Bridging the Cultural Gulf Between Poverty, Medicine

March 20, 1998

Training young doctors about poverty so they can treat children more effectively is the goal of a University of Rochester pediatrician who is organizing a national conference on poverty and health care for children. Ideas from the conference will form the core of a new textbook that organizers hope will begin to affect doctors' attitudes about the patients they serve.

Next week's conference in Washington is an outgrowth of Julius Goepp's training and experience working in inner-city Boston and Baltimore. Goepp often wondered why residents there turned to the nearest emergency room for obviously non-acute cases like bumps and bruises, sore throats, and other infections. Later, as an attending physician and now director of pediatric emergency medicine at the University's Strong Memorial Hospital, new doctors came to him with the same question.

"Why are all these people coming to the E.R. with minor problems? It's a question you hear over and over again," he says. Even though E.R. personnel exist to handle life-threatening, urgent situations, 40 percent of patients they see are non-urgent cases that could have been seen in a doctor's office. Many of these are poor people; Goepp says emergency departments are where most of the nation's more than 20 million children covered by Medicaid get their medical care. Goepp says that oftentimes, physicians and others wrongly view these patients as "abusers" of the health care system, taking up precious resources when they shouldn't.

"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 there are good answers to 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 instruments like nebulizers for asthma, to having their prescriptions pilfered by drug-addicted acquaintances.

Consider, says Goepp, a mother who brings her six-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 brings 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 roused her son out of bed at that hour for a routine exam," says Goepp.

He says there might be several reasons why the woman is acting this way. "She might work the late shift as a custodian 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 waiting for her is a note from the child's teacher 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 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 treat many poor people, Goepp says most physicians receive little or no training about working with people in poverty. Thus they become frustrated and angry when patients act in ways that don't seem appropriate. In addition, he says, physicians often fail to see the incredible strength and resilience of people who live in poverty. Goepp says that preparing doctors to deal with such patients would not only benefit the patients but also ease doctor burnout. He says a good start toward solving the problem is a new curriculum being developed by the Ambulatory Pediatric Association for serving the poor.

At the conference physicians, educators, law-enforcement officers, community organizers, clergy and others will come together to discuss the issues and solutions. Goepp expects about 50 participants, including Sen. Bob Kerrey of Nebraska; Peter Edelman, professor of law at Georgetown University; and Melvin Jenkins, professor emeritus at Howard University College of Medicine. The conference is being sponsored by Georgetown's National Center for Education in Maternal and Child Health, which is associated with the Federal Bureau of Maternal and Child Health.

"Doctors do a great job teaching medicine, economists do a great job describing poverty, and law enforcement officials can discuss the consequences of poverty," says Goepp. "Each of these groups is interested in children and poverty, but they don't talk to each other regularly. We're hoping to begin and sustain such a dialogue."

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