Wednesday, October 29, 2008

Emergency Room Meditations

My wife and I are hosting a close friend from India - a poet and professor who is doing readings at several U.S. colleges. Yesterday after he read and spoke at Wellesley College he started to experience groin pain. He ate nothing at the celebratory dinner, and by the time we got home even I as a psychiatrist could diagnose a hernia bulge. When the bulge didn't go back where it belonged by early morning I took him to a suburban emergency room.

Before we went I asked him about insurance. Luckily he had taken out a travel policy before leaving India. When we got to the emergency room, as I had prepared him to expect, the first interaction all had to do with money. The intake "financial counselor" was considerate, friendly and polite. We were told that on leaving we would be directed to pay $500 because of his out-of-the-country status.

The medical care reflected U.S. medicine at its best. The facility was clean and attractive. The nurses were efficient, warm and attentive. The physician explained his diagnosis (threatened strangulated inguinal hernia) clearly, and, in response to our questions, the mechanisms behind the symptoms my friend was experiencing. He told us that with good luck he would be able to reduce the hernia in the emergency room. An IV was started and morphine was given. Despite hefty doses of morphine the procedure was VERY painful, but it worked. I said to my friend - "this is like labor pains, except here your bulge went back in, and in labor it comes out."

The follow up advice was clear an to the point. On standing there was no new hernia bulge. The physician explained the risks of recurrence, and advised about the pros and cons of doing an elective repair in the U.S. before returning to India or back at home. The acute problem was solved, questions were answered well, and the caretaking experience engendered trust.

When we were told we could leave we were not directed, however, to go to a financial office to make a $500 payment. We wondered what this meant. I suggested to my friend "maybe they put your travel insurance through and it's all taken care of." In light of one of my favorite aphorisms - "it is better to ask for forgiveness than for permission" I suggested that we leave. "The hospital has my phone number and can call me if they need to."

When my friend called his uncle in New York to tell him he would not be coming to NYC today and explained why, his uncle's first question was "is your insurance OK?" And in conversation my friend told me that despite his having insurance his fear of what he might have to pay led him to tell me last night that he thought the hernia was starting to go back in and to resist going to the emergency room this morning.

I think all of us as citizens should think about the costs of health care and how they can best be covered, just as we should think about the costs of other basic goods like housing and education. But my friend's experience reinforced my belief that the U.S. doctrine that "skin in the game" will encourage more responsible use of health care resources is a loose policy cannon. Allowing a hernia to strangulate is potential suicide, not "prudent use of resources."

This experience, just 16 hours from the first pain until the resolution of the problem was a microcosm of health policy. We saw pain, uncertainty about what to do, reluctance to make use of needed care because of financial worry, and the caretaking vocation exercised with skill and compassion.

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