US Medicine: We Can Do Better Than This by Dave Dvorak, MD How much will this cost?” he asks. It’s the question at the heart of any business transaction: Is this new car, this plane ticket, this iPad worth the asking price? But the man sitting before me is not a customer in an automobile showroom or an electronics store. He is my patient in the emergency department, and he is weighing whether to undergo the chest CT scan I have just recommended. “I’m uninsured,” he says. “I lost my health coverage when I got laid off from my job three years ago. This is all coming out of my pocket.” An ex-smoker in his late 40s, he has been coughing up increasing amounts of bloody sputum over the past month. What began as occasional, tiny red flecks has progressed to thick crimson streaks he can no longer ignore. “I can only give you an estimate,” I say, “but I’m guessing a chest CT scan plus the radiologist’s fee will run in the neighborhood of $2,000.” Like most emergency physicians, I have catalogued in my brain an endless litany of precise numbers—physiologic parameters, normal lab values, weight-based drug doses. But when it comes to knowing the costs of the myriad tests, medications and treatments that I routinely order for patients, I can offer little more than a rough estimate. “I was afraid you’d say something like that,” he says. “I figured CT scans don’t come cheap.” He sighs quietly. “I’m raising my 8-year-old daughter on a pretty lean budget.” He looks thin in his hospital gown and a shade pale, a few days of graying stubble on his chin. “But I’ve been worried about this for too long,” he says. “I know I need to have it.” An hour later, I am seated at my computer scrolling through digital CT images while the radiologist on the phone describes the findings. “In the hilum of the left lung there is a 4.5 centimeter lesion very likely to represent malignancy,” she says. My gaze falls on the irregularly shaped white mass, its tiny tentacles invading the delicate latticework of the surrounding lung tissue. “Unfortunately, it gets worse,” the radiologist says. “There are also multiple scattered smaller lesions throughout both lungs, highly suspicious for metastases.” There was a time during medical school and residency when I regarded abnormal clinical and radiographic findings with intrigue. I remember the excitement of hearing my first heart murmur. Of palpating a thyroid nodule. Of visualizing an ovarian mass on pelvic ultrasound. But after years of clinical practice and countless patient encounters, I now find it difficult to view abnormal findings separately from the human lives they affect. I see an elderly woman’s hip X-ray, knowing that the fracture line coursing through the femoral neck likely spells the end of her days of independent living. A peculiar bright patch lighting up in the brain’s left hemisphere on an MRI scan signifies that a man will no longer be able to grasp a pen or a coffee mug in his right hand, will never again be able to speak a meaningful word to his family. I hang up the phone, my eyes lingering on the CT images, the sinister white lung mass and its small-but-ominous satellites. And I am aware of their significance—that a middle-aged man will not live to see his daughter’s wedding. I return to the patient’s room and sit down on the bedside stool. Before I speak, I feel his gaze upon me, anxiously searching my face for any subtle indication of the words to come. “I’m sorry to have to give you this news,” I say, “but your CT scan shows findings concerning for lung cancer. It’s possibly spread to both lungs.” He stares ahead, unblinking, his facial pallor seemingly more apparent. After a few moments, he speaks. “On some level, I was expecting something really bad like this,” he says. “But, of course, you always hope that everything will turn out fine.” My mouth, having grown dry, lacks the appropriate words to console him in this moment of utter sorrow. So I put a hand on his arm. “I’ll talk to our on-call oncologist,” I tell him. “We’ll figure out a plan for you.” He waits patiently until I return to his room once more, armed with an action plan. “The oncologist is going to admit you to the hospital and start the workup,” I explain. “He’ll order a PET scan to see if there’s been spread to other parts of the body. Then they’ll do a biopsy of that main lesion in your lung to determine the best treatment options—whether it be radiation, chemotherapy or some combination of the two.” A long period of silence follows, time for my patient to process the information I have conveyed. I anticipate forthcoming questions. “I suspected that you’d want to do all those things,” he says, finally. “But I’ve already been thinking this through, and I’ve decided that I’m going to have to pass on your recommendations.” It is not a reply I was expecting. “Why is that?” I ask. “As I said before, I’ve got no health insurance,” he says. “But there’s one thing I do have—my house. And it’s fully paid for. I guess I’m not willing to mortgage it—and ultimately lose it—to pay off endless medical bills. My house is the only thing…” His voice trails off. After a pause, he continues. “My house is the only thing I’ll have to leave my daughter when I’m gone.” Tears have gathered in the corners of his eyes. I offer him a box of tissues, and he takes one. We sit together in a room in a modern emergency department in a rich country, a land where highly trained specialists confidently wield the newest technologies and expensive pharmaceuticals. But these treasures are not accessible to all, for ours is also a land where private health insurance is bought and sold as a commodity. Ours is a system known to shake down sick people for money they don’t have. Ours is the only wealthy democracy that fails to guarantee health coverage to all of its citizens. Just as it is failing now. He looks down at his watch. “Thanks for all you’ve done. I really appreciate it. But I’ve gotta leave now,” he says. “I have to go pick her up from school.” As I watch him reach behind his neck to untie his hospital gown, I can’t help but feel that we owe him so much more. I can’t help but feel that we—health care providers, hospital administrators, insurance company executives, politicians, all those who strenuously fight the changes that our system desperately needs—we all have failed him. I can’t help but feel that we are better than this. This article first appeared in the July 2012 issue of Minnesota Medicine. © 2012 Minnesota Medical Association Dave Dvorak, M.D., practices emergency medicine in Edina, Minn. Dvorak is a member of Minnesota Physicians for a National Health Program.
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