It's a typical Thursday afternoon at Mercy Family Medical Clinic in Merced. The waiting room is full. Regular patients mingle with the 30 or so people who have waited weeks to get into a special weekly dermatology clinic.
They've got only a four-hour window to be seen by a skin specialist, Dr. Albert Col. The doctor and two residents must diagnose eight patients an hour. Patient ailments range from eczema to skin cancer.
Col runs a private practice in Merced, but spends most of his time treating patients at similar specialty clinics in Atwater, Mariposa and other rural sites.
At Mercy, Col keeps color photos of some of the most serious cases posted on his office door to show the medical residents training there. One patient walked in with a mummified cancerous growth sticking out of the top of his skull. Another made it as far as the clinic with a cancerous gash the size of his ear on the back of his head.
Dr. Col, this clinic and others in the Valley see the worst of the worst. Many of their patients have gone without necessary care for years. The patients have never been exposed to care that might prevent the worst from happening to them.
Mercy Family Medical Clinic is a "safety-net provider" in Merced -- a nonprofit clinic that cares mainly for the poor and uninsured. Similar one-day specialty physician visits are a way of life for many residents, who know they need to book appointments weeks in advance. The staff is well aware of how desperate residents are for care. On a recent Thursday, a woman showed up more than an hour late for her 2 p.m. appointment. She told the nurse she had car trouble. To spare her several weeks' wait, the nurse decided to squeeze her in that day.
Some specialty clinics set appointments even less often. Right across the street, for example, patients crowd into a waiting room for a pulmonary clinic held once a month. On other days, specialty clinics are set up to treat podiatry or fracture injuries. Almost like circuit-riding judges during California's Gold Rush days, doctors move from hot spot to hot spot, in effect applying a Band-Aid to a sucking chest wound.
Lack of access to care affects people of all walks of life here. Out of the 58 counties in California, Merced ranks 55th for its high diabetes death rate, yet there is only one endocrinologist in the entire county. The number of senior citizens receiving flu shots in Merced -- 58 percent -- is among the lowest in the state.
San Joaquin Valley residents have the least access to physicians per capita of any region in California. On average, there are 302 physicians per 100,000 people in California. In the San Joaquin Valley, the number of physicians plunges to 173.
In many communities, there is no dermatologist, psychiatrist or cardiac surgeon. As a result, residents hobble through life without pertinent care or travel huge distances for it. Cardiologist Dr. Hanimireddy Lakireddy has practiced in Merced for 24 years. When he hung up his shingle in town more than two decades ago, there was no heart specialist. He was the first, Lakireddy said.
Over the years his job has swung from fairly easy to just plain frustrating. As recently as just a few years ago, Lakireddy said he could refer his patients to any one of four cardiac surgeons in town.
Today there are none.
"It is really sad. We really need more doctors, more specialists," Lakireddy said. "Instead of getting better, we really are going the other way."
The Valley is home to a number of persistent social and environmental issues that worsen medical problems.