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Wednesday, Dec. 03, 2008

On the front lines, a call for reinforcements

One doctor sees local med students practicing here

The man from the Congo came to Dr. Silvia Diego's Modesto clinic with seemingly straightforward symptoms: a fever, a cough. But what appeared to be a simple pneumonia did not ease as quickly as it should, and soon the man was on a hospital ventilator, his condition worsening fast.

"I knew he needed a specialist. He needed a pulmonologist," said Diego, 43, chief medical officer for Golden Valley Health Centers, a not-for-profit network of 26 clinics in Merced and Stanislaus counties.

So Diego contacted the pulmonologist on call. The doctor didn't come. The patient had Medi-Cal insurance, and the pulmonologist — like a number of other doctors in the valley — didn't take Medi-Cal.

Diego is a slight woman, just 5 feet 2 inches tall, with dark hair pulled back from her expressive face. She typically speaks of her patients with passion, but when she remembers the man from the Congo, nearly five years later, her voice still swells with emotion.

"I did call the pulmonologist personally, and asked him, ‘Please, can you come see the patient? I don't know what I'm doing with this patient. I know he needs help.'"

After practicing family medicine for 14 years in the San Joaquin Valley, Diego is all too familiar with its shortage of specialists, especially those willing to treat the residents who rely on state Medi-Cal insurance for the poor.

She has seen Medi-Cal patients with a fracture transported to another hospital because an orthopedist could not be located to treat them. She used to struggle to find specialists to see children in need of simple procedures -- tonsils removed, tubes placed in ears — who were forced to seek treatment two hours away. She negotiated with a group of specialists who now work with her young Medi-Cal patients in the Modesto clinic.

A native of tiny San Joaquin, near Fresno, and the daughter of farm workers, Diego would have been a likely candidate if UC Merced was around in the 1980s.

Instead, she did her undergraduate work at Cal State Fresno and went to Stanford University School of Medicine as a National Health Service Corps scholar, receiving three years of tuition in exchange for her promise to return to the Valley for three years to practice. The federal program grants awards to students who agree to work in a region under served by physicians. Diego would have returned anyway, she said. She strongly backs plans for a UC Merced medical school, saying it could mean more primary care doctors and specialists for Valley communities. She hopes that some students will train right here in her clinics.

"We certainly currently feel that there is definitely a double standard -- that in urban areas, patients may be receiving different care than our patients here in the Valley."

As Diego saw patients at a Golden Valley clinic in Modesto in late November, late last month, a nurse noted that she has cared for four or five generations in a single family. Two bulletin boards outside the examination rooms are covered with baby pictures that resemble hundreds of tiles in a pastel mosaic.

"My passion is delivering babies. I love to deliver babies. In the middle of the night. In the day," Diego said, her face glowing. She has four children of her own; the oldest is 24, the youngest, 3.

As a primary care physician, she cares for the dying, too.

That is why she called the pulmonologist repeatedly and offered to pay out of her own pocket for him to come treat the man from the Congo.

"Unfortunately, the provider didn't come," she recalled. She appealed to hospital administrators and the insurance company that provided the patient's Medi-Cal coverage. But she couldn't find help.

"The patient did unfortunately die, after five days in the hospital," she said.

An autopsy would reveal the man, weakened by tuberculosis, was suffering from Valley Fever, a disease caused by fungi imbedded in arid alkaline soils like those in the San Joaquin Valley. In a letter to hospital administrators, Diego would question how the man could have been left without expert care.

"The sad part to me was that he was a 38-year-old, he had a teenager and he had a 10-month-old baby. He just didn't have access," Diego said recently.

"It took me three weeks before I could walk into that hospital without crying."