The inability to access health care affects the health of many individuals and populations around the world. Many barriers exist, including financial and geographical barriers to care. While rotating through a family medicine practice in my third year of medical school, one of my patients described how his culture had prevented him from accessing care from a young age. This man in his 20s presented for a follow-up visit of sexual dysfunction secondary to selective serotonin reuptake inhibitor treatment of major depressive disorder and anxiety. While gathering the history, I uncovered that the patient was diagnosed with depression after sustaining a career-ending baseball elbow injury. After playing baseball his whole life, he found himself lost without baseball, which had been his plan A, B and C. Hoping to learn more about the etiology of my patient’s depression, I asked him if I could interview him in depth about his experiences, to which he agreed.
First, he described his childhood. He was born and raised in the Dominican Republic. His parents loved him greatly, but experienced financial struggles, which were common in their community. With their primary concern of taking care of their basic needs, they did not have money to pay for health insurance or doctor visits. The patient grew up without contact with the medical community. At a young age, he worked odd jobs to provide resources to take care of himself. When he was 13 years old, the patient was diagnosed with appendicitis and was taken to a hospital for an appendectomy. At the time, he was nervous because of his limited exposure to the medical community. His parents avoided going to the doctors and lacked trust in many aspects of modern medicine. Many of his close friends and family shared this sentiment and had a cultural stigma against health care and medical providers.
Despite his initial medical encounter at 13, the patient suffered from mental health struggles since he was 10. Panic attacks, anxiety, depression and nightmares plagued him daily. Additionally, he believed he had undiagnosed attention deficit hyperactivity disorder (ADHD), which made him unable to concentrate in school. He received very little support from teachers and was continually blamed for his lack of concentration on academic tasks. By the time he was 13, he was afraid to go to sleep because of panic attacks that he would experience in the middle of the night. When he told his parents and teachers, they said it was normal and he was experiencing nightmares like everyone else.
Having prepared his whole life to play baseball professionally, the patient moved to the United States by himself after earning a scholarship to play baseball at the college level. While in the United States, he sustained an injury to his elbow, which was different from all his minor injuries growing up. This time, he would be unable to fight through the injury and keep playing. He needed surgery and could have the surgery covered by the school’s health insurance. However, though finances were not preventing him from seeking medical care this time, the patient had developed a distrust of the medical community due to the beliefs of those around him while growing up. The elbow injury caused him extreme emotional distress, and he ultimately decided against the surgery. Unable to play baseball, he lost his scholarship and moved back to the Dominican Republic, where he plunged into severe depression. At only 19 years of age, his baseball career had ended. At this point, he felt he had little to strive for in life anymore.
He started creating a business to supply supermarkets. Once COVID-19 hit, he had to close his business, putting him in debt, which further contributed to his depression and anxiety. The patient moved back to the United States to find opportunities to make money. With encouragement from friends, he turned to the medical community to address his mental health struggles. After an appropriate workup, he was prescribed Lexapro and atomoxetine. Following a year of treatment with Lexapro, he began experiencing sexual side effects from the medication, such as erectile dysfunction and low libido. He felt that the Lexapro had helped his depression and anxiety monumentally and was worth it despite the side effects. After a discussion with this physician, he was prescribed tadalafil. Now, he feels in control of his depression and can manage his side effects. He attends weekly sessions with a mental health therapist, where he talks freely about life stressors. These appointments are of utmost importance to him, and he never misses one. Since getting involved in the medical community, he feels his life is stable and is in a better mental state. He now works two jobs and has been paying off his debts in the Dominican Republic and supporting his family from afar.
Having had exposure to the medical community in his adult life, he realizes what he experienced as a child (the panic attacks at night, difficulty concentrating and anxiety) was not his fault and could have been helped. He has developed trust in the medical community and is actively trying to get his parents to seek medical care. He hopes to spread awareness about the benefit of regular medical care to his community in the Dominican Republic and share his positive experience of conquering mental health struggles.
Through this interview, I gained a greater perspective on the impact that poverty and cultural stigma can have on an individual’s decisions to access health care. Choosing to receive medical care is a significant decision when there are insufficient finances to cover basic needs. I was previously not exposed to the stigma and distrust that some families in the Dominican Republic have towards the medical community, as described by my patient and his experience. If the patient had experienced dishonesty or distrust by his mental health providers, it would have likely reaffirmed his previous beliefs about medical providers, threatening his future health. By building a trusting relationship, his providers have not only helped the patient, but they have helped the patient’s family and others in his hometown community due to the patient’s continued advocacy. I will never take for granted the meaning of someone coming into the office and taking the time to speak with me as a physician. Doing so can be a testament to a patient’s courage, strength and motivation toward improving their health.
Author’s note: To protect patient confidentiality, identifying details have been changed in this article.
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