By Stefanie Flippin DPM; Associate - American Academy of Podiatric Sports Medicine, American Board of Foot and Ankle Surgery, American College of Foot and Ankle Surgery; Certified VDOT Running Coach; High Performance Endurance Coach with Lift Run Perform, Professional Runner for HOKA
I can still hear my grandfather's cries of pain and wincing in my mind, even though he passed away twenty-six years ago this year. I can still see my adoring grandmother rushing to his side, bringing warm water for him to sip on - and a litany of medications meant to treat his failing heart, pancreas, and kidneys. My grandfather was eligible for a heart transplant, but he quietly waived the opportunity, stating someone younger and healthier would benefit more. He was sixty-four years old when his heart gave out, on my seventh birthday. It was the first time in my life I felt like my own heart was shattering.
My grandfather was eligible for a heart transplant, but he quietly waived the opportunity, stating someone younger and healthier would benefit more.
My grandfather, half Japanese and half Chinese, was adopted as a young child by a Chinese-speaking couple in Los Angeles, California, so that he could escape being sent to a Japanese internment camp. Growing up, I spent every weekend with my grandparents, and I have the fondest memories of going hiking, camping, gardening with my grandma, and learning the wildest things from my grandfather. By wildest things, I mean - my grandfather was a world-famous puzzle maker and magician and is still extremely renowned in that arena. He was also a professor, teaching the very brightest minds in San Diego, where I grew up. It's hard for me to express just how much of an impact my grandfather had on my life because every single quality about me, every aspect of my personality, and every career path I have chosen is centered around him.
My mom encouraged me to spend every possible moment with him because she knew we were on borrowed time. His doctors told him he'd never live to see me born. He held on for eight more years, bestowing me the Chinese name: Golden Heart, after observing what he called was a wealth of empathy for other humans and their pain. It was never really a question if I would go into medicine or not. I knew in my heart, since the day my grandfather died, that I would. My passion in life has always been to help others - to help them find and be their very best selves. This passion is something I know all healthcare providers have, but I recognize this passion can become quite jaded and clouded in our current world, especially as we face the enormity of decisions like the recent overturning of Roe vs. Wade.
It has been difficult for me to confront the fact that practicing medicine in 2022 is less about actually practicing medicine and more about jumping through insurance hoops, addressing the lack of accessibility and glaring disparities for my BIPOC and LGBTQ patients.
The continual emphasis on retroactive, "cost-effective" care vs. preventative care drives the long-term costs skyward, while the preventative approach often yields an improved patient quality of life while saving money over time. This is the constant fight providers face with insurance companies.
I don't want to sound beaten down though - each day when I get to my office, I begin the day with the same principles and goals instilled in me as a child. This means giving each patient the empathy and time they deserve, and need, to walk me through all they have been through leading up to our encounter. Most patients I see have been rushed through prior appointments, and often I'm a second, third, or fourth opinion.
The most consistent feedback I receive is that I actually took the time to listen; this is the main reason I knew I had to open my own practice to be able to provide treatment in a manner that is consistent with my beliefs about medicine. In other words, to avoid a largely profit-driven system that centers around monetary gains, such as working as an associate under a partners demands, or providing services in a way that a major hospital system would place stipulations on (adhering to productivity standards that often aren't patient-centered.)
That said, I will always choose to think that most everyone that went into healthcare did so for the right reasons. Many practitioners carry enormous amounts of student loan debt and must balance the significant (unpaid) time demands of the work week that go into charting and performing peer-to-peer reviews: arguing with insurance companies on the patients' behalf for necessary interventions. This constant churning is true for the majority of my colleagues as well, and the pressure continues to mount. It's not so much that we as providers are being forced to conform to what insurance companies are dictating, but these trends act more as a barrier in finding ways to subsidize costs for patients if their insurance company decides they won't cover what's needed.
Working as a private provider, I am sometimes able (depending on the specific procedure) to cut out surgery center or hospital fees since that typically constitutes the bulk of a medical bill. For example, in a recent review I performed on invoices from a surgery center I work with, my own fee for the surgery itself constituted about 25% of the patients’ entire bill. Creating this model for a private practice is costly and requires things like an in-office surgical suite, the surgical equipment that comes with it, and of course, the liability. However, by providing this as an option, I can alleviate at least some of the financial strain on my patients.
I won't pretend that I know what it will take for the US to have a healthcare system that truly benefits every human. Still, I do know that I was never driven to go into medicine for the potential to maximize my income.
I have colleagues reach out who explain how they've made such a big difference transitioning to a cash payment system, which allows them to cut out insurance companies and charge fair prices for their services. This makes total sense, and we would all do this in an ideal world; however, this model only works in a very specific demographic and I am left torn on which model would serve the greatest number of communities that would benefit from affordable access to healthcare the most.
Many of my patients don't have the cash on hand and rely on government-funded programs like Medicaid, Medicare, and state-specific programs for coverage. Others are battling many different health conditions that they rely on meeting their deductibles (despite being exceedingly high) in order to survive for the remainder of the year, as there's no way they could afford the cost of their pharmaceuticals out of pocket. Offering patients cash discounts when you are in contract with their insurance company is not an option, as that's considered insurance fraud and puts the provider at significant risk when it comes to audits.
Each year that goes by, especially since the COVID-19 pandemic, states have been approving increases in malpractice insurance that those companies then enforce on their customers (the providers). Concomitantly, each year the Medicare fee schedule, which dictates what providers are reimbursed for and what insurance companies follow as a guide, seems to dip lower and lower. Insurance companies pocket around 30% or more of what the provider bills. And while I can only speak for myself and my practice, I refuse to "make up" for that loss by charging my patients more. As everyone knows and has been impacted by, inflation continues to reach astronomic levels. The reality is that I am only touching on the very recent, specific impacts I have personally experienced. Many other facets, including low pay yet excruciating hourly demands on our registered nurses, leading to burnout, and the people we need the most in healthcare, are leaving.
State-funded programs serve large numbers of Latinx, Native, and Black communities in my region-further increasing the already omnipresent disparitiy across the board.
Recently, a state-funded program I was a part of decided at the corporate level to cut my services. When I probed further for a reason, I was informed that it simply had to do with saving money. In other words, you take too much time; you're doing too much as a specialist and recommend too many things. It's nothing new and certainly not surprising. These state-funded programs serve large numbers of my region's Latinx, Native, and Black communities.
Restrictions on healthcare services and locations where these communities can receive care further increases the already omnipresent disparity in healthcare access. The basis of medicine is ensuring equal access to it. As a provider, a critical part of the oath I took is the consequential responsibility to protect the communities I serve. Laws that limit healthcare directly negatively impact our most vulnerable communities and this is a grave injustice within our healthcare system and country.
As mentioned previously, I am often a second, third, or fourth opinion for the patients I see. The many times a young family member, often acting as a translator, has told me their parent, grandparent, or sibling encountered discrimination is far too many. Their recounts of how they were made to feel inferior or uncomfortable about their health are unacceptable and something I have no problem with reporting to the state.
Many of my Latinx and Native patients tell me they were told, "You have diabetes. You need to cut out sugar and change your diet." Telling someone to just "change their diet" has significant implications and undertones, as traditional meals and specific foods are a central part of many cultures.
In general, there is just an enormous lack of a holistic approach to healthcare. For example, many of my Latinx and Native patients tell me they were not provided with a referral to a registered dietitian, and they were given no tangible education on how to implement these dietary changes - simply to just cut out the bulk of their meals. Being a responsible and thorough healthcare provider means referring patients to specialists and ensuring a team approach.
An added layer of compassion and education is needed on the provider's end, considering that traditional meals and specific foods are a central part of many cultures. Telling someone to just "change their diet" has significant implications and undertones. I serve a number of trans patients in my community, and the stories are the same—similar encounters where they did not feel comfortable or heard in various healthcare settings. This world is challenging enough. Patients' trauma and concerns need to be taken seriously. It is the responsibility of all healthcare providers to ensure that those with voices that are so often suppressed are heard and valued.
I want to underscore that I am optimistic and certainly not dogging on every aspect of healthcare. Many wonderful practitioners share the same sentiments as I do. We're living through a period of cultural shift when we are all confronting decades of silent discrimination that the system was constructed around. I hesitate to say that the system is broken, as the longer I am steeped within it, the more I see that it was carefully designed this way.
I often feel my words here lack meaning, as I am not presenting a clear solution. But the more I think about it, the clearer the solution becomes.
In my own sphere, I will continue to take the Hippocratic oath as seriously and to heart as I did a decade ago, but with the added wisdom of being out in the world as an attending physician. This means doing no harm, yes, but there is so much more to that promise.
It means protecting my patients to the very best of my ability by creating a safe place to speak freely about their health and lives. It means standing up for them and not being afraid of the consequences of doing the right thing. It means taking the time each unique encounter deserves to ensure that every question is addressed and the patient leaves feeling educated and empowered about their health. It means protecting my vulnerable communities in every possible way, in a country that has become complacent in the shameful widening gender, racial, and socioeconomic gaps within healthcare and beyond.
"Our greatest strength as humans is our empathy for one another" ~ Stefanie Flippin DPM
The goal for my patients and every human shouldn't be to just get through the days - it should be to live and thrive. While there are struggles and flaws within the healthcare system that must be addressed daily, the best we can do is remember that life has and will always be about genuine human connections. Our greatest strength as humans is our empathy for one another.