Old Doctors Never Die

They just lose their patients.

It's an old joke, but I am old, and now it applies to me. But, I claim it is not my fault (although everything really is my fault in the grand view).

I have long since lost my patience, particularly with insurance companies, regulatory agencies, and all and sundry entities that inhibit my efforts to provide medical care. But now I am losing my patients. This is sort of God's joke on me, making a fool and a hypocrite out of me.

Let me explain.

Currently I am practicing in a suburb a little northeast of Atlanta. It turns out that there is a large Hispanic population in this area. Further, I happen to speak Spanish, which few doctors do in this area, save those who are Hispanic themselves. The practice that I work for accepts Marketplace insurance (Obamacare), which here is represented by Oscar and Ambetter. Few other established endocrinologists in this area accept those insurance products. I started practicing here about a year ago, due to circumstances beyond my control (I aver). I got barraged with Hispanic patients, almost exclusively Spanish-speaking. There are a pair of sisters from Venezuela who are general internists here, seeing the large population of Hispanic patients. We encountered each other when I began working here, and those sisters have filled my practice with their Hispanic patients. I am their go-to Endocrinologist. Nice to be needed.

I, of course, never enquired about immigration status for any of those patients. I was happy to see them. Now, it appears that at least some of them were illegal immigrants. I saw a patient yesterday who declined to make a follow-up visit as she was losing her (Oscar) insurance policy. I asked why, and she told me she was a DACA recipient and was now excluded from having Oscar insurance. So she was going to look for other insurance and let me know when she would be back. She needed med adjustment for her diabetes, which was very difficult to control, and I was very frustrated.

Patients on my schedule have not been showing up. Most have Oscar or Ambetter, and many of them now seem unreachable. One of them had a critically low calcium level on her labs, and our efforts to reach her about this finding have failed. The calcium level was low enough that it could be lethal. I have been frantic about that. She had an all too interesting medical history. She had had a thyroidectomy in Peru for thyroid cancer, which was a successful surgery. However, the parathyroid glands that control calcium, located adjacent to the thyroid, were destroyed in the surgery (as they occasionally are), with rather severe, permanent, hypocalcemia resulting. Ordinarily this can be controlled with calcitriol and calcium supplements. Her calcium was somewhat difficult to control.

When I first saw her, although I didn't enquire about it, she related her journey to America. She had come through the Darien Gap. She is a delightful person and very religious. She told me she prayed every step of the way. She ran out of her medicine, and by the time she came in to my office, her calcium was critically low, as were her thyroid levels. I am still amazed that she survived. She was sunshine personified in my office, obviously delighted to be here, enthusiastic, happy, hardly able to contain herself. Over several weeks we got everything back to baseline, but her calcium was difficult to control. I then tried to get a newly available treatment for hypoparathyroidism, namely Yorvipath. It took a couple of months as her insurance (Oscar) repeatedly denied coverage. Ultimately, through appeals and a lot of work, we got approval for the medication and started her on it. It worked beautifully, and her calcium levels were normal and stable. In follow-up a month later, however, her calcium dropped to a critically low level. I called her and had her go back on calcitriol and calcium rather than increase the Yorvipath. My confidence in the medication was gone. We tried to get her back in the office to check her calcium levels, but have been unable to reach her. She may be in ICE custody. I would hope they would contact me about her treatment, but I have heard nothing.

Another patient was recently referred for type 2 diabetes on Ozempic and oral diabetes medicines with poorly controlled sugars. Her story was that at age 49, she wanted to get pregnant. I didn't ask why. Generally that is encouraged. Given her age and circumstances, she was seeing a fertility specialist who was proceeding with in vitro fertilization. Ozempic is discontinued during pregnancy, and her A1C was already high, above 8%, not suitable for pregnancy at all. We had to start insulin, basal and prandial, and quickly titrate that to very tight BS control so that sugars would be essentially normal at conception and stay that way throughout the pregnancy. To assist that effort, I ordered a Dexcom CGM system for her. Oscar denied it. I appealed a couple of times, but ultimately had to arrange a "peer-to-peer" (advertised to be a discussion between physicians in the same specialty) call. I was put on the line with a PharmD (not a physician). I explained the circumstances and got a noncommittal response from the PharmD. I basically told her that I could not safely manage the diabetes in pregnancy without a CGM. The PharmD appeared to be unaware of the patient's circumstances, her care by fertility specialists, and the referral to me (endocrinologist) to manage diabetes with the planned pregnancy. Several days later (yesterday) I got a frantic call from the patient's son, begging for the medical records and medication list for his mother, my patient. He duly informed us that his mother had been apprehended by ICE as an illegal and they were in a panic about her care.

An after-the-fact thought was that she might have wanted a pregnancy for an anchor baby, but with an adult son, that seemed unlikely.

Whereas I had been seeing 20-25 patients a day, mostly Hispanic, speaking only Spanish, from all parts of Central and South America and the Caribbean, suddenly I am seeing 10-15 patients, barely half of my usual practice. If it seems the illegal immigration crackdown is wreaking havoc with my practice. Well, I asked for it. I voted for it. And I have supported Tom Homan to a fare-thee-well. I'm living in a Jimmy Buffett Margaritaville. I'm getting what I asked for.

So, when the Democrats say that illegal immigrants are not on Obamacare and won't benefit from the extension of the subsidies (they won't if Tom Homan gets his job done, of course, because they will be elsewhere), I can verify from my medical practice that that is not the case. But I do so enjoy seeing these patients. I am a hardcore devotee of the Hispanic culture, literature, and history. At the drop of a hat, I can give you a better rendition of Jalisco than Teddy Kennedy ever could. And if you want to listen to a recitation of the Argentine literary classic, El Gaucho Marin Fierro, I can oblige. Or a Borges poem. I know, I know, please control myself.

I should have retired 10 years ago, but am still working at 76. But, with Tom Homan on the job, my practice may not survive the year.