One of my colleagues referred her. He volunteers at the free clinic ten miles away. He asked me if I would see her as a favor. She had no insurance, her knees were giving her a lot of pain, and he knew that I would not charge her.
She is in her forties; at least six feet tall. When she sat on the exam table, she towered over me. She wore a worn out, wrinkled blouse, maybe the best item that she owned. Discolored jeans; no makeup; no effort had been made at taming her hair. She occasionally flashed a tired smile. It was clear that there was nothing this poor soul had looked forward to for months, maybe years.
She lived with her mother, who collected social security and a tiny pension from janitorial work. A daughter and a grandchild shared these tight quarters. When her daughter’s boyfriend had no money, which was a frequent occurrence, he slept in the apartment. The only source of income was her mother and the occasional babysitting job that her daughter could land.
When she was younger, she had also worked as a cleaning lady, or she babysat. She had done well in high school, but an accidental pregnancy kept her from finishing other studies. There had been several men through the years. All of them were mean and abusive, and none of them ever stayed. She had borne two daughters; one of them left when she was 16 and did not keep in touch.
What can I do for you?
“It’s my knees.”
As I lean closer to her, it strikes me how large this woman is. We could not weigh her accurately, because our scale is not reliable past 300 pounds. Years of going up and down steps, and kneeling to clean floors and change diapers, had worn out all of her knee cartilage. She could no longer trust her knees to hold her when she went down steps. The pain was constant. She needed to sit or lie down most of the day.
This is a common story. A small percentage of these patients respond temporarily to cortisone or other injections into their knees, but the only definitive treatment is a knee replacement. But she had no insurance. Even had she been covered, the risk for a knee replacement in a patient this obese is significant. The synthetic materials that we use are not meant to withstand severe loads for many years. Many surgeons will not venture into this arena.
Halfway through the visit I got a feeling that this woman was different. The more we spoke, the clearer it became that she was very articulate. She knew her medical history up and down. She expressed herself clearly and concisely. She obviously understood everything that I said, and she asked good questions.
You’re very smart.
She looked at me like I had just told her that she had three heads.
“Thank you.” Not really a thank you; just something that she felt needed to be said.
Why would this be important? For almost every disease entity the prognosis improves (a lot) as the level of education rises. Part of the reason is obvious: better educated people are more likely to be insured and to follow doctors’ advice. But even after adjusting for these variables, educating yourself is the next best thing to having good genes and not smoking if you wish to live a long and productive existence.
I got excited. Maybe this woman had a chance in life. If we could get her trained, we could help her find a job that would insure her. I visualized her as an able receptionist in a professional office. We could get her to join a gym and sponsor dietary counseling and physical therapy sessions. Her pain level may even decrease enough that she would not need surgery.
I mean it. I do not say this just to make you feel good. You can go to the community college. They will test you to see what you can do best. Then they will tell you which classes to take.
The sad smile came back. A lot of it. As if she really, really wanted me to be pleased with her.
“I don’t have any money for this.”
I will pay for it. Just watching you succeed will be my reward.
“We do not have a car.”
We can find a way. I can reach out to some volunteers; I can see if the state will help.
“That’s very nice of you…” I could sense a “but” coming my way.
“Can’t you just sign my disability forms?”
I explained to her that all I do is provide medical records to social security. I do not make those decisions. I told her that she was 45. If she were awarded disability, for sure she would never exercise or lose weight (because if she lost weight and her condition improved her check would be taken away). I told her that most of us live to be 85. Did she really want to sit on a sofa and do nothing for the next 40 years?
The more I talked, the sadder her smile turned. When I finished my speech, she was almost in tears.
“I can’t move. We have no money for gas. I cannot do this. I worked for my disability; it is not too much to ask…”
The pleas and excuses came in desperate waves. I could see in her face that she thought that I had not heard anything she said.
You can do this. Just go for an evaluation. I will find a way to get you there. I did not say it would be easy. Think of the plusses! Your grandchild will have someone to look up to. He may end up going to college. You do not have to be poor the rest of your life. You want to be able to go to a movie and a restaurant; to own a car…
She looked to the floor. The final sign of surrender. Her eyes closed for a few seconds.
I injected her knees with cortisone. I told her that I could do this until we could find some way to insure her. I asked her to keep in touch.
I still think about her a lot. Maybe I overreached. In retrospect, it was obvious that no one had ever believed in her: not her parents, or boyfriends, or employers; even her daughters. It was unrealistic to expect her to see herself in the future. She had been raised to just get through today. Nothing that your eyes cannot see exists. She was locked in; there is a flashing red light in this room that says “EXIT” in large letters. She does not see it. She cannot see it.
She is one of millions. It is extremely unusual for a person that has been awarded disabled status to go back to work. A large part of this disappointing statistic is due to the fact that most disabilities are permanent. Yet there are many people who cling to the handicapped plates and the monthly (small) check as if giving them up would mean losing their life. Even if there are better alternatives within reach. These people have had a traumatic exposure to the workplace: measly wages, rude bosses, no benefits, no transportation, no security. They do not want to go back. It will take a daunting effort to bring them into society as productive citizens. Whether we are ready to commit to making this change is an open question.