From Harvard Medical School, Boston, and the Department of Anthropology, Harvard University, Cambridge - both in Massachusetts (G.K.); and the Department of Anthropology, the Center for Social Medicine, and the Semel Institute of Neuroscience, University of California, Los Angeles, Los Angeles (P.B.).
N Engl J Med. 2019 Jan 17;380(3):205-209. doi: 10.1056/NEJMp1811542.
Mr. M., an uninsured, 44-year-old Puerto Rican man with chronic back pain, diabetes, hypertension, asthma, and a history of incarceration presented to a free clinic with acute exacerbation of back pain triggered by carrying heavy loads of trash at work. A premedical student acting as his health care advocate accompanied him. Mr. M. was hesitant to seek health care because he had no health insurance and mistrusted institutions as a result of his extensive negative experiences with the criminal justice system. He was visibly nervous in the unfamiliar institutional environment of the clinic, which had no Latino staff and was located in a middle-class neighborhood far from his home. The advocate reassured him in Spanish that the doctor was trustworthy and urged him to speak frankly about his health problems, including his challenges in obtaining medication. Embarrassed, Mr. M. reported that during recent back-pain exacerbations he occasionally resorted to purchasing one or two 5-mg oxycodone tablets in the open-air drug market operating on the inner-city block where he lived. The physician gave Mr. M. ibuprofen and a prescription for five 5-mg oxycodone tablets, enrolled him in the clinic’s diabetes and hypertension programs, and scheduled a follow-up visit. Mr. M. never filled the prescription and did not return to the clinic, despite repeated entreaties by the advocate both in person and over the phone. Mr. M.’s pain had eased, and he claimed to be managing his diabetes, hypertension, and asthma by splitting medication with insured family members. To stretch their supply, they rationed their doses for use only on the days when they “felt symptoms.” Finally, 8 months later, Mr. M. admitted that he had not dared fill his prescription or return to the clinic for fear of being rearrested after admitting to the doctor that he had purchased oxycodone illegally.
M 先生是一位 44 岁的波多黎各男性，没有医疗保险，患有慢性背痛、糖尿病、高血压、哮喘和监禁史。他因在工作中搬运重物而导致背痛急性发作，来到一家免费诊所就诊。一位医学生作为他的医疗保健倡导者陪同他。M 先生因为没有医疗保险并且由于他在刑事司法系统中经历了许多负面经历而对机构产生了不信任，所以一直不愿意寻求医疗保健。他在诊所这个陌生的机构环境中显得非常紧张，诊所没有拉丁裔工作人员，而且位于远离他家的中产阶级社区。倡导者用西班牙语安慰他，说医生是值得信赖的，并敦促他坦率地说出自己的健康问题，包括他在获得药物方面的挑战。M 先生感到尴尬，他报告说，在最近背痛加剧期间，他偶尔会在他居住的市区街区的露天毒品市场购买一两片 5 毫克羟考酮片。医生给了 M 先生布洛芬和五片 5 毫克羟考酮片的处方，让他参加了诊所的糖尿病和高血压计划，并预约了复诊。M 先生从未服用过处方药物，也没有回到诊所，尽管倡导者亲自和打电话多次恳求他。M 先生的疼痛已经缓解，他声称通过与有保险的家庭成员共享药物来控制他的糖尿病、高血压和哮喘。为了延长供应，他们只在感到症状的日子里分配剂量。最后，8 个月后，M 先生承认他不敢服用处方药物或返回诊所，因为他害怕向医生承认自己非法购买羟考酮后再次被捕。
