It's a Wednesday night. A Latino mother with three kids comes through the door, followed closely by a dark-haired woman in modest business attire and an African-American man sporting immaculate Nikes. A woman dressed in pink from her hair-tie to her pulled-up ankle socks maneuvers through the entrance with a cane and sits across from a young woman with spikes on her military-surplus purse and silver studs in both her eyebrows. The tattooed teenager doesn't look up; her eye is on a lanky guy in his midtwenties with shaggy hair and snug corduroy pants.
Patients sit shoulder to shoulder in the lobby.
Behind the front desk, students from the University of Kansas Medical Center squeeze into a physician's office, crowding around doctors who try to get in bites of dinner while doling out advice on how to handle patients.
Out in the hallway, more students lean against the wall, chatting or impatiently twirling their stethoscopes as they wait for open exam rooms.
Slicing through this chaos is Adam Obley.
One minute, the second-year med student is balancing a medical chart on top of a Tupperware container full of brownies as he coaches a patient over the phone about how to take her medications. The next, he's rifling through a drawer, looking for a tape measure or a fetal heart monitor. As he bolts from the triage area to the exam rooms to the back office, he fields rapid-fire questions from other first- and second-year med students.
"Hey, Adam, we can do Department of Transportation physicals, right?"
"Her blood pressure's 165 over 85 should I send her to the ER?"
"Adam, do we have any blood pressure cuffs ... that work?"
Obley explains medical acronyms the way that other 25-year-old guys fire off stats from Saturday's ballgame.
These Jayhawk med students have their own brand of school pride, which shows in the name of their all-volunteer effort: the Jay Doc Free Clinic.
This year, Obley is one of three co-directors. He's the one who arrived early this evening and marked up the white board that dictates the night's lineup, assigning exam rooms and scribbling the names of two or three volunteer doctors if he's lucky who will coach the students with their diagnoses.
The lobby will fill to capacity as more than 50 uninsured people many of them from Wyandotte County but plenty from the Missouri side, too wait for someone to attend to their medical needs.
With the lanky, spectacled look of a future academic, Obley has unrelenting energy and a split-second answer for everything. But on this late-summer night, the man in perpetual motion is sitting perfectly still.
"So the antidepressants aren't working?" he asks a woman on the phone, an increasingly uncomfortable look spreading across his face.
"OK, well, would it be possible for you to come into the clinic tonight? ... There's no way for you to come in? ... OK, well, tell me a little bit more about how you're feeling.... OK, just a minute."
He turns to Sharon Lee, the doctor who, during the day, runs her own clinic, Southwest Boulevard Family Health Care, in this angular, corrugated-steel building in the shadow of peeling grain elevators at the corner of Southwest Boulevard and Rainbow. The Jay Docs work here, a few blocks north of KU Med Center; now that her own patients have left and the Jay Docs have taken over her rooms, Lee has been poring over after-hours paperwork. Obley tells her that he's on the phone with a woman who came to the clinic last week for a urinary tract infection. But the discussion has veered from Obley's explanation of her lab results.
"She says she wants to go to sleep and never wake up again."
Lee takes the phone and leaves the room.
For several seconds, questions ricochet among the students in the office. Does the woman need to go to the emergency room? Should we call the police?
Lee returns a few minutes later and assures Obley that the woman will be fine. Lee says she spent some time talking with the caller about her dead-end relationship and her lack of a job. "It was a mama call," Lee says.
"You're better at that than I am," Obley replies, visibly relieved. "But we did take care of her urinary tract infection."
Tonight, he'll barely have time for a few bites of his Wendy's salad. The potential suicide call is quickly lost in the waves of patients complaining of panic attacks and asthma attacks, heart trouble and hernias.
"How's triage going?" Obley asks second-year student Lase Ajayi as she makes a beeline through a group of students to a closet in the back room.
"Oh, you know," she replies. "Everybody's dying." ast month marked the clinic's third anniversary, but it's a rare student who can still remember Jenni Koontz, who floated the idea of a free, student-run clinic in the spring of 2002. A hundred of Koontz's fellow KU Med students rallied around the idea, securing $60,000 in startup funding from the Association of American Medical Colleges. They approached Lee, who operates a sliding-fee-scale clinic where 40 percent of the patients are uninsured, and easily talked her into allowing the Jay Docs to operate out of her facility on Monday evenings.
The first night, 20 people showed up. Soon, lines started forming outside every Monday. It took only a year for the clinic to expand to two nights a week.
"In the last year and a half, I can't think of a night that we didn't have more patients than we could see," Obley says.
The clinic operates just three hours at a time, so there's no guarantee that every person will receive treatment. Numbers scrawled on Post-it notes dictate the triage order. But as the student doctors are well aware, these patients are willing to wait and take their chances.
About 190,000 residents in the eight-county Kansas City region do not have health insurance, according to a July report commissioned by the Mid-America Regional Council. The Jay Docs serve a tiny fraction of those patients, often turning away as many as they treat.
There aren't many other places for their patients to go. Throughout the metro, free or reduced-fee medical services are available at eight county health departments; another 15 clinics provide general health care services for uninsured and low-income residents.
But Lee says there are barriers to access even at safety-net clinics such as her practice on Southwest Boulevard. Some clinics require daytime appointments, which people can't make because they can't leave work or have kids to take care of, she says. For some patients, even a fee of $10 puts health care out of their price range. Then there's the simple problem of capacity. The KU students quickly learned that referring Jay Doc patients to other clinics, in hopes that they would receive longer-term, consistent care for chronic conditions like diabetes, wasn't doing much good. Instead of establishing relationships with doctors, the patients would sit on waiting lists, often for months.
Forty percent of uninsured Missourians and 45 percent of uninsured Kansans were unable to see a doctor when they needed care in 2004 a low enough number to give Kansas the 11th-worst ranking in the nation, according to an April report from the State Health Access Data Assistance Center at the University of Minnesota.
Adam Leight, a resident in KU's family-medicine unit and volunteer physician at Jay Doc, isn't surprised by such a lack of access. Back in San Antonio, Texas, where he started his medical training, uninsured residents had access to a county hospital system and county-sponsored health insurance. Not so in the City of Fountains. On the Missouri side, uninsured people can seek care at the publicly funded Truman Medical Center, he points out. But in Wyandotte County, residents of Kansas' poorest county per capita have no hospital to serve them.
"Since coming to Kansas City, I've been variously puzzled, saddened and frustrated by the burden of untreated disease in the community," he says.
Because of that burden, the Jay Doc clinic faces a difficult task. As second-year student David Harmon puts it, "Our patient population isn't the normal, suburban, he-has-a-cough, mommy's-here-with-him, everything's-fine type of crowd."
One July night, that crowd includes a Latino woman who has been self-medicating seven months of back pain with pills from Family Dollar. A rash creeps down her legs. In the next room, an obese diabetic recovering from heart surgery applies for assistance to receive the eight medications he needs.
The students try to keep patients cycling through at a brisk pace. They know the woman in the third exam room has been waiting for three hours and has promised her daughter ice cream afterward to try to sweeten the kid's growing impatience. But the Jay Docs are often tripped up by barely adequate resources.
Nick Stucky, a second-year student who handles the Jay Doc's finances, says it costs an average of $3,500 to keep the clinic going each month. Those funds go to the reduced rent they pay Lee, the lab tests they send off-site and the oversized bottles of generic medication that fill a large plastic tub in the back office. Last year, operating costs were covered by a grant from the Wyandotte Health Foundation, and last month the group secured a similar grant from the Health Care Foundation of Greater Kansas City to pay the clinic's operating expenses through mid-2007.
Still, the clinic remains largely dependent on miscellaneous donations a random Wednesday-evening call from KU Med's Department of Psychiatry offering a load of chest tubes, for instance and dipping into Lee's already thin resources. Unless Leight can find a knee brace among the supplies at the bottom of the stairwell, a 64-year-old patient who fell and injured her leg will go without. But one lucky patient will walk away with the last two sample packages of birth control pills that Lee found stashed in her drawer.
As they scavenge for supplies, the students fuel themselves with sugar homemade chocolate-chip scones one night, brownies the next and college humor.
"Hey, Nick, you put that tie on in the dark?" a fellow student asks Stucky.
"Do we know what happened to Mr. 'When I Defecate, I Ejaculate'?" Leight wonders during a brief respite between patients.
Lase Ajayi, a Nigeria native who had childhood aspirations of being an actress, stands behind a fellow student, trying to confuse him by chanting random numbers "37, 86, 42" as he counts pills into a prescription bottle.
"Hey, Adam," she says, leaning against a desk and picking up Obley's cell phone later that evening. "If I stop opening beer bottles with my teeth in front of you, can I have this?"
Obley chuckles, eyes the door.
"Don't you have a patient?" atasha Steele is looking for shaving cream and telling anyone who will listen that she has absolutely no idea what she's doing.
At the end of the hall in the last exam room, a middle-aged man has stacked his camouflage ball cap atop his gray Grumpy T-shirt and stretched out on the exam bed. His lab work shows high levels of potassium in his blood, suggesting possible heart trouble. Steele, a second-year, has been tapped to shave the patient's chest and administer an EKG.
In the hallway, her eyes dart between two doctors looking over the jagged lines on the printout. When Steele returns to the exam room, she's flanked by a doctor who tells the patient he has an irregular heartbeat. The man says he already knows that. In fact, he was on medication for a while.
"But it was rat poison," he adds with the gruff chuckle of a lifelong smoker.
Steele peels the sticky pads off the man's chest as he continues to ramble about rat poison. The doctors decide that he needs to go to the ER.
Steele isn't the only one to point out that, as med students still at the start of their education, sometimes the Jay Docs don't really know what they're doing.
During their first two years at KU Med, students take basic science courses to prepare for their first national board exam. That first test behind them, students move on to clinical clerkships, where they get hands-on experience at various clinics at the Medical Center during their third and fourth years. If they get past a second national board exam after their third year, graduates apply to a discipline-specific residency program that will take up the next few years of their training.
Last semester, KU Med counted 2,615 enrolled students and 786 faculty members. In recent years, as many of 130 of the 170 incoming first-years have volunteered at Jay Doc, getting clinic experience before it's required. During the day, they take classes introducing them to the basics of medicine, such as Human Anatomy I and general pathology. But at night, they treat patients, some of whom have unusual conditions.
Harmon, now in his second year, admits that some of his tasks here are beyond what he has learned so far. To sign up patients for drug assistance programs, he relies on a black binder with page after page listing available medicines. But the alphabetized prescriptions are still Greek to him. "I don't know what 90 percent of these are," he says. "I haven't taken pharmacology yet."
That's why the Jay Docs depend on volunteer doctors.
Problem is, not many doctors are willing to help them out.
Among the 49 doctors on the list of volunteers (almost all of them physicians at KU Med), only eight have consistently taken shifts, says second-year student Ashley Robertson, who is in charge of finding doctors.
"Often times, the doctor won't show up until 7 or 7:30, and the patients have been here since 5," Harmon says. "We've had people say, 'I see you back there doing nothing, screwing around.' And it does look like we're screwing around. But all the rooms are full, and we're waiting for the doctor."
Sometimes even a full roster of doctors can't help.
"Obviously we can't do major surgery here," Harmon explains. "Anything more major than a regular office visit, we only have the resources and relationships to send them elsewhere. But when someone needs an MRI or a high-level X-ray, those are expensive. We found one place where they give MRIs for $500. That's a steal. But $500 for most of our patients is not realistic at all. That's when it really hurts."
It's also not uncommon for the Jay Docs to send their patients to the emergency room. Co-director Claire Zeigler remembers when a volunteer at the clinic sent a patient with a possible intestinal abscess to the hospital. The doctor called ahead, suggested that the patient needed a CT scan, maybe even a procedure to have the abscess drained. Instead, the patient was dismissed.
No matter how many grants the students get to expand their services, no matter how many phone calls they make trying to coax a specialist to see one of their referrals at a reduced rate, the moneyed system always seems to block their efforts. edical school doesn't just turn kids into doctors. It makes businessmen out of them, too.
"Most of our students went into medicine because they want to make the world a better place," says Joshua Freeman, chairman of the KU Department of Family Medicine and a faculty advisor to the Jay Docs. But, he admits, "The system does tend to beat it [that idealism] out of them as they go through the four years into residency."
Classes focusing on the business aspects of becoming a doctor are vital preparation for the next generation of physicians anchoring private practices and staffing major hospitals. Rigorous study schedules keep them busy in the evenings as they cram to make the grades and secure an impressive residency that will launch their careers.
During his first year, Ben Hall assumed that he was just studying himself sick. After all, the workload was enough to give anyone an ulcer.
But just after spring break last year, Hall's stomach pains gave way to bloody diarrhea. His roommate rushed him to the emergency room. Three days later, while lying in a hospital bed in his hometown of Topeka, Hall was diagnosed with ulcerative colitis, a chronic digestive disease characterized by bleeding, pussing sores in the colon and rectum.
"The nurses there on the floor compared it to the pain of childbirth," he says. "I wanted as much Demerol as I could."
He was stabilized after six days in the hospital, but Hall's symptoms returned before the end the semester. This time he was vomiting. By the time he checked back into the hospital, he'd lost 20 pounds and the physicians recommended the Mayo Clinic in Minnesota. Doctors there told him he had two options: surgery to remove his entire colon or a drug called Remicade that would cost $3,000 for each of the infusions he would need indefinitely every six to eight weeks.
Twenty-three years old and living away from home, Hall wasn't sure he would be covered by his parents' insurance. Hall panicked, dreading what might happen if he were forced to pay $45,000 in medical bills. Luckily, his father's insurance plan at the The Topeka Capital-Journal covered Hall's costs.
"But if I was a student without insurance, who knows what would have happened?" he says. Suddenly, the kid who had run cross-country and never come down with much more than an ear infection was feeling a lot like the patients he saw when he volunteered at the Jay Doc clinic.
Now all the theoretical talk he'd heard in lecture halls and the articles he'd read in The Economist, about how the U.S. model of health care is "unsustainable," made sense.
Nationwide, more than 46 million Americans lack health insurance, a number that swelled by more than 1.3 million in 2004 alone, according to the U.S. Census Bureau. According to the Institute of Medicine at the National Academy of Science in Washington, D.C., that lack of coverage kills 18,000 citizens each year, or 50 Americans every day.
In Kansas, where 300,000 residents are uninsured, a July report from the Kansas Hospital Association found that 58 percent of residents called the widespread lack of insurance a major concern.
In Missouri, 700,000 people lack health coverage. An April survey from the Missouri Association for Social Welfare indicated that 90 percent of consumers were concerned about health care for themselves. Among doctors, 76 percent cited "too many uninsured patients" as their top health concern.
Doctors worrying about uninsured patients isn't news. What isn't part of the public discussion is how many of those doctors favor a single-payer national health care program, one in which the government bankrolls medical coverage for all citizens.
Though conservatives scorn universal health care as "socialized medicine," 49 percent of U.S. physicians supported legislation to establish national healthcare insurance, according to a widely cited national study by researchers at the University of Washington and the Indiana School of Medicine in 2003.
Concerned health care professionals organized Physicians for a National Health Program and published an article proposing a single-payer national health care program in The New England Journal of Medicine in 1989. In 2002, KU joined the ranks of a half-dozen universities where students have organized into an offshoot of PNHP called Students for a National Healthcare Plan. Research published last month in Academic Medicine found that two-thirds of first- and fourth-year medical students support a universal health care system.
Last fall, when a professor prompted KU Med students to contemplate solutions to the nation's health care crisis, two of them fell into a lengthy e-mail debate that filled the in-boxes of hundreds of first-, second- and third-year students.
One of the most passionate responses came from third-year Blair Thedinger, who started a special diabetes program at Jay Doc in 2005 and spent two years as president of KU's SNHP chapter. A Prairie Village native, Thedinger argues in favor of a single-payer system, wherein, he tells the Pitch, "being a resident of the U.S. ensures you have medical coverage as does every other developed nation in the world."
He encountered an antagonist in Josh Umbehr, a fourth-year from Alma, Kansas, whose perspective on medicine is based on his conservative politics. He's a fan of conservative think tanks, reads Capitalism Magazine and thinks that liberals overestimate the number of Americans who want Uncle Sam administering their health care.
Umbehr favors the free market. After all, he tells the Pitch, "The government doesn't pay for food, so why should the government pay for health care?"
Umbehr started one e-mail by agreeing with Thedinger: "Like Students for a National Healthcare Plan, I agree we should limit our use of insurance companies. However, that is where we diverge: I believe people should pay for their healthcare."
He went on to explain a cash-only system for primary care, coupled with health savings accounts for catastrophic events such as major surgery. This program, which its proponents have labeled "SimpleCare," also would allow doctors to cash in on the benefits of being a physician namely a six-figure salary.
"Imagine a system where a doc could charge $20 for 15 minutes and make a significant amount more than the average family practitioner $200K," Umbehr wrote in the e-mail debate. "Or, even better, the same doc could charge $10 for 15 minutes and make $100K. Those prices are near 'free clinic' prices. By doing so, this empowers the people and utilizes the forces of a free market to drive the prices lower via competition."
Thedinger wasn't impressed. "While I wholly support their recognition of the fact that private insurance companies are an inefficient middle man that sucks cash out of health care," he shot back in an e-mail, "believing that the health care system can be fixed by simply removing all regulations and allowing doctors to practice in the paradise of free-market policy is a little naïve ... Again, one must ask what this plan does to address the lack of access to healthcare for millions of Americans. Nothing! It provides a way for well-to-do people to get their checkups without the fuss of dealing with an insurance company. It is an inventive way for the SimpleCare folks to make money in the suburbs, but is hardly a model for addressing our nation's healthcare woes."
Umbehr says the often impassioned exchange petered out before the end of the semester. But at the Jay Doc clinic, many of the students say they're inclined to side with Thedinger.
"I find it absolutely unconscionable that we persist in a health care system where the suffering and ill health of others is translated into profit for hospitals, insurance companies and drug manufacturers," Obley says.
He goes a step further, adding that medical schools fail future doctors by not preparing them for political advocacy. Physicians, he says, should be at their city council meetings and lobbying at the statehouse. For Obley, that's familiar ground; he worked on health care policy for Kansas Governor Kathleen Sebelius for two years before going back to med school.
But most of the students at Jay Doc admit that the longer they train, the harder it is to find time or inspiration to do anything outside their studies.
Even Thedinger had to step back this year from his organizing role in SNHP and the Jay Doc clinic so that he could devote his time to clinical rotations in trauma surgery at KU Med. He says he sees rising frustration among both doctors and students. "But people are not taking a unified stance and saying, 'Well, we need to move to this better system,'" he says. "They're just dealing with the status quo on a day-to-day basis."
Which is one reason that scores of patients spend hours in a clinic waiting room just to see someone who doesn't even have a degree yet.
s the Lexapro clock inches toward closing time, it looks like the Jay Docs will have turned away fewer than half a dozen patients this evening.
"So are you going to get us out of here before, like, really, really late tonight?" volunteer doctor Adam Leight asks student co-director Zeigler.
"9:15, Dr. Leight, 9:15," she assures him.
From the other side of the room, Obley plays down Zeigler's confidence.
"Make no promises," he says.
Leight doesn't much care. He gulped down a can of Pepsi and a snack bag of peanuts during the first deluge of patients, and he's still wisecracking his way through diagnoses. Leight is the clinic's most reliable physician; even after a full day at his own clinic, he calls another six-hour shift with the Jay Docs "refreshing."
He says he is inspired by their enthusiasm and enjoys the opportunity to work in an environment divorced from any profit motive.
"Most of them [the students] still have no clue how broken the system can be," he says. "Or, if they do know, they haven't really lived within it yet. They haven't watched themselves become a functioning part of it on a daily basis, metamorphosize like Kafka's worker, as we all do to a greater or lesser extent."
Tonight, Lase Ajayi is looking for a syringe and advice on how to administer her first butt injection.
"It's probably best to reconstitute the stuff out of the room," Leight tells her. "The more people see you play with needles, the more nervous they get. It's best to just walk in there and, you know, whip it out of your back pocket when they're not even looking."
"This'll be a night of a lot of firsts for me," she quips. "First gluteal injection, first urethral swab ..."
"Male urethral swab?" Leight asks. "You used the blue ones, right?"
"Yeah," she says.
"The other ones are like Q-tips," he says, causing the men in the room to cringe.
"What does it feel like?" Ajayi says in a tone that sounds like a set-up to a joke. "Like, how painful?"
"I've never personally been swabbed," Leight says. "But it wouldn't feel good."
"Hey, Adam, you get swabbed every day," Ajayi says, turning to Obley.
"Ask him," Obley says, pointing at an unsuspecting student who walks into the back office at the wrong moment.
"And another thing," Leight continues. "If you like the guy, you should probably reconstitute it with Lidocaine instead of water."
The Jay Docs show no urgency to head home. Kicking back and eating slices of a carrot cheesecake, they chat about their dorm days at KU and debate whether one of them can really communicate with her cat.
"There are times when you just get so into it and the people you work with, that you forget about the rest of your life," Ajayi says.
Before the clinic's next open hours, Harmon will get calls on his cell phone from patients who need help with their prescription assistance programs. On off nights, he'll ride his bike to the clinic to catch up on paperwork.
And he'll keep thinking about the patients he's had to turn away.