My patient had onychomycosis – toenail fungus.  Not a devastating disease.  The treatment for this fungus is a 12-week course of terbinafine.  About $50 for a month’s supply … $150 for 3 months.  Terbinafine’s potential side effects include liver toxicity.

During my primary care clerkship at the Bronx VA Hospital, I treated several patients who had onychomycosis and had undergone the antifungal treatment.  One patient declined treatment with terbinafine because of the possible risk to his liver.

My patients at the VA Hospital had a choice.  They were able to choose treatment or no treatment for this relatively benign condition.

But for this patient I was not at the VA.  I was volunteering at a free clinic for the uninsured.  And neither I nor they had a choice.  I wasn’t going to treat this patient’s moderate onychomycosis, period.  Even though her liver was healthy, we were not going to prescribe terbinafine.  Terbinafine is too expensive for the clinic, and onychomycosis is not worrisome enough for the CoSMO clinicians.

CoSMO is the Columbia Student Medical Outreach, a student-run free clinic for uninsured (and largely undocumented) patients in our neighborhood of Washington Heights.  It’s an in-depth undertaking, with senior clinicians (3rd and 4th year med students and advanced nurse practitioner – NP – students) teaching junior clinicians (1st and 2nd year med students and new NP students), interpreters, nursing students doing blood draws and vaccinations, nutrition students doing health education, social work students offering assistance, and student administrators doing scheduling, grant applications, drug assistance applications, quality assurance, etc.  Students run the clinic, with one physician supervising.

Despite the fact that we’re all still students, patients at CoSMO receive quality care, with an emphasis on prevention.  They are also able to be referred to necessary specialists or get X-rays and lab tests as indicated, through various partnerships and limited funding sources.

But because the funds are extremely limited, the student administrators and we clinician volunteers are forced to consider costs in every decision we make.  At the VA Hospital, I’d send a patient over 50 for a colonoscopy for cancer screening, repeated every 10 years or as necessary.  At CoSMO, however, the more cost-conscious screening (which is still evidence-based) is noninvasive, annual fecal immunochemical testing (stool cards).  Whereas a patient in a private clinic who is insured may get a Pap smear annually for cervical cancer screening simply because they ask for it, CoSMO stringently sticks to guidelines that state that Paps are indicated every 3 years after 3 negative Paps over the age of 30.

The biggest item in CoSMO’s budget is prescription drugs.  One patient of mine was on 7 different medications for his diabetes, hypertension, and hyperlipidemia… and his monthly bill alone would have been almost 1/15^th of CoSMO’s entire medication budget.  And we see almost 15 patients in one Saturday!  We send most patients to Target for $4 generics (if they’re available).  But some patients can’t pay even $4 monthly for their medications (or the $4 x however many meds they’re on).

Another patient came in with empty bottles of 2 different drugs for his blood pressure.  He’d run out of refills, and he’d just been laid off and lost his health insurance.  I thought this was a simple enough case, writing prescriptions for those same drugs as they were controlling his pressure.  The physician signed the prescriptions, agreeing with my clinical decision-making.  But then I presented the scripts to the clinic administrators…and they told me No way, come up with a better plan.  Those 2 drugs alone would cost $70 for a month – but if I switched the meds to cheaper alternatives, he could pay just $4 at Target.  We didn’t necessarily know if the new drugs would work for this patient, but, financially, it was worth the bet.

The exact same antihypertensive medications I ordered over and over again for my patients at the VA were out of the question at the CoSMO free clinic.  When I started volunteering as a senior clinician at CoSMO, I was just beginning to feel comfortable with my clinical decision-making.  I was quickly reminded that I still have much to learn about comprehensive decision-making.

Suchita Shah is a medical student who blogs at University and State.

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