Sunday, November 28, 2010

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.


  1. Wonderful story, but... an otherwise healthy 29yo male going to the hospital for Chest Pain after some cheap pizza? Health Illiteracy at its finest. And an ED Attending wanting to cover his butt? Lack of Medmal reform at its finest.

    Two fearful fools in this one: the patient and the doctor.

  2. We see this type of story all the time on our medical bill negotiating platform, where a self-pay uninsured patient may have been billed significantly higher than if he had insurance where the bill would have been discounted by up to 50 percent or more by the insurance company. This patient knew it was going to be expensive but had no clue about the cost, nor did the bill reflect a market-based price, but like nearly all bills, was based on cost to deliver with the hospital's profit margin built-in. It's a continued recipe for medical bill disaster for patients and providers when consumers can't assess the market price of treatment, and can't negotiate a discount. I hope he called the hospital and offered them significantly less on the bill based on what he could afford so he doesn't end up like millions of other Americans in bankruptcy due to medical bills.

  3. The guy called 911 and was brought in by EMS because they were worried about a heart attack. If you want to be sure it's not related to the heart, then this is the way to do it. If he thought it was indigestion he should have taken some Tums and called his PCP or a clinic in the morning.

    If this guy has turned out the be the 1 in 100 who did have a heart attack with the exact same story, this case would go to court and the pay out would be in the millions.

    Chest pain is considered a chief symptom of heart related problems. It can occur due to various causes such as heart attack, pulmonary embolism, thoracic aortic dissection, oesophageal rupture, tension pneumothorax and cardiac tamponade.

    By conducting several medical tests, the above causes could be ruled out or treated as recommended by medical professionals. If acute chest pain occurs, the patient should be admitted immediately for observation and sequential E.C.G.'s are followed up.

    Just like in all medical cases, a careful medical history and detailed physical examination is essential in separating dangerous from minor/trivial causes of disease. Sometimes, there is need of rapid diagnosis to save life of patient. A deep study of recent health changes, family history, tobacco consumption, smoking, diabetes, eating disorders, etc. is useful in treatment of chest pain.

    Features of chest pain could be generalised as heaviness; radiation of the pain to neck, jaw or left arm; sweating; nausea; palpitations; pain coming from exertion; dizziness; shortness of breath and a sense of impending doom. On the basis of these characteristics, a number of tests can be carried out for proper treatment. X-ray and CT scan of the chest help in determining the basic cause of pain. An electrocardiogram helps in detailed study of the problem.

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