Slate’s Working Podcast, Episode 2 transcript: Dr. Meri Kolbrener on working with inner-city patients.

Slate’s Working Podcast, Episode 2 Transcript: On Being a Doctor When Your Patients Are Poor 

Slate’s Working Podcast, Episode 2 Transcript: On Being a Doctor When Your Patients Are Poor 

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Oct. 23 2014 11:28 AM
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Slate’s Working Podcast: Episode 2 Transcript

Read what David Plotz asked Dr. Meri Kolbrener about her workday.

Meri Kolbrener.
Dr. Meri Kolbrener.

Photo by Ralph Alswang

We’re posting weekly transcripts of David Plotz’s Working podcast for Slate Plus members. This the transcript for Episode 2, which features Dr. Meri Kolbrener, a family practice doctor in Washington, D.C. To learn more about Working, click here.

David Plotz David Plotz

David Plotz is the CEO of Atlas Obscura and host of the Slate Political Gabfest.

You may note some differences between this transcript and the podcast. Additional edits were made to the podcast after we completed this transcript.

David Plotz: What's your name and what do you do?

Meri Kolbrener: My name is Meri Kolbrener and I’m a doctor, but I’m an inner city family practice doctor who works at a federally funded community health center in Washington, D.C. And I always feel when people ask me what I do, that the doctor part isn’t really as important as the where I doctor part.

Plotz: What is the very first thing you do when you get to work each morning?

Kolbrener: The first thing I do when I walk into the office is, I—well, the first thing I do actually is, I see how hot it is. Because this is a really, really old building, and it's a building that Unity Healthcare doesn’t rent from the Department of Health, but they give it to us. And so nobody wants to put a lot of money into the building, so there are times during the winter when you walk into the building and it's like, 90 degrees. We’ve had to close three times this year.

And so, the first thing I do honestly is, I walk in, I try to figure out if I’m warm because I just came from outside or if I’m warm because it's already 95 degrees, and if there are all these patients in the lobby part I know it's because it's really hot and the waiting room is, like, not a healthy place to be. So, that's the first thing I do. Then I walk past, I go into my office. The way—I walk through the waiting room to my office, which is always sort of an obstacle course of sorts, because there are—I’ve been working with the same people, many of them for 10 or 11 years.

And they feel like they own a part of me, right? So, when I walk into the waiting room, it's like, “Dr. Kolbrener, you've got to talk to me about my leg!” And so, every morning I walk in and I smile, and I say, “I’m happy to see you when you come back into my offices.” And then I go into the group of offices. So, the way it works in my office—and again, this is by default, it wasn’t like someone said, “what's the best way for doctors to work together?” It's just a site that doesn’t have a lot of options, so all the doctors are together in a big room, and we all have our computers.

So, I go in, I sit down, I log onto my computer, and I see if I have any patients waiting for me. Usually my day begins when my medical assistant—who is marvelous and incredibly smart and funny—comes back and says, “Dr. Kolbrener, I’ve got two ready for you.” And often during the day I won’t get back to my office for hours because I’m just going exam, exam, exam, exam, exam.

Many doctors the day before their patients come in look to see who’s on their list, so they know who to expect. I have this weird desire—and they also prepare for that person, right? And I think there are medically very good reasons to do that, and yet I have never done it because I like the moment of walking into a room and being surprised by who’s in front of me.

Like, I find that, whatever, 18 times a day gives me a kind of pleasure, especially again, because, you know, I would say 50 percent of the time it's someone I know. And sometimes it's someone I’ve known for years and have experienced lots of different kinds of things with them.

So, my—what do you call it—my panel, you call it a patient panel, is incredibly diverse. Not rationally diverse—my patients are mostly black—and not economically diverse, although there are people who have left poverty who keep seeing me, which is a lovely feeling. But they are diverse in that most days—so, Monday mornings actually they are not diverse. Monday mornings tends to be when I do my narcotics. So, I have dedicated slots for patients who need monthly pain medication, according to the law in D.C. and Medicaid law. So, I think if it's not Medicaid you might be able to get more than a month’s worth of narcotics, but all of my patients are medicated.

I have to write prescriptions for people every month, so I have dedicated slots. So, on Monday morning I know usually that my first three patients are going to be amongst the 20 or 30 patients I see monthly to give narcotics for chronic pain too.

One might be a 60-year-old woman with really bad arthritis in her knees who just takes a Percocet every once in a while in order to get through. Someone else might be someone who is a heroin addict, who’s finally clean but has back pain, and there's a lot of issues with pain thresholds in old opiate addicts. And so that's somebody who I might give stronger medicine to, although—you know, the politics of this are really, really complicated. So, somebody comes into your office, you know, I have patients who I’ve been seeing for ten years. I’ve been given them narcotics once a month for ten years.

And before I saw them, you know, ten years before that they were heroin addicts. But they have genuine pathology, which means they have things that are wrong with them that cause them pain. Managing pain now has become one of the things that's most difficult for me, because we know we don’t do it well. And we know even when we do it well, we create addicts. And so for me, Monday mornings can be a little rough sometimes because, you know, everybody always wants a higher a dose. Nobody is ever—has pain control.

And when I was younger—and the literature on pain was younger—I mean, I sort of grew up in the whole world of pain medicine. And there was a moment medically where there was the belief that you treat pain, and then you treat pain and the pain is better, and that's why we do it and that's humane. And that's still true very much, I guess, for cancer patients or terminal patients. But now I would say the literature says, we treat pain, patients are going to continue to be in pain, you're going to use higher amounts of medicine, but it's not going to lower their pain. That you're going to end up in this spiral.

And so, I do that on Monday mornings, and that has a—there's always a sadness in that. There's always a sadness in that.

Plotz: So, if a patient who you're giving regular narcotics to say, “You know what? I want a higher dose. I need a higher dose. Dr. Kolbrener, I need a higher does.” What’s your response?

Kolbrener: I have an “S” for “sucker” tattooed on my forehead. I tend to believe anything everybody tells me, So, I don't like to be skeptical. I just don’t. Now, that said, I drug test my patients who are getting narcotics. And that took me years to do without feeling guilty about it. And I felt less guilty when lots of them came back with lots of things that weren’t supposed to be in their bodies, right? In other words, you're testing the guy you're giving Percocet to and they come back positive for cocaine and PCP. And that has happened more often than I would like.

And then I end up in this crazy situation with patients where I become the sort of “general” as opposed to the doctor, and I say, “If you have another positive I have to cut you off.” And I find that role just difficult, because, you know, I had a patient for a long time who was an HIV patient, and I bartered pain medicines for her taking her HIV medications. I don't know how else to say it. Did she have real back pain? Sure, and she had the history of a crack addict, and she knew she had to be clean, that I was going to test her every month, that she had to be clean. But I made the choice. I said to her, “if you come every month for your narcotics, and when you come every month I can tell that you are seeing our on-site HIV specialist and getting your blood work, and your blood work shows you're taking your medication, you're not going to get any problem from me. That's the deal, right? That's the deal.”

And for two years it worked, and a patient who had never taken her HIV meds regularly, we got her HIV numbers down, and I felt like, sort of smug. Like, I had done this sort of arrogant thing and not totally followed the rules. And then she came back positive for cocaine, and then I had to cut her off. And then I never saw her again in the clinic. We have a very good HIV team, and the HIV team has continued to call her. And she says she’s going somewhere else to get her HIV care, but, like, I’ll never know.

Plotz: So, you do end up cutting people off? That does happen?

Kolbrener: I do end up cutting people off. I would say every three or four months there's somebody who I have to say, this is not something I can do. The most peculiar thing that I sometimes do is, I’ll have a patient—I had this awesome guy who I saw for maybe three or four years. He was hit by lightning and had severe back pain, and he was a construction worker. And he was a bright guy, and you could—he was desperate to work. And I said to him when he first came in, all right, we’re going to medicate you so you can work. We’re going to medicate so you can work. That's going to be our goal, because you don’t trust the back surgery, and you've tried the physical therapy, and you've had the epidural injections, and this is the end of the road. I really, really respected this guy and really was rooting for him hard. And he was a construction worker and he worked for about a year or two, and became manager of the site and was doing great. And I was giving him his meds. And then I got a letter—sometimes we get these letters, they're very distressing—from the insurance company saying, “These are the different people giving this patient narcotics.” And you're like, “Oh! Not this dude. Not this dude. Not this dude.” Right?

So, I go in the next time he comes and I say, “Sir, what?” And he looked at me very clearly and he said, “Dr. Kolbrener, I’m an addict. I don't know what to say. I’m an addict now. I needed the pills to work, and now I need more pills because I’m an addict.” And I looked at him and I said, “You know that this conversation means that I can no longer be your drug dealer, right? Like, this is done. It's over. There's no—this is it.” And he looked at me and he started to cry, because we really—because of so many different losses for him, right? It wasn’t just that I was cutting him off.

And he said, “I don't know what to do. There’s no good rehab options for me with my insurance. I don't know what to do, and what I’m going to end up doing is buying on the street.” And I thought, like, watch the system fail.

Plotz: Are all of your patients coming to you on Medicaid?

Kolbrener: I have some Medicare patients—I have primarily Medicaid patients—and then I would say I have a handful of federal workers. The other phenomenon that's starting to happen, which is really recent, is the neighborhood that I work in—which is southeast—the site itself isn’t in a great neighborhood, though it's not in a terrible neighborhood, but is proximate to some nice capital city neighborhoods.

And people come to D.C. for their federal job, and they need their insurance, a doctor who’s going to accept their insurance. And D.C. is a disastrous place to find medical care that accepts insurance. Internal medicine and family practice doctors are really hard to find. So, they open their book, they see my name, and they come to see me. And they walk in in their suit and tie, and they come into the waiting room, and they’re like, whoa, this isn’t Kansas, right? Because the waiting room is, you know, 50 folding chairs in an uncarpeted room with, like, two TV sets on the wall. It's not a high-end waiting room.

And so, I’ve had a couple of these patients, many more lately. Because I think what's happening is, Capitol Hill is getting nicer and nicer. And they come back, I have to say. I see them, and they come back and they see me again. It's an interesting turn of events for me.

Plotz: You have the narcotics patients, but that isn’t obviously the majority of your practice. What's another kind of category or set of things that you tend to deal with a lot, or are particularly fun to deal with?

Kolbrener: Part of the reason I became a family practice doctor is because of the variation. Like, I wouldn't want to just see pediatrics, but having a day punctuated by pediatrics is awesome, right? Because kids are usually well in big ways, right? I mean, they have little ups and down but—so, they’re not as intellectually challenging unless they are very sick, and very sick kids tend to go to specialists. So, my adult patients are much more intellectually challenging for me, but my pediatric patients are challenging in other ways.

So, because I’ve been practicing in the community for 11 years now, my kids have grown up. I’m taking care of babies of kids I took care of as teenagers. And that is really a privilege. It's really magnificent. I mean, on one had I can be snarky sometimes and be, like, well, you know, I met her when she was 10 and now she’s 15, so I’m taking care of her baby. Which happens.

But, you know, sometimes that 15-year-old turns out to be a lovely mom and you get to watch her find who she is. I don't know, I don't mean to sound Pollyanna. Like, I’m not Pollyanna. I see a lot of bad things. I see a lot of kids who are not getting what I believe kids should get, right? They’re certainly not getting what my children get from me. But then I also see that there's—that kids don’t need as much attention as these, you know, upper middle class kids like my kids expect, and that there's something about the freedom in these families that I always somewhat envy. Like, “What happens when you get home from school?” “I get my brother and we go to the park.” Right? That's awesome, right? They have their own world. I guess that's what I’m trying to say is, a lot of these children—even though there's something that's hard for me to think about—they spend a lot of time on the street with other kids.

And for a lot of these kids, that's awesome. I think we live in a world where you think, a bunch of kids on the street have to be, like, engaging in drugs or running for the drug dealer on the corner. They’re not. They’re, like, playing basketball and they’re playing soccer, and the community takes care of their own in a way. And so I find that piece of it really interesting.

I mean, what I do with pediatrics—pediatrics is hard for me, because when you see a kid from 5 to 15 every year, you just sort of love them, right? And then, I just had something happen which I found just—two kids in the last week came in, both boys I started seeing when they were five, both African-American boys in single mom families with multiple brothers and sisters, and both are now in prison. Or in halfway houses, or—you know.

And both kids I had seen in the last, like, four months. And you start to talk to—I started to talk to one of them. One of them was a kid who was a Type I diabetic, and he came in, I remember when he was 7 years old and I diagnosed him with diabetes thinking, “what is going to happen to this kid?” And then, you know, eight or nine years later he’s in Children’s Hospital because he’s 14 years old, he’s fighting with his mother, he’s hanging out on the street, and he doesn’t take his insulin.

And so, it's super crazy dangerous. And there's very little I can do. You know, what I’ve been thinking about lately with these two moms—both of whom I know well and both of whom I respect enormously, who really want the best for their kids and have tried—right, they have tried to do right for their children. I think both kids do okay in school as well. And both moms when I recently saw them had a kind of passivity that was new, like, “There's nothing I can do.”

One of them who’s more—one of the moms is very, very, very outspoken. And she’s always like, “Dr. Kolbrener, you don’t – you’re a Washington, D.C. Northwest, white girl. You don’t know anything.” And I always say, “You know, yeah, you're right. I don't know anything about what your reality is, but I do know what you're doing right now might not be working, right?” But she and I have a very, very sort of open relationship, in that she feels completely comfortable telling me she thinks I’m an idiot a lot of the time.

But what I saw in her was—what I saw in her—what she said to me was, “Dr. Kolbrener, there is nothing I can do for that boy anymore. There is nothing I can do.” And I sort of—it stopped me in my tracks, because the idea of being done with your kid when they’re 15, when you're a good mom—I mean, she takes care of her kids. She works, her kids eat all dinner together, she’s doing her best. And I don't know where to put it.

And I said to her, I said, “With all due respect—” I really try to be respectful—I said, “If you don’t have faith in him, what does he have left? I mean, what does he have left?” And she sort of—there was sort of a jolt of recognition and she said, “I heard that, Dr. Kolbrener. I heard that.” And I thought, that's like, the best I’m going to do.

And I have this other mom of this kid who’s a diabetic, who I don't see how this kid is going to survive for the next five years. And she said—she’s much less forthcoming—and both of these moms, I should mention the reason I’ve been seeing both of these moms so frequently is they both have new babies. So, they’re bringing in their babies, and when they bring in their babies I’m saying, “How’s your 15-year-old?” Right?

And, the other mom, I walked in the room and she had her 9-month-old baby on her lap. A cute, cute, cute baby. And she’s holding the baby and she’s lifting him, and you see in her eyes this love and hope and possibility. And she’s home with this kid. She’s unemployed. She lost her job, and delighting in it, and taking wonderful care of this child. And then I say, “How’s your other son?” And she’s like, “I don't see that there's anything I can do for him.” And this difference between this mother who’s pouring herself into this child—like, I’ve been thinking a lot about, how does that happen?

How does that happen, where you give up on your children? And I’m not judging these women, right? I’m not judging them. And I don't feel—they just don’t know what to do. They haven’t given up in, like, an existential way, they’ve given up in a practical way. They have no options. They don’t know how to help their children, and that feeling of helplessness is so palpable that, what can they do?

So, what I’ve been talking about is what we call “well child” care, which is, like, ironic. Because, you know, they come once a year and my speech is always—to the 15-year-olds I always say, like, “What do you think is going to happen in your life that you need a doctor for?” And they usually look at me sort of like, “I don't know.” You know, they’re teenagers. And I say, “Well, I mean, you're likely to be healthy. People your age are likely to be healthy. What do you think are the things that make people unhealthy who are your age?” And then I say, “Violence, motor vehicles accidents, sexually-transmitted diseases, and that's what I’m going to talk to you about today. And it's going to seem weird because you're here to the doctor and you want me to look in your throat.”

And, you know, I do a mixture of these things. I mean, I think that's the hard part of this job. So, a kid comes in and they’re 15 years old, and they’re sexually active and maybe or maybe not using condoms. And he’s also a football player with a knee injury, right?

It's hard for me sometimes to remember that the knee injury is my job, too, because the other stuff seems so pressing. Like, if he gets that girl pregnant he’s not going to get the football scholarship, right? So, it's a really—but of course I deal with it, what's happening with his knee. And I examine his knee and I see what I can do for his knee, and get him the services that needs.

But in some ways I feel like I’m always playing—perhaps because of the population I work with—the juggle between the physical and the not. So, a lot of my patients, the adult patients, one third of them probably are, you know, obese, diabetic, with hypertension, Type II diabetes from the weight. And that's really challenging. Because really, you know, sometimes I start—depending on where someone is—if someone is on the beginning of this journey into chronic illness, right? And I’ve had some patients recently who are on the beginning. So, they’re like, 50 years old. Their blood sugar is up, their blood pressure is up, and they come to see me.

Sometimes you can say to people, like, “you know what? Never see me again but exercise five days a week and eat fruits and vegetables, and you will be better off than if you come to my office.” And sometimes that works, right? I mean, they keep coming to my office, but the idea is, what I have to offer is not half as important as what you have to offer.

But, you know, the “obesity” epidemic is not uncomplicated. So, when I first started working they were like, “we’re going to figure out the Body Mass Index on people and we’re going to discuss it with them, and we’re going to change the obesity epidemic. It's just about acknowledging it.” And I remember thinking always that this is just total crap, right? And it's still true for my kids who are overweight. I’m supposed to get their cholesterol, and get their blood sugar, and I’m like, but why? We don’t treat at that age and it doesn’t do anything to help anybody.

So, with my patients, the frustration is, is that—I read—I can’t remember who wrote this, but it was really compelling to me—that the reason poor people eat so poorly is because it tastes good, right? Now, that sounds really, like, dumb, but it's totally true. If you have $20 a week for food for one person, right, it's hard to—I mean, I’m not even talking about the cost of produce. Let’s not even do that. Let’s say you have a choice of going home and making yourself rice and beans and some broccoli or going to McDonald’s, costing you the exact same amount.

Your life is stressful. You don’t have enough money. Your housing situation might not be stable. Your kids stayed out all night the night before. Your kid who’s going to college, you don’t know how you're going to pay for it, if you're going to make it through the four years. At that moment you want a little pleasure, right?

And so, what I’ve learned over the years is that, that I can’t be a medical voice. That the medical voice of power, and this is what’s right for you, is just so unhelpful because the patients are smart. They know. They’re just looking for some pleasure. Now, they don’t have access to the same pleasures that I have, in terms of even coming how to a full refrigerator and making a delicious meal for my family, because my delicious meal for my family costs $30 for one meal, right? And so, the longer I’m at this the longer I struggle with my own role as the advisor, because—because of the gap in our opportunity—because of the opportunity gap. The opportunity gap.

And what I think about it is, an opportunity for pleasure. So, now when I talk to patients, I try to say, like, how much—I have diabetics. “How much soda do you drink?” You know, the liter sodas cost $0.99. The big chip bags cost $0.99. “So, every day I go to the—every week I go to the market and I get five of those sodas and five bags of chips.” And I say, like, ouch. I mean, I try to give them an image that's hard to live with, like, when you drink soda it's literally like putting an IV in your arm with sugar in it. But I can’t say that helps.

Plotz:            What are health problems that the poor have that others don’t?

Kolbrener: You know, I’m not an expert on this because I only work with the poor, right? And so, I think what we see with the poor—certainly because there's more obesity I think—we see more chronic illness of the kind of diabetes, hypertension, kidney disease—we see tons of really severe arthritis. Because if you're walking with 300 pounds or walking on those knees, those knees are going to have a hard time.

You know, I see a lot more sexual and physical abuse and a lot more loss. You know, there was a period of time when I was asking every patient if they had lost anyone to violence, and, you know, 4 out of 6 patients said yes. I mean, there's a kind of loss.

What do I see? Again, what do I see? I see these opportunity gaps which make it harder to live healthfully, right? I mean, you know, the chronically poor and disabled—so, patients with arthritis bad enough that they are disabled—they become extremely isolated. I see a kind of isolation I hope doesn’t exist anywhere else. I don't know for sure.

But, you know, many patients wake up in the morning, they turn on their television, at the end of the day they turn it off and they go to bed, right? I mean, I had one patient who told me she watched Law & Order, like, nine times a day because she could go from one UPN channel to another UPN channel. And so, I mean, it's much harder to have hope in poverty, right? I don't know. It's hard for me to answer that question.

I certainly definitely have more 15-year-old kids who come in pregnant, right, who I’m helping navigate that. I just had someone come in the other day, and she was a cute little 24-year-old woman who already had two children who were, like, I don't know, 6 and 3. And two weeks before she had come in for a kind of birth control that you insert in your arm, and you can’t put it in unless you're sure the patient isn’t pregnant. So I said to her, “Listen, have you had unprotected sex in the last two weeks?” And she said, “I have.” And I said, “Listen, come back in two weeks, we’ll get another negative pregnancy test, and I’ll put it in.” And she came back and it was positive.

And I told her, and she works—she’s a manager at a fast food restaurant—and she’s proud of her life. Like, she’s a single mom but she takes care of her kids. And she just wept and wept—not sobbed, just, like, the tears running down her face—and the struggle of trying to choose—she has children. She knows what an abortion means. It's painful to her.

But, she has children and she knows if she has another one, she’s not going to be able to stay manager of that restaurant because they’re not going to give her, you know, adequate leave—and so, those moments. And the other thing is, she needs $350 because Medicaid doesn’t pay for abortions, because we’re in the District of Columbia and the Congress won’t permit it to. And $350 is a lot of money. It is enough money that she might not get it because she doesn’t have the money. That she in her mind—you're watching her scramble in her mind, how do I do this?

So, she’s ashamed, and she needs to ask for help, and Jesus Christ, she had unprotected sex even though she has two children and knows how it works, right? And so, that's sort of the feeling I have a lot, which is, I feel so much compassion for you—what were you thinking?! But temperamentally—and maybe you can tell this from listening to me speak anyway—I say, “What were you thinking?!” I do not feel that my being inauthentic helps anybody.

And I feel that they—that my patients know that I feel every time I walk into a room, it is a privilege for me to talk to them, and that I can say something judgmental without being judgmental, right? I can say, like, “You need to take hold of this or that.”

Or this other patient I was telling you about from earlier with the son who’s in a halfway house now, hallway to prison—one would like to think it's halfway to home, but it's more likely halfway to prison—and she and I had a conversation about hitting your kids. This was last week.

And she was saying, “Dr. Kolbrener, sometimes you have to whoop your kids. Sometimes you have to whoop your kids because you're so angry at them there's nothing else you can do.” And I looked and I was like, “I never hit my kids.” And she looked at me and was, like, “You, again, Dr. Kolbrener, are a white woman in Northwest Washington. You don’t know what problems are.”

Okay, that's right. So, then I go to my next tactic. “Does it help?” She says—she’s really smart—she says, “I feel better afterwards.” I say, “But does it stop whatever behavior they’re doing that you don’t want?” “No.” I mean, it's just—there are so many cultural differences, right? So, that “no,” she didn’t have, like, an epiphany and say, “Dr. Kolbrener is right, I’m going to stop hitting my children because it is not effective parenting.” She was just, like, “I do it because I’m angry.”

Plotz: So, a lot of what you're talking about, it sounds as though your practice is psychotherapy. But is that just because you're picking out examples like that, or is it—are most of the patients, are you treating them as a psychologist might at the same time you're treating whatever medical problems you're treating?

Kolbrener: You know, maybe this is—I don't think this is about poverty, I think this about human connection—that you can’t treat anybody for anything without connecting to them. So, even if a kid—you know, my day is not—I couldn't possibly sustain a day of 18 patients like the ones I’ve talked to you about, right? It would be unsustainable. I couldn’t psychologically do it or physically find the time to do it. But I do believe in connections. So, if I walk in and there's a 2-year-old on the table, I walk up to the 2-year-old and I say, “Hello, what are you here for today?” So, what I would say is, all healthcare should begin with connection. Even if I’m doing a strep test or treating your high blood pressure, I don't know—there's some number, like more than 50 percent of patients on medicines are noncompliant, right?

So, walking in and being, like, well, you have high blood pressure and you need the Norvasc—I mean, I do that, right? I hear myself say it a hundred times a day. “We’re going to put you on medication for your high blood pressure, and high blood pressure is the silent killer, and I know you feel fine. It increases your risk for stroke. Blah, blah, blah.” But I try not to be the person in the Peanuts cartoon going “blah, blah, blah.” I try to say something that shows I’ve connected to the person, and maybe because that's what interests me.

You know, medicine has become really algorithmic in way that I think most people don’t realize. So, if you're doing “good medicine” today you are following algorithms. Most doctors don’t want to say that, because it makes them feel like, why the fuck did I go to school for so long to follow an algorithm? But, you know, if I’m treating hypertension now I’m supposed to use a certain kind of medicine first, and if that's not enough I’m supposed to add another kind of medicine.

And there's some choice within this, but the choice doesn’t matter. So, if you are self-important enough to believe that that choice matters, maybe that's enough to get you through the day, but I guess the part of myself I haven’t shared with you at all is the evidence-based doctor in me. I read all the literature. I don't believe in my intuition more than I believe in the algorithm, so I’m not going to say—now, I mean, I’ve had a lot of experience, so I don't want to put that way.

I had a really interesting thing happen the other day, which belies this whole thing, sort of, which is a 23-yaer-old kid who I’ve known since he was 12 came in, and he’s a kid who came out to me. Like, I saw him and when he was, like, 13, it was clear. His, you know, eyebrows were waxed and he was, you know, all groom-ied. But he never would—I would say, do you have sex with men, or women, or both, or are you interested? And he was always really closed about it.

And then he turned about 17 or 18, and I think he came out to his family, and he, like, came out to me. It was sort of one of the sweetest moments of my career. “Dr. Kolbrener, I’ve been thinking a lot about this, I really want to tell you that I’m gay.” Anyway, I hadn’t seen him in a couple of years, and he came back and he came in, and he had this weird constellation of symptoms, just weird. And he had been to the ER with kidney stones, and his CAT scan showed inflamed lymph nodes in his abdomen.

And so, my hackles are going up, and he’d lost some weight, and I’m like, what is going on with this kid? I’m going to have to do a really full evaluation and do all the blood work. And I do all the blood work, including an HIV test, but I swear because I’ve been this kid for ten years—and I’ve talked to him about condoms 900 times—it doesn’t occur to me that he has HIV.

Even though the medical story that I picture—that I painted—is an HIV picture. It's new onset HIV. And I didn’t make any medical mistakes, right? I checked him, but when it came back positive I was like, oh my goodness! That's so shocking. Oh, no that's not. Right, so the medical and the personal are a complicated interaction, right? It's just complicated. And, you know, I felt really glad to be able to tell this kid so he could cry, and come back and see me, and I could set up him with the HIV—our HIV clinic is superb.

And I could set him up with people who would be really humane with him. But I guess what I was trying to say is, the sort of personal and the medical and how they interrelate get complicated. It's not always straightforward, right? I didn’t do him a disservice, and I probably did more for him in fact because I was listening so hard because I’ve known him for so long, but it just shocked me that I didn’t come to the obvious conclusion because I didn’t want to.

David Plotz:   So, you're in your 40s, barely. Do you see yourself doing this job to retirement? Is this something you can do? You've done it for most of your medical career.

Kolbrener:    All.

Plotz: All of your medical career. Do you see yourself doing this until your 70?

Kolbrener: I think so. Every time—you know, we have three children, and talks of private school, and I say to myself, “Really, Meri, it’s time to actually earn some money, right? You just have to stop making decisions the way you've been making them.” And then I play it out in my mind and I feel really sad. I don't want to do it. And, you know, these are questions of identity I think in some ways. Like, maybe I just like being the person who helps the poor. Maybe it’s that narcissistic.

Maybe there's an authenticity in my dealings with my patients because we come from such different cultures that we don’t get lost in the trappings at all. There’s a real connection. I know that sounds counterintuitive, but sometimes difference makes connection more honest, right? And there's also something really awesome about waking up in the morning and doing something you know it's really hard for them to find doctors to do, right? Like, if I leave, the likelihood I’m going to be replaced by someone with equal experience is zero.

They might get some really smart kid straight out of residency who’s going to work three years—because our site is a—they get, what's the word? They get funding, they get loan repayment. But most of them aren’t going to stay more than those three years. Like, I am the old lady at the clinic, but I don't feel that like I’m the old lady and worthless. I feel like I’ve worked three days a week for many, many, many years. And I keep thinking that there's more that I need to do, whether right, or get involved in policy.

But then it becomes a different question about parenting, and marriage, and division of labor, and just time constraints. So, I would say that if I had no time constraints I would do this forever and I would do something else also, but because I have the time constraints at this point in my life I will probably just do this forever.