Cheryl was a cancer survivor, recovered drug
addict, HIV carrier, and devoted mother of 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 called my attending and paged the ICU team
simultaneously.
The ICU fellow came promptly, and briskly refused to accept her to his unit…again. “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 site. 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,
she had controlled her heroin addiction, and her HIV viral load was
undetectable. She had fought hard to get to this point and wasn’t quitting 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 nursing assistant checking
vital signs. Cheryl had quietly passed away in her sleep from a massive
gastrointestinal bleed.
My experience with Cheryl was one of the most
difficult and meaningful moments in my residency. I still wonder if I made the
best choice. 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 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 broader health care 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 if it were his
own family member on the stretcher.
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. I had armed myself with the academic tools
to appreciate the context before becoming a doctor. 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. Creativity
and adaptive skills are the bread and butter of survival in an academic medical
center; ask any intern.
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.
