Cost-awareness anecdote: From Pain to Poverty (contest finalist)

The following anecdote is from Dr. Steve Sanders (Twitter: @spsanders), a primary care doctor from Tulsa, OK.

“What am I going to do now Doc?” asked Mike, a down on his luck, 29 year–old recently unemployed truck driver, as he handed me his hospital bill.

Mike was seen at our local emergency department on a Friday evening with complaints of indigestion. Earlier that day he and his wife Susan celebrated their second anniversary by splitting a store bought pepperoni pizza. Mike had just lost his job and his wife, already working two jobs, managed to keep them afloat. When Mike later complained of indigestion, Susan became alarmed. She had just read about the symptoms of heart disease in the local paper. Mike wanted to get some antacids but Susan demanded he go to the hospital. Mike stated he initially protested, but when it came to his health he looked to his wife for advice.

He said he wanted her to drive him to the hospital and told me his wife wouldn’t hear of it. “We’re going to call 911, she told him. “You could die on the way to the hospital.” Now, Mike admitted, that made him scared and he quickly agreed. Fifteen minutes later he was on a gurney rolling through the double doors of the emergency department.

Physical assessment by the emergency resident physician came quickly followed by an EKG, chest x-ray, CT scan of the chest (“they said I might have had a blood clot”), and lab, specifically including cardiac enzymes. Mike said his only complaint was it took over five hours before he heard any news.

“Everything looks good,” said the resident. “Let me run all this past my attending and see if we can get you home.” Mike said by then his pain had been gone for hours and he relaxed by receiving the good news. When the resident returned, however, Mike said he knew something was wrong.

“Sorry Mike, but my attending thinks you need to stay for a chest pain evaluation, “ stated the resident with no hint of emotion. “Your first cardiac enzyme was normal, but he thinks you need another evaluation in six hours followed by a stress test, “ he continued.

Mike said he tried to protest. “But everything was normal? Can’t I just see my primary physician later,” he quizzed the resident. He said the resident looked down at his chart seemingly trying to choose his words and said, “Can’t be too careful with chest pain.” With that, the resident physician disappeared, followed by the nurse who quickly added insult to his non-injury.

“We don’t do stress tests on the weekends,” she explained. “The Hospitalist will need to keep you until Monday at the earliest.” Mike said upon hearing this news he protested, again wanting to just go home.

“Then you’ll have to sign out AMA (against medical advice). We can’t be responsible if you go home and have a heart attack and die,” she quickly added.

Mike said by then he was too tired to protest. The thought of dying at home also had him upset. He stated when he told his story to the Hospitalist, she just shook her head and laughed. “They just don’t want to get sued,” she explained. “We get these normal cases all the time. We try to tell them this can be handled on an outpatient basis, but what can we do?” She laughed again, which Mike took as a good sign he was really okay.

He left the hospital the following Tuesday—the heart scan machine was broken on Monday—with a clean bill of health and a diagnosis of “gastric reflux,” which I explained was the indigestion he first described.

I looked at his hospital bill. Charges for everything from the ambulance ride to the emergency department evaluation and eventual hospitalization with cardiac stress tests came to just under $11,000. This number was circled at the bottom of the bill with several question marks in red ink written to the side by Mike’s wife.

“We don’t have any money,” Mike explained. “Susan’s insurance won’t cover it, since we forgot to put me on her policy when I lost my job,” he continued. “We’re gonna have to file bankruptcy Doc. I don’t know what else we can do.”

What would have been a 15–minute office visit providing reassurance and education to a patient we knew quite well became a 72–hour ordeal by a health system treating a disease and not the patient, trading a patient’s pain for financial poverty. Surely we can do better.