30 Days on Doctoring: Reflections on Death and Eternity

As doctors, we carry our dead with us no more or less than anyone else; it is only that we generally have many more to carry.

I can still bring to mind the faces of every patient I’ve lost. Some of them I remember only as faces and stories, or mainly stories, the names long since faded. The older or very ill men and women for whom I led resuscitation attempts for no other reason than that I was the closest doctor to their hospital room when their heart stopped beating, the children and infants I continued efforts for in the emergency room, who had died in the field but compassion dictated we exhaust every possible option for, and talk with the parents carefully and in person, before discontinuing our final attempts to bring them back. These people, created in the Image of God and bearing their own unique identity and personality I never knew, stay with me as memories of the last desperate battle against death, difficult decisions made rapidly, and finally small, quiet prayers offered in the unofficial office of priest I unknowingly accepted when I enrolled in medical school all those years ago. The memory of who they were in life is left in the safe keeping of others.

Others I had a greater privilege of really knowing; I was there not merely in their last moments but for their last weeks or days, saw them battle with and often come to peace with the drawing near of their time on this planet; saw them experience and then cease experiencing pain, anxiety, worry, doubt. Like anyone who has lost somebody, I have been struck by the strangeness of spending those days with them in conversation, earnestly offering what comfort I could, only to be in the room with them bodily again sometime later, but now utterly alone. I hold these images together, the person living and the person dead; but am thankful the former is by far the stronger impression. I have been thankful, when medical circumstances have allowed, when those last days have resulted in choices that led a person to die in relative peace and comfort at home or otherwise surrounded by loved ones, and my role of final comforter in life and companion on the very brink of death has been taken by others infinitely more qualified. In those cases, I have the privilege of keeping only the living person in my memory.

Still others I remember in three dimensions; their face and voice in life, their sense of humor, their struggles and triumphs. Those whom I have been physician to over many months and years and, like the patient I called ‘mi abuela’ and who used to slap me on the arm for being such a bad grandson, only learned of their deaths after the fact. Often those relationships went far deeper than the mere clinical as over time a very human fellowship came to define our patient-doctor relationship as much as any exchange of medical information, advice, or prescriptive guidance. These patients especially kindle in me the hope of Heaven, and I find unspeakable comfort and joy in the not unreasonable hope of a continuance of the friendship and brotherhood between two souls we began on this Earth, then unalloyed by any thought of medical knowledge or clinical skill needed or offered.

We cannot recall all of these many losses with complete satisfaction. Often times we do reflect on our role in informing and preparing a patient for death with some degree of contentment, with the assurance that we had the needed foresight and skill for the moment and can take comfort, at least in our small part, in a job well done. In contrast, there are for each and every one of us mistakes we know we made, and hopefully have apologized for, that accurately place on us some small or large degree of responsibility for a person’s death. I am grateful that these experiences have been rare, and am deeply grateful to have found compassion, understanding, and forgiveness at the close of each of those stories.

But most often, neither of these is the case; neither perfect complacency nor right and accurate self denouncement, and we are left with less closure, less complete understanding than we would have wished. For every tragedy where a family and friends are left to wonder “what could anyone have done?” there is a physician who is left to question, earnestly drawing on all their clinical reasoning and accumulated knowledge, “What could I have done?”

People think that as a profession, as a field of study, we engage in post-mortem examinations, case reviews, and mortality and morbidity conferences either because we long for greater academic knowledge or because we wish to find someone to blame for the tragedy of death. These are both true, though decidedly not in the way that most people think. The longing for knowledge is not sterile or disconnected from the human story or from grief, and the desire to assign responsibility is not adversarial or blaming, but rather both seek to view tragedy as an opportunity to grow and provide still better care in the future. In our anatomy classes our dead were our first teachers; ever after they remain our best teachers, because the lessons they provide are the most powerful. But there is a third motivation that I think is equally as powerful as the others. As physicians we carry our dead, and when a loss is unexpected or tragic, or holds any possibility of error (as almost all do), we carry the weight of the burden of that death all our lives. In seeking to understand the role we might have played we are attempting to define the dimensions of that burden; to know exactly how much of the weight we are, personally, to carry.

The Hope of Heaven is what remains. Similar to (I am certain) lawyers and social workers, physicians long for a day when our particular skills, abilities, and expertise are utterly and permanently irrelevant. The farmer or craftsman may contemplate eternity with an expectation of some continuation of a form of his earthly work, and hope to see it brought to completion by an increase and perfection of skill or else a diminution of toil; the doctor believes his work will be perfected only in eternal uselessness, when in the presence of the Great Physician we can have nothing at all to contribute. The most skilled physician on earth longs to be only a poor apprentice pruner or assistant herdsman in eternity, when pain, illness, and all forms of human, Earthly suffering are at a final and unequivocal end. It is with this hope that we walk into every exam room, approach every hospital bed, and delve into every instance of physical, emotional, and spiritual pain. It is this hope alone that makes them bearable as a physician.

And it is this hope that we, implicitly or explicitly, hope to impart to our patients who are undeniably bearing the greatest part by far of those burdens, which with all our training we can only strive to lessen but know we can never truly undo or perfectly prevent.

Lord, hasten the day.

30 Days on Doctoring: I don’t get to pick which medicines your insurance company will pay for.

In late 2019 I began to write about my experiences as a Family Medicine Physician, and particularly my motivations, reasoning, and practice style. Over the last decade of medical school, residency, and practice, I had come to believe that the steadily eroding trust in doctors was a true public health emergency. My theory was that, while some of this was due to profit or power-driven elements like the anti-vaccine movement and alternative health industry, and some was due to legitimately unconscionable treatment at the hands of a relative few unethical and immoral doctors, the vast majority was due to the complex and often confusing nature of medicine itself. I believed, or at least hoped, that if people understood their doctors better and knew how deeply they cared about their patients and how hard they worked for them behind the scenes, they would come to see doctors- and other healthcare professionals- as I do; as their allies and advocates in our deeply broken healthcare system.

Since the COVID-19 pandemic began I have found my attention called more and more to medical misinformation about the virus, which is what ultimately led to my starting this blog. Yet at the heart of so much of this misinformation is that same mistrust and suspicion. So partly to find a home for these few stray essays, and partly to continue pursuing my original goal of pulling back the curtain and helping others better understand the convictions and reasoning their doctors bring to their care, I am sharing these posts here.

I recently encountered a situation where a patient was very upset with her doctor for switching one of her medications. This medicine had been affordable, easy to use, and had seemed to be working well for her, and you can imagined her frustration when her doctor suddenly stopped prescribing it and prescribed an alternative medicine instead. I explained that this didn’t sound like something the doctor would do maliciously, and offered to restart the old medicine if the patient thought it would work better. The patient exclaimed angrily, “Well now my insurance won’t pay for it ever since Doctor —- took it off of my formulary!”

Of course I wanted to help her make sense of this, so we sat together and reviewed the medical records; phone calls with the patient, office visit notes, even the internal messages between our staff and this doctor- everything pertaining to this medication. Here’s what had happened: when refilling the medication, the clinic had received a prior authorization from her insurance company, as the medication was no longer covered as a first line option. When the PA was completed and sent back, it was rejected. The medication is about $550 per month; $470 with the best coupon available. The doctor was stuck; the patient could keep taking the medicine and pay cash, of course; but this patient didn’t happen to own a chain of hotels or a major golf course, so she didn’t have that kind of money. The only other option was to prescribe an alternative that was still covered (for now) and hope it worked as well. I can’t tell from the chart if this was explained in detail to the patient originally or not, but it was obvious she hadn’t walked away understanding the situation in the slightest. Even after this visit and my detailed explanation that her doctor has zero input on what her insurance company will and won’t pay for, she has repeatedly expressed frustration that her doctor ‘took [this medicine] off of my formulary’.

There’s a lot to unpack here. In an ideal world, the most important factor in what an insurance company would pay for would be the doctor’s determination, after carefully evaluating the patient and engaging in shared decision making about a treatment plan. Cost should be a consideration, but if a patient needs a certain medication or is stable on a certain medication, that should be the medication they end up with. In reality, the biggest factor is cost; cost to the system, to the insurance company. I don’t know the ins and outs (I spend all day trying to treat people and don’t have the time or leftover emotional resilience to dig into the underworld of insurance and pharmaceutical company business practices), but I understand that contracts between drug manufacturers and insurance companies seems to be a major factor. In my more cynical moments, I also suspect that there’s an element of strategy involved on the part of the insurance companies; for instance when they get a windfall of savings every few years by suddenly changing which type of basal insulin they will pay for and pocketing the cash while patients do without insulin for a month or two as they and their doctors scramble to catch up.

A lot has been written about prior authorizations, and I’ll just add a little bit here. One of the strongest arguments against a single payer system seems to be that if you put the government bureaucracy in charge of healthcare, healthcare will become muddled and inefficient. What most people don’t realize is that there is already a bureaucratic army making healthcare inefficient. Those rejections for medications, MRI’s, specialist referrals, support services, physical therapy and medical devices I deal with every day are not being done by Physicians and Nurses reviewing my patient’s chart and disagreeing with me about what’s best for them based on a lifetime of providing clinical care; they are being rejected by someone with little to no medical knowledge or training, checking to see if there is any undotted i or uncrossed t in the patient’s chart that would allow them to reject it based on criteria that is, essentially, arbitrary. Because rejecting things is their entire job; because that’s how the insurance company makes profits, by getting insurance premiums from members and then finding ways to not pay for medical expenses for those members. I’m not sure what to call this system, but evil seems pretty close to accurate. I’ve had paralyzed patients wait for months and months, with countless phone calls and office visits, in order to be approved for an electric wheelchair; even though anybody regardless of medical training could look and see they needed one. But the person reviewing the claim isn’t paid to get the person a wheelchair, or even to figure out if the patient needs a wheelchair; they are paid to find a way not to not have to pay for a wheelchair.

Everyone worries about doctors abusing the system, handing out medical devices and expensive treatments willy-nilly because they want patients to be happy or because they somehow get a cut. This probably does happen (see this video from ZDoggMD for a great example), though I think it’s fairly rare, and oversight and accountability are very important. But the current system isn’t built on oversight, it’s built on profits, and the overwhelming majority of honest patients and ethical doctors are the ones who end up paying the price for those profits. When your insurance company won’t pay for a covered service or medication you and your doctor have determined you actually need for your health… they are literally robbing you.

Insurance companies love that stereotype of the unethical doctor abusing the system, by the way. They want to be seen as the good guy, to tell society that if it weren’t for them healthcare would be way worse off because nobody would be keeping those terrible doctors and those patients exploiting the system (everybody but you and your doctor, don’t you know) in check. They send you a notice in the mail that explains the charges and what they paid for, and right at the top it says “this is not a bill.” If it’s not a bill, why did you mail it to me? Because they want the opportunity to tell you, “this is what your doctor wanted you to pay, but we paid this much and now you only have to pay this much.” Often times this is the very same doctor who has spent extra time (and brought work home with them for the evening or weekend) trying to help you figure out the Rubik’s Cube of getting the care you need without going into medical debt, and who would actively be working to find a way to provide the care you need with fewer visits and lab tests and referrals, even if that wasn’t exactly ideal for your medical issue, if you were paying out of pocket and had to face the cost of those visits on your own (we literally do this all the time; I even ask insured patients what their copay to see me is in order to help them figure out a follow-up schedule that balances their medical needs and their out-of-pocket expenses).

Now, surely, some people who work for those companies do care, at least in a general sense; they want healthcare to be better, they want things to be ethical and smooth, they value customer service. There are probably entire departments that are like that; patient liaisons and advocates working within the insurance company, maybe even some executives. Probably there are some people in these claims rejection roles who, like Mr. Incredible, are intentionally worse at their job of rejecting claims than they could be because they are driven by compassion (I’m pretty sure I’ve spoken with some of them during the Prior Authorization process). But at the end of the day, for profit insurance companies are for profit, and because they are dealing with systems and not individuals, the blame for practices that hurt people feels very diffuse, anonymous, and impersonal. No, they won’t twirl their mustaches and look your kid in the eye and tell them they won’t help mom get her medicine; but they will create company policies and appeal systems that are obstructionist and slow down the delivery of care and ultimately hurt people, and then refuse to be overridden by your doctor who actually knows you and understands what you need from talking with you and examining you. They will let you die if they have to in order to make their money; they’ve been doing it to people for years.

Wow. That got a lot darker than I had intended. I’ll try to post something lighter over the weekend.

30 Days on Doctoring: Medical Roadblocks and Barriers to Care, A Story.

This is a story about Prior Authorizations. The American Medical Association defines Prior Authorizations as “A health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage,” and the Hitchhiker’s Guide to the Galaxy describes the insurance company executives who invented this process as “A bunch of mindless jerks who’ll be the first against the wall when the revolution comes.” Doctors just define Prior Authorizations as “Oh no, not again.” One would imagine that after the involved process of history taking, physical exam, strategic work-up and diagnosis, and careful shared decision making between a patient and a doctor, the two of them could be trusted to come up with a treatment plan together. Insurance companies don’t believe this; or at least, pretend not to. Sometimes these processes are routine and streamlined enough that they represent only a minor hiccup in the patient’s care. I’ll even admit that sometimes the processes probably do catch cases of insurance fraud. But what they actually do much of the time is block the patient from receiving the care that both they and their doctors believe is necessary, at least until seemingly arbitrary and intentionally onerous hoops are jumped through first. 

This story is a real life example (of course names have been omitted and a few details have been changed), and I know this because I was involved in this case, though I don’t enter in within this part of the narrative. But as illustrative of the problem as this case is, any doctor you know could provide a dozen or a hundred other examples at the drop of a hat. If you live in the American medical system, if you have a medical emergency or a catastrophic diagnosis, of course you are going to be thankful that you have insurance, and the better your insurance the more grateful you will be (though even this might not protect you from incurring astronomic medical debts). But ultimately, unlike your doctor or nurse or physical therapist who chose their profession because they wanted a vocation that allowed them to make a living while helping others, these companies exist to make a profit, to take in more money from insured people’s premiums than they pay out in claims or expenses; and we forget that, and think of them as real allies in healthcare, only at our peril.

A 2 year old little girl fell and broke her arm. It happened while playing outside in the evening, and when she wasn’t able to move it without excruciating pain, her family went to the Emergency Room at their local hospital. They chose that hospital, out of all the hospitals in town, because it was owned and operated by the same company through which they have their medical insurance (this is important). The child was found to have a fairly rare and complex fracture, and it was intra-articular; it was affecting the bone at the elbow joint. This always makes for a more complex and unstable fracture, with greater risk for poor or dysfunctional healing and long term sequelae. Fortunately, the hand and arm beyond the fracture had good blood flow and sensation, and the fracture didn’t appear to be displaced. The Emergency Room doctor and nurses splinted the arm to keep the joint stable, but didn’t have a pediatric Orthopedic surgeon on call; since it was a weekday, however, they made a referral to a surgeon within their system for the child to be seen the following day. The appointment was scheduled and the child went home with her family.

So far, except for the actual breaking the arm part, everything had gone smoothly. And it just happened to be in a neat little package; the Emergency Room, the x-ray machine and radiology tech, the ER doc, the nurses, and the Pediatric Orthopedic surgeon, his clinic, the nurses he works with, and the OR he operates in were all under the umbrella of the very same company that provides the patient’s insurance. This, surely, is how these systems are supposed to work, right? Scenarios like this are exactly why this family, or your family, would prefer to have private insurance instead of, say, Medicaid. All that needed to happen now was for the patient to be seen the next day (Friday) by the Orthopedic surgeon, for that surgeon and the parents to decide on a course of action, and then either cast the arm or schedule surgery, or both.

That’s what should have happened, but because of policies that insurance company had in place to slow down utilization and save money, here’s what happened instead. The family called the Orthopedic Surgeon’s office the following morning, bright and early, to confirm the appointment time; they were told that without a referral she couldn’t be seen. They explained that they had a referral from the day before, but this insurance company’s policy is that the referral has to come from the Primary Care Doctor, not from the ER; it is part of their prior authorization process. If the patient were seen without that referral, the insurance wouldn’t pay for the visit and the full cost of it would be on the patient; since sometimes patients don’t pay their medical bills, the Ortho clinic wouldn’t schedule the visit until they received (and processed) the referral. The family had no other choice; they scheduled an appointment with their Pediatrician, who works in a totally different healthcare system,  just to get that referral.

Now, if the family had known they had this option, they could have called their Pediatrician and explained the situation, and she would have sent the referral right away without an appointment, and then spent the morning advocating for her to be seen that very afternoon even before the referral had been ‘processed’, eventually either sweet-talking or strong-arming the clinic’s front desk into getting her on the schedule, or failing that, going over their heads and asking the surgeon directly (who despite all the stereotypes typically have strong feelings about not ignoring little girls’ broken arms); as primary care physicians we have to do that kind of thing all the time. The family didn’t know this, however, so they schedule an appointment for that afternoon with the Pediatrician; it felt like the best they could do.

So just after 4 PM on Friday afternoon, after seeing who knows how many patients that day already, the Pediatrician has this little girl walk into her office and she discovers the situation they are facing. It’s far too late to get them in to see the Orthopedic Surgeon that afternoon, even if they could get them on the schedule (they couldn’t), and even if the clinic were only across town (it wasn’t). The Pediatrician asks her nurses to call the Ortho clinic while she researches more about the type of fracture she has, which is very rare in a child this age. Every case study she can find tells her that the break will need surgical fixation; but some have it being done immediately and others have it casted for 2 weeks first, and the Pediatrician simply doesn’t have the Ortho background to know which is best in her case. Her plan is to ask the Pedi Orthopedist to look at the x-rays and give them an opinion; can the child wait to be seen Monday morning, or does she need to send her to the ED in another town where the Orthopedist consults, so they can treat her that evening?

The nurses get in touch with the front desk at the Ortho Clinic, and they actually tell the team that the Pediatrician can’t talk to the Orthopedist about this patient until they receive the referral (which the medical assistant was faxing at that very moment); the nurse transfers the call to the Pediatrician and she ‘pulls rank’, something we Primary Care Doctors rarely do (and even more rarely succeed at); they page the surgeon, and the Pediatrician waits on hold. Eventually they let her know that they will keep trying and will pass along the message, and she gives them her cell phone number. Despite having other patients to see and being behind on charts that afternoon already, she has a long discussion with the family about the plan, and the contingency plans, and the backup contingency plans, all revolving around what the surgeon says and if they are even able to get through to anyone with the Ortho team in the first place.

-At 4:45 she hasn’t heard anything, so she calls again.
-At 5 she lets the family know she is still waiting on hold, but they can go home and she will call them as soon as she hears from Ortho; she makes sure the mom’s number is correct in the computer system so she can reach her.
-At 5:15 she gets in touch with Ortho; with the resident on call, I believe. He takes the medical record number and date of birth, and the Pediatrician’s cell number; he isn’t is a place where he can look at the x-ray right now but will call her back.
-At 6:30 she still hasn’t heard back (and didn’t think to get his cell phone number, she later realizes), so she calls the mom and lets them know she is still waiting. The child is doing well and they have bags packed in case they need to go to the ED to get seen by Ortho that night, which is one of the possible plans they discussed.
-Also at 6:30, the Pediatrician takes her kids to a local park. Even though she is not on call, she checks her phone about every 5 minutes to make sure she hasn’t missed a call from Ortho. She doesn’t.
-At 8:30 she is back home, and her partner gets to put the kids to bed alone while she sits on the phone, on hold again waiting for Ortho. She spends her time reading every case study she can about this type of fracture; she is increasingly unconvinced that it can safely wait until Monday to be addressed.
-At 9 PM she hangs up and calls the mom instead (at that point you are reaching the unprofessional hours of the night, and as silly as it seems a lot of doctors feel like they are leaving the wrong impression by calling past 9 or 10 PM); she apologizes profusely that she hadn’t been able to reach Ortho and advises her to go to the ED in the other town where they can get Pedi Ortho to look at her arm. Hopefully that ED trip will end up being ultimately unnecessary, she says, and the surgeon will look at her arm and get new x-rays and tell her to come back to clinic on Monday after all (now that she at least has a referral in place)…. But if not, if they do think she needs surgery right away, it will have been worth it. This is an exercise in frustration, but it’s what she would do if it were her kid and she couldn’t get an expert opinion in any other way.
-At 9:10 PM Ortho calls her back in response to that second round of calls; an older doc this time, probably the attending. She tells him the story and he is motivated to help this kid, as most doctors almost always are. He pulls up the x-rays and they aren’t showing him what he needs to see; he asks if she can get new x-rays at different angles (naturally assuming she is at an ER or Urgent Care facility because of the hour). She explains that she is in her living room, and the patient is in her living room, and neither living room has an x-ray machine (the snarkiness is my own addition). He wants to run the x-rays by a colleague; he will call her back. She calls mom and lets her know to pump the breaks on driving to the other ER, which I should mention at this point is over an hour away.
-At 9:20 the surgeon calls back. They agree the fracture shouldn’t wait until Monday, and they need additional x-rays to come up with a specific plan. But, realistically they aren’t going to do anything about it at midnight tonight anyway, especially with it already in a cast. They recommend letting the family sleep at home and then heading to the ER first thing in the morning; he is going to notify the ER doc and the Orthopedist on call the following day to make sure everything that is suppose to happen, does happen.
-At 9:25 The Pediatrician calls mom again and explains everything about the plan in detail, and reassures her that now there is solid Orthopedic surgical advice behind the recommendation; mom is comfortable with the plan and is ready to drive to the ER tomorrow morning. The child is resting comfortably after taking some pain medicine, but still not moving her arm. The Pediatrician finishes the visit note on the computer, then goes back to her other lingering clinic work, and eventually goes to bed. She would have clinic work to catch-up on the next day (Saturday), of course; but that’s the natural penalty for 1. taking the extra time to coordinate care for this patient, and 2. daring to spend a few hours with her kids on a Friday evening.

Saturday morning the family arrived at the ER promptly, and after a little confusion and a few explanations, everyone realized this was the child the Orthopedic surgeon and ER doc had been talking about last night. Ortho was paged, she had her new x-rays done, and had surgery on Sunday to fix the fracture.

From Wikipedia: “Insurers have stated that the purpose of prior authorization checks is to provide cost savings to consumers by preventing unnecessary procedures as well as the prescribing of expensive brand name drugs when an appropriate generic is available.”

So to sum up, this Pediatrician spent well over 2 hours on the phone over the course of an entire evening, coordinating care between two hospitals, her clinic, and two Orthopedic surgeons, in order to facilitate weekend, emergency room based specialist care for a little girl with a broken arm… who should have just been seen in Ortho clinic on Friday instead of seeing her Pediatrician in the first place. (By the way, the doctor in question billed this to her insurance at the level of a 25 minute visit; we don’t really get to bill for our full time the way lawyers do).

Why? Because this healthcare system’s policy is to not trust an ER doctor that they employ to know that the patient needed to see an Orthopedic surgeon they also employ, and instead require a referral from the PCP. Because that policy slows down the delivery of care and, in aggregate, means they have to pay for fewer specialist visits, and that means they get to keep more money from insurance premiums as profits; or in their words, “cost savings to consumers.”

I absolutely do look at your insurance (repost).

In late 2019 I began to write about my experiences as a Family Medicine Physician, and particularly my motivations, reasoning, and practice style. Over the last decade of medical school, residency, and practice, I had come to believe that the steadily eroding trust in doctors was a true public health emergency. My theory was that, while some of this was due to profit or power-driven elements like the anti-vaccine movement and alternative health industry, and some was due to legitimately unconscionable treatment at the hands of a relative few unethical and immoral doctors, the vast majority was due to the complex and often confusing nature of medicine itself. I believed, or at least hoped, that if people understood their doctors better and knew how deeply they cared about their patients and how hard they worked for them behind the scenes, they would come to see doctors- and other healthcare professionals- as I do; as their allies and advocates in our deeply broken healthcare system.

Since the COVID-19 pandemic began I have found my attention called more and more to medical misinformation about the virus, which is what ultimately led to my starting this blog. Yet at the heart of so much of this misinformation is that same mistrust and suspicion. So partly to find a home for these few stray essays, and partly to continue pursuing my original goal of pulling back the curtain and helping others better understand the convictions and reasoning their doctors bring to their care, I am sharing these posts here.

Originally posted December 5th, 2019.

30 Days on Doctoring: I absolutely do look at your insurance.

Every day I hear from a friend or a patient, or see an article, a post on social media, or somewhere else where someone has written that your doctor only cares about you if you have the right insurance. Doctors will only order the right test, only give you the ‘real’ medicine, only spend their fair share of time face to face with you if you’ve got the right coverage. The link between your local PCP and the Walgreens across town or the medical equipment company isn’t exactly clear; somehow the doctor is getting kickbacks, though, and those kickbacks don’t happen if you are paying out of pocket or if you have to use a coupon or have the types of insurance that don’t come with a premium ‘gold status’ membership; to have the right insurance is to be in the club, and everybody else is left to suffer and make their way the best they can.

I’d love to tell you that I don’t care what insurance you have. I’d love to say it just doesn’t matter to me, that every patient gets an equal share of my time, energy, and attention. I’d love to tell you that I treat your CHF and shoulder pain exactly the same if you have Medicare, or Blue Cross and Blue Shield, or our local state grant funded coverage program, or are paying out of your own pocket.

But it isn’t true.

My confession: I absolutely look at your insurance. Every day, every patient, every visit. I may even ask you what insurance you have, right in the middle of our visit, just in case that tab on my computer screen isn’t accurate or up to date. Let me tell you why.

Let’s say you come to me for that congestive heart failure that we just mentioned. For the sake of discussion, let’s say you’ve never been diagnosed with it before and have only recently developed the symptoms (dyspnea on exertion, unexplained weight gain, swelling in the legs) and have risk factors (a heart attack a few years ago, years of high blood pressure, a strong family history of heart failure). I’m going to need to do a few things regardless of who you are and what your insurance is like. We are going to spend time talking about your symptoms; when did they start, what have you tried already to relieve them, are they getting worse and if so how quickly? We are going to talk about your history; has this happened before, has it already been worked-up and to what extent, any other medical problems that could be causing these same symptoms, mimicking CHF? And we are going to do an exam; listen to your heart, listen to your lungs, press on your legs to see if and how much swelling you have and whether it is pitting or non-pitting, check your abdomen for pain and free fluid or enlargement around the liver and any signs of cirrhosis (which causes a lot of the same symptoms as heart failure). We are going to do all of this for every single patient presenting for the symptoms of CHF. And then we are going to get an EKG, because it’s quick and fairly cheap and can be done in my office and gives us some good information about your heart.

Then I’m going to look at what insurance you have- and maybe even ask a little bit about your finances- because here’s what else we need in order to figure this out:

  • Basic labs including a complete metabolic panel (CMP- information about kidneys, electrolytes, and your liver), maybe a complete blood count (CBC).
  • A B-natriuretic peptide level. This is a protein produced by the chambers of your heart in response to increased stretch/pressure, and it helps lower pressure and -as the names suggests- works as a diuretic to clear fluid. As a lab test, we use it as a surrogate for how much the pressure within your heart chambers is increased; a marker of congestive heart failure and the resulting overload of fluid.
  • A Chest X-Ray to evaluate whether there is extra fluid both in the blood vessels that supply your lungs and in the pleural space around your lungs, and whether your heart is enlarged.
  • An Echocardiogram; this is an ultrasound of your heart and the most important test in your CHF work-up; it tells whether the heart is actually pumping normally and if not, exactly which chambers, valves, and phases of your heart beat are affected.
  • A referral to a Cardiologist, and probably some associated programs like CHF clinic and cardiac rehab.
  • Treatment! Not only cardiac rehab, but dietary and lifestyle changes and also multiple cardiac medications.
  • A follow-up appointment with me to look at the results of all of these tests, make sure we really have the right diagnosis, and evaluate whether your treatment is helping you at all.

You’ve all been around the block, so I don’t have to tell you how expensive this is all going to be. The answer is: probably very very expensive.

And if you have Blue Cross Blue Shield, or better yet Medicare or Medicaid, that’s probably ok. You’ll have some out of pocket expense and maybe have to meet a deductible; it could still be a financial hardship, but with your insurance it shouldn’t be a true financial disaster, at least not all at once.

But what if you don’t have insurance? Or what if your coverage is grant funded and only applies to the treatments we can do in-house? Well now we have some decision to make.

Labs: Some of this blood work is more expensive than others, and some is more vital for working-up this condition than others. In some situations our in-house lab is going to be your cheapest option, but sometimes it’s going to save you a lot of money for me to order the labs to be done at another site where you pay cash up-front for a cheaper price. This is actually more work for me and my staff, but if it saves you the money you need to put away to get some of this other work-up done (or, you know, pay your rent this month), then it’s worth it. The decision of where to do which labs and trying to figure out how much it’s going to cost you is one I have to make a dozen times a day.

Imaging: Again, we can do some of this in-house, but we’ll need to talk about the cost. I don’t have as many options for outside imaging; we can do your x-rays here and the hospital can do your Echo, but there are costs associated with both. If you are paying out of pocket or only some of these tests are going to be covered, we need to prioritize and work on figuring out exactly how much each is going to cost you. Some hospitals have patient assistance programs; maybe you would qualify, so we need to get you in contact with the right department and start getting cost estimates. Again, more work for me and my staff, not to mention for you, but the alternative is for you to end up with an unexpected $2,000 bill for the Echo I ordered, and then you might not be able to afford the ACE Inhibitors, Beta Blockers, and diuretics you are going to need to actually treat this condition. Which brings us to…

Medications: Do you know how much a month’s or 3 months’ supply of those medications costs? Do you know which is cheaper with HEB or Wal-Mart generic pricing, which is cheaper with a GoodRx coupon (at the pharmacies that will accept one), and which is cheaper at our clinic’s pharmacy? I do, because a medication left at the pharmacy because it was too expensive has just unbelievably poor bioavailability. It looks great on paper if I prescribe all the right, best medications; it does nothing to help your heart if you can’t actually get those medications. So we are going to talk about each medicine and the rationale for it, the risks and benefits, etc.; of course we are. But we are also going to talk about which pharmacy you want to use, how much I expect it to cost there, what the alternative options are, and because I’ve been burned in the past I’m going to say the same phrase at the end of almost every single patient visit; “If you get to the pharmacy and one of these medications costs more than we are expecting, and the cost is prohibitive or just seems really high, please call us before you buy it so we can look for a coupon or recommend an alternative.” The first time your patient tells you they borrowed money from friends and family so they could pay for the $120 medication you prescribed, when you know it was actually $8 at another pharmacy or with the right coupon, you will start saying this at the end of every visit too.

Specialists: We have a lot of excellent specialists in the city where I work, and ideally your CHF is going to be managed through regular visits with a Cardiologist and CHF clinic, with me along for the ride to explain things when they aren’t clear, keep an eye on your other medical issues, and keep you out of the hospital (or get you to the hospital) when you have an exacerbation and your Cardiologist is booked solid or not available in clinic. If you have private insurance or medicare, that will almost definitely happen. Even if you don’t have great insurance coverage, this is still ideal, and I have many patients who have worked with the local specialists to come up with a payment plan; I don’t know the details of those arrangements, but I’m often pleasantly surprised by how much our specialist clinics work with people to get them seen. If that’s not possible, many of the specialists in town create access for our patients by volunteering their time at our clinic. Often times there is a wait list, though, and until then (and in between visits), I get to be your “cardiologist”. Or your “rheumatologist,” “pulmonologist,” “endocrinologist,” or you name it. I put those in quotes because while as a full-spectrum Family Medicine trained Physician I have worked and trained and studied in all of those areas of medicine, I am an expert in none; ours is a Jack-of-All-Trades specialty by design. But if your financial and insurance coverage situation means that you can only see me right now, you can believe our visits are going to be longer and more frequent.

Follow-Up Appointments: I can’t count the number of times that I’ve asked a patient what their co-pay to come see me is, only for them to start explaining when they are going to pay their bill or some similar concern, as though I knew what their account balance was and wanted to make them feel bad about it. I’m grateful to work in a clinic where that is not my job at all. I’m asking because if your Co-Pay is $10, I’m going to be prioritizing some of the above conversation for today and save some of it for 2 weeks from now, so you don’t feel overwhelmed and have time and space to process your diagnosis. If your co-pay is $80, or you have no insurance and so you are footing the entire bill, we are going to address as much as humanly possible because I know seeing me again in 2 weeks is going to be a burden, and if there’s a way we can put it off for a month by doing more today, then we will.

So the TL;DR version here is that I definitely do look at your insurance. Because if you have great access to wraparound care, testing, and specialists then you aren’t any less deserving of my time, but you probably don’t need quite as much of it, at least usually. But if you have limited access, you aren’t any more or less deserving of my time or energy but you are probably going to need more of both; if you only have a few medical professionals in your corner, then each of us is going to have to step up and give some more time, some more creative thinking, and some more effort to get you the closest thing we can to comparable, just care. The only alternative is to simply accept health disparities as an unavoidable and uncorrectable fact of life, and that’s something our Oath just doesn’t allow for, no matter how broken the medical industry we work within happens to be.