Monday, March 12, 2012

A Question of Worth

Dr. Eijean Wu is a gynecologic oncology fellow at the University of Southern California Medical Center, and was a finalist in the 2011 Costs of Care Essay Contest.

As an OB/GYN resident, I tried to reconcile quality and cost of care every day. This is the story of one patient who cost the system a lot of money, but I don’t know to this day if it was too much.

Cheryl (name changed) had HIV, a history of cervical cancer, and 3 kids. At age 35, she had been cured from cervical cancer after surgery and radiation therapy. However, due to treatment-related fistulas, she had been in and out of the hospital for most of the year. I was taking call for the gynecology service the last time her family brought her in, delirious and with black, sticky stool oozing from an opening in her unhealed abdominal incision. She needed wound care and close monitoring in the intensive care unit (ICU). I paged the ICU team.

The ICU fellow came promptly, and briskly refused to accept her to his unit. “She is a poor use of scarce resources,” he stated matter-of-factly. “Further treatment is futile.” Without missing a beat, I looked him in the eye and countered, “What if this was your sister? Your mom?” He relented begrudgingly, but added, “This is why health care is so expensive in this country. You surgeons don’t know when to let go.”

Thanking him for accepting my patient, I went back to Cheryl to clean up her wound. She grabbed my arm and whispered, "Dr. Wu, I'm scared. Don't leave." I assured her that we would do everything we could to get her back to her kids. Afterall, her cancer was gone and her HIV viral load was undetectable. We couldn’t quit now. Two days later, Cheryl was leaving her room to sneak a cigarette. One day after that, she was found dead in her hospital bed by a nurse checking vital signs. Cheryl had quietly passed away in her sleep from a massive gastrointestinal bleed.

Had I gotten too attached and lost sight of the big picture, as the ICU fellow purported? Who deserved that last ICU bed that night? Someone who would have only cost taxpayers $10,000, $100,000, or $1,000,000 during her stay? Would it have mattered to the hypothetical taxpayer that Cheryl had lost her professional job and employer-based insurance due to her long treatment, then lost her home, then spent down her income and thus qualified for Medicaid? Was it my responsibility to be considering resource allocation while my patient was critically ill? Besides, the ICU fellow abandoned his cost-conscious argument quite quickly at the mere suggestion that he would do otherwise for his family member.

I had worked in the private, public, and not-for-profit sectors prior to going to medical school. I had pondered the roles of corporations, governments, and single-issue foundations in shaping our health care system. I knew about the slippery politics, limited data, legal pressures, and economic realities. Yet, time and time again when my patients come into the emergency room or are lying on the operating table or get better or worse after some intervention, I struggle to see the forest for the trees.

On some level, I don’t think my patients want me to be thinking about the sustainability of the health care system when I’m counseling them about their options. They want to know that I am their unwavering advocate. Their interests are my top priority in that fiduciary relationship. If I suggested more or less, it would only be watching out for them, not for the general public.

Yet, my experience tells me that providers, the people who oversee these cherished doctor-patient interactions, must play a principal role in revamping this overwrought and overpriced health care structure that does not produce the quality and safety outcomes any moral society would demand. Doctors wrestle with the nuances and inefficiencies of the institution every day. Medicine is not mathematics, but it is prudent to inject a measure of cost-awareness into our diagnostic work-ups, treatment algorithms and clinical trials. It may seem distasteful to knowingly put a monetary value on life, but we already do that calculation with each clinical decision we make. Higher quality can be affordable and accessible.

So for now, I continue to navigate that difficult space between being a good doctor and a conscientious citizen. I will see many more patients like Cheryl in my career. They will always be pushing me to do better.


  1. Perhaps the key is that this is really "the story of one patient who made the system a lot of money?"

    1. It has become far too easy to make glib comments about 'the system' especially as related to money. The day one receives that dreaded phone call relating the bad test result is the point of change at which (s)he begins to understand there is more to the issue than politicking over costs. Despite 'the system,' Dr. Wu sounds like the kind of physician I would trust to have my back.

    2. Thank you for your comments! I wanted to highlight that in day-to-day practice, there can be a conflict of interest between dollar costs for the system versus an individual patient. This is a classic dilemma in policymaking. I don't have the answers, but I believe people like Dr. Berwick (former Medicare administrator) and organizations like Costs of Care have identified some key areas for eliminating waste and increasing financial transparency. What we all strive for is to increase *value* in how health care is delivered, which for me, means biggest bang for the buck.

  2. It is easy to take the high moral ground when you are spending someone else's money. I wonder what choices you would make if the dilemma were to choose between paying out of pocket for end of life care for 1 loved one, vs. putting food on the table for the family (or paying that semester's tuition for a child). An

  3. Ironically, it is increasingly becoming "our money" that is spent, by which I mean taxpayer dollars. But it is true that not having to personally write the check changes the way health care decisions are made. There is no easy answer or single answer that is appropriate for all patients and families. Ultimately, it doesn't depend on what doctors want, but what the patients want.

  4. Thanks for such a nice Blog and useful story. I need to share with my friends. Keep it up dear..