that the money was better spent on them.” It had been a decade since he had stopped taking this medication, and he had never followed up elsewhere. He came to the clinic because he had been feeling much worse recently, had been reading up on the complications of diabetes, and was seeking advice now on what he should be doing about it.

He first noticed it in his toes—they started feeling numb. Over the past months his vision had also worsened, so much so that he was afraid to drive. In addition, his fatigue and headaches were becoming unmanageable. All these symptoms were putting a strain on his ability to be a father, a husband, and a provider. We then learned that his initial diagnosis of diabetes came about only because he went to the hospital for an unrelated concern. At the time, his hemoglobin A1c, was worrisomely high (more than 11%).

Perhaps he didn’t understand that this number was of dire concern. If not, his constellation of troubling symptoms might have at least made him realize the importance of managing his diabetes. How could he have waited this long to see a doctor? Why didn’t anyone help him back then? And how had he been lost to follow-up? 

He went on to tell us that he had a bad infection in his foot 2 years ago, which had started out as a small sore but then began to eat away at his flesh. He didn’t realize he had a crater in his foot until his wife pointed it out. He was now truly scared. 

We proceeded to examine his foot and detected no edema—a cardinal symptom of diabetic foot—but it was clear to us while manipulating his toes that he had lost considerable sensation, likely due to peripheral neuropathy. Gross examination also revealed a scar leftover from the foot ulcer his wife had discovered. 

We expressed our grave concern that he had let matters get this bad. Had he fallen through the cracks, or had some social issues contributed to the state of his health? These sequelae had been entirely preventable. In response to us asking what made him wait 10 years to see a doctor, he shrugged and remained silent.

At this point, our thoughts about social issues coalesced more firmly. We started to put together why Mr Smith had waited so long to seek care. He was a husband, a father, and a household provider who put his family’s needs before his own. He was scared to hear the truth, perhaps because of the way it might impact his employment. Over the past decade, he’d suffered from unstable employment, drifting from one odd job to the next. Likely, he was afraid to take sick days. 

It had taken him a good deal of courage to come into the clinic. With a complete medical history taken, we thanked Mr Smith for answering our questions, then left to present our findings to our preceptor, Dr Roberts. When we returned with Dr Roberts he reassured Mr Smith that he would help him to the best of his ability. 

Mr Smith was a reminder of what happens when patients lack access to a family physician, and when financial and social stresses get in the way of seeking care. Dr Roberts ordered laboratory tests, started Mr Smith on metformin, and described programs and various eligibilities that might help him with the cost of the medication. We scheduled a follow-up visit in 2 weeks to ensure that he wouldn’t be lost to care this time. Although he had allowed his symptomology to reach the last straw, we felt relieved that he was finally getting the care he needed.
—Paul Rooprai, BHSc
—Neel Mistry, BSc

This post has not been peer reviewed by the BCMJ Editorial Board.
Mr Paul Rooprai and Mr Neel Mistry are medical students at the University of Ottawa.
Mr Smith and Dr Roberts are pseudonyms used to protect the confidentiality of the patient and preceptor, respectively. 

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