The space between being a good doctor and a conscientious citizen

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.

Eijean Wu is an obstetrician-gynecologist who blogs at The Messy and can be reached on Twitter @eijeanMD.

This story was part of the Costs of Care 2011 healthcare essay contest, with the goal of expanding the national discourse on the role of doctors, nurses, and other care providers in controlling healthcare costs.  These stories from care providers and patients across the nation illustrate everyday opportunities to curb unnecessary and even harmful health care spending on a grassroots level. 

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  • Kevin T. Keith

    This is appalling.

    There is no question that the US healthcare system is hemorrhaging money in pursuit of frankly bad care for large percentages of our citizens, and inefficient care for the rest. But placing the blame for that on the backs of individual high-need patients is short-sighted as well as insensitive.

    Some patients do need high-intensity or high-technology care; this patient was clearly one of those. That drives up the average cost per patient, but the solution is not to cut off care for those patients. There are vast improvements waiting to be made throughout the system that would bring down overall costs without penalizing patients whose only transgression is to actually need treatment.

    Better routine and preventive care would save money and also reduce the incidence of high-cost care later in patients’ lives. More home care would reduce hospitalizations for routine treatment, and for end-of-life care that could be provided in the family setting. Consolidation of the wasteful, inhumane, and greedy healthcare financing industry to eliminate the vast administrative meddling, redundancies, and profit-taking that siphon off 30% or more of healthcare dollars would solve much of the problem by itself. Until these obvious and necessary changes are made – and even more subtle efficiencies are sought and implemented – the call to reduce costs by simply denying care to patients on a selective basis is viciously immoral, as well as unrealistic.

    Even worse is the ICU resident’s mis-use of the term “futile”. Futility is a controversial but necessary concept that is receiving wider application in healthcare; it refers to cases of end-of-life or permanent vegetative care in which continuing intervention provides no hope of improvement or quality of life as experienced by the patient. It arises, typically, when family members demand “everything” in cases in which there is no treatment that will produce a change in the patient’s condition, and the patient cannot benefit from the continued care. In this case, the patient clearly could benefit from ICU treatment: she could expect a cure for her intestinal fistula, stabilization of her wound, and possibly, had she had better luck, eventual discharge. At the very least the admission gave her several added days in which to live her life as best she could. She was not vegetative, not actively dying, and clearly wanted the treatment, and it clearly would have improved her condition. This treatment was the farthest thing from “futile” even if the odds of a complete cure were low. In invoking the powerful concept of “futility” – used to justify denying care over the active objections of the patient’s decisionmaker – the ICU fellow unilaterally erased every expectation of benefit the patient perceived, and inserted his own judgment that those benefits were not, in his opinion, worth their financial cost. This is an inexcusable act of literally deadly arrogance, and a grossly immoral misuse of the medical-ethical concept of futility.

    Both these mistakes – the attempt to alleviate the systemic problem of financial inefficiency by penalizing individual patients on an arbitrary basis, and the aggrandizement of decision-making power away from the patient through the mis-application of medical-ethical concepts – illustrate how vital it is to re-center the patient in the treatment plan, and to put the particular needs of individual patients foremost in the clinical setting.

  • Anonymous

    I think the ICU Fellow defined “Parsimonious Care” quite nicely. Bravo for standing up for what you thought was right for your patient.

  • Marc Frager

    This is exactly why the ACP/ABIM formulation of “professionalism” is so wrong. The patient can never know if the doctor is respecting his/her primacy or the importance of “parsimony” in deciding how to provide care under that formulation. Patients really do require an advocate!

  • Erin Conroy

    Frankly, I rather have her in an ICU bed then some 95 year old demented patient dying slowly from some complications of their chronic diseases. Based on your description, she was young, relatively healthy despite her HIV status. Yes, she was critical, hence why we have ICU beds… but she stood a better chance of recovery than some.

  • Anonymous

    Thank you for your comments! I think it’s hard to argue that doctors should have anything except the patient as the primary priority in the care setting. That is the job. At the same time, doctors are also in a unique position to guide changes to the whole system, which means wading into the policy and political issues. I don’t think these two roles are exclusive, but rather informative of each other. It is a matter of which hat one’s wearing at the time.

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