Joshua Lilienstein lined up for treatment this summer at Los Angeles County-USC Medical Center's general oncology clinic. A medical student who'd been battling cancer for four years, Lilienstein had little choice. In June 2009, he lost his insurance after maxing out on the lifetime benefit.
At 30, Lilienstein found himself playing two roles: a patient negotiating the county's options for the uninsured and a medical student working the halls of the same hospital to finish a demanding 12-week surgery rotation.
The line at the metal detector near the county's oncology clinic snaked out the door. Lilienstein, who'd arrived straight from morning rounds in his doctor's coat, stood out among the patients. Security guards took one look at his white jacket and ID badge and waved him through.
He was in his first year of medical school at USC when doctors diagnosed testicular cancer. At the time, he was insured by Anthem Blue Cross through the student health insurance program.
Lilienstein sought treatment at USC Norris Comprehensive Cancer Center, one of the nation's leading cancer research and treatment sites. He withdrew from school three times for chemotherapy and surgery so radical, doctors called it "heroic" — removing his testicle, clusters of tumors, portions of his liver and bowel, his spleen and lymph nodes and replacing bone marrow destroyed by chemotherapy with a transplant.
In January, six months into remission, Lilienstein returned to complete his third year of medical school. By then he was among the more than 2 million uninsured Los Angeles County residents.
The oncology clinic's waiting room was packed. It was a far different crowd than at Norris. Most of the patients were minorities; many Latino, Spanish speakers. Some had amputations. They looked desperate and broken.
How strange, he thought, that I look like the healthiest person in the room.
He was handed a financial questionnaire full of small print. He looked around the room, wondering how many of his fellow patients would understand their options.
When he returned hours later to wait for his appointment, a loudspeaker blared names. The voice was harsh to Lilienstein's ears. Chemotherapy had damaged his hearing, leaving him dependent on hearing aids. He could not understand the voice on the loudspeaker. Many others in the room were also struggling.
Fellow patients, noticing his white coat, assumed he was a clinic doctor and approached him for help.
"I'm Gonzalez," one man said. "Are you looking for me?"
When Lilienstein told the man he was not his doctor, he wilted back into his seat.
Within the hour, a resident was recording Lilienstein's medical history in an exam room. Lilienstein wondered if he was getting preferential treatment and vowed to leave his doctor's coat behind next time.
When his oncologist arrived, they spoke briefly, reviewed his records and confirmed the blood tests he would have that day. After about five minutes, the oncologist moved on. Doctors at Norris usually spent more time with Lilienstein, but their clinics were not inundated with chronically ill uninsured and underinsured patients.
These are the moments when Lilienstein thinks about the paradox of public hospitals and the promise of national health reform.
"County is an amazing public service; look at all these hundreds of people getting free or low-cost medical care. But on the other hand, there's a stark class division in terms of access to medical care and engaging with the medical system that's very uncomfortable," he said. "This is not how it looks in other developed countries. We can do better."
On a midsummer day not long after his first appointment at the county clinic, Lilienstein greeted Lydia Nueva Espana, 77, in the preoperative area at the private USC University Hospital, a short walk across the medical campus from County-USC.
Lilienstein does not tell every patient he is a cancer survivor. Sometimes it can be a distraction. But other times, his story can offer encouragement.
He had shared his history with Nueva Espana, whose battle with breast cancer had begun in 1978, before Lilienstein was born. She had a mastectomy soon after her initial diagnosis more than three decades ago, but the cancer had recurred three to four years ago.
Nueva Espana was already in a hospital gown, and as nurses settled her onto a gurney, Dr. Stephen Sener, the cancer surgeon, arrived to explain how he and two other surgeons would remove the lump and rebuild her breast.
"It's what that medical student had: multi-disciplinary surgery," Sener said, pointing to Lilienstein as Nueva Espana beamed.
Doctors who survive cancer and return to work show a different perspective and dedication, Sener said, adding of his younger colleague: "He doesn't have to be here — he could have just curled up in a ball."