“I want answers!” My mother was upset over the care for her ill husband. Previously able to converse normally, he was now incoherent and disoriented. The recent recipient of a bone marrow transplant to treat his advanced leukemia, he probably experienced a brain infection because of the immune suppression therapy needed to accept the marrow. The marrow transplant didn’t work. He was sent home from the hospital on hospice care and died soon afterward in the hospice addition of the hospital where I was an intern at the time.
My mother insisted that something went wrong, that the hospital was trying to cover up a mistake. I tried to explain that there were risks to the procedure but that it was his only hope for survival. This was unfortunately a common outcome in the type of leukemia he had. I saw nothing wrong in his care.
Where did the process break down? Did the oncologist not explain this possibility? This is unlikely. Did my mother not understand the risks and benefits? This is possible, though I think it is more likely that she didn’t want to comprehend them.
Our expectations are influenced by our hopes and fears. Another patient encounter from my internship comes to mind. A 65 year old had been admitted overnight for chest pain that had been coming and going off and on for several months. Her primary care physician had been unable to elucidate the cause of her chest discomfort.
Unbeknownst to many patients, the hospital is not necessarily designed to answer all questions; it is a place to be treated when the consequences of poor health require monitoring to avoid serious harm or death. A patient admitted to the internal medicine service overnight for “chest pain, rule out myocardial infarction (heart attack)” was a common patient when I was an intern. All such patients were worked up with a similar diagnostic battery and sent home if a heart attack had not occurred or referred to a cardiologist if a cardiac source of chest pain was uncovered. Finding the exact cause for the pain is not always an achievable goal.
“You are supposed to feel better after you come to the hospital,” the patient told me as we were discharging her. Just like my mother with my stepfather, there was a healthcare expectation that could not be met during the hospitalization.
Instances such as these remind me just how broken our medical system is. Essentially all care that takes place inside the hospital is more expensive than if it happened on an outpatient basis. As a radiologist, I have seen this firsthand. Hospitals typically delay MRI scans on inpatients, for example, because routine outpatient MRI scans performed during daytime hours generate more profit than the exams ordered on patients in the hospital. It comes as no surprise that more cost-efficient outpatient imaging centers across the country have relatively unused scanners compared to similar scanners inside hospitals.
As physicians, we don’t always have the answers that my mom so desperately sought concerning the demise of my stepfather. Our culture is often geared toward a “100 percent satisfaction” paradigm that just doesn’t always pan out no matter what tests are ordered or how much expense is exhausted.
There is no substitute for proper counseling and guidance from physicians regarding appropriate expectations. My stepfather died from an incurable disease, and he was going to die regardless of what our system could offer. There could be many reasons why my patient with chest pain was afflicted, but the need to be hospitalized to continue to investigate was not justifiable.
For decades, doctors have known that the hospital-centered approach to disease is far costlier and less solvent than a public health approach to patients. Hospitals can’t always give the answers we want, but hospitals will always try to capitalize on the fact that people think that they can. The fact that we can’t fix this is both frustrating and sad. Why our leaders can’t propose a solution leaves me wanting answers.
Cory Michael is a radiologist.
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