Bottom Line Vs. Hippocratic Oath
Jul 16th, 2008 at 10:26 am by Susie
A pediatrician reflects on his days as a resident:
Take my experiences in a Los Angeles hospital with kids who needed a surgeon. I would be on call, living in scrubs, trying to digest hospital chow. In the dead of the night, my pager would begin squealing, jarring me awake (if I was lucky to sleep in the first place). A number from an outlying hospital would flash on the screen. Stumbling out of bed to the nearest phone, I would learn that a child with, say, an open fracture of his leg needed to be transferred to our hospital since we offered “a higher level of care,” which often meant an orthopedic surgeon who could treat the child.
Indeed, this is what happened one night. With the child on the way, I paged the orthopedic surgeon on call. Surgeons like information given to them concisely and directly. I ran through what I would say: “Sorry to wake you, Doc, but I have a 5-year-old male en route from a community hospital who has an open fracture of his right femur. According to the transferring physician, he will need to have a reduction in the operating room tonight. While we’re waiting for you, we’ll start morphine for pain relief and some Ancef (an antiobiotic) for infection prophylaxis.” Then I waited for the phone to ring.
When the surgeon, a partner in a private Beverly Hills orthopedic group, returned my call, I was naive enough to expect some further questions about the child’s history, requests for some laboratory work or more X-rays, and instructions on how to prep the operating room. Instead, his first question was: “What’s their insurance?”
Medical students and residents are trained to anticipate and prepare for a lot of things. If we’re doing rounds with a senior physician, we try to be prepared for questions about the illnesses of our patients and how to treat them. For those reasons, and for our love of learning, many of us would talk about our patients and read in advance of our rounds, even when we could have been sleeping.
But I was not prepared for this question. I told the surgeon I would call back with the insurance information, which forced me to call the transferring doctor. I can’t remember if the child was underinsured, uninsured or was insured by the state, but it didn’t matter. When I called the surgeon back, he refused to come in. His group didn’t cover “those kinds” of patients.
So there we were — me, my intern, a nurse — somewhere between late at night and early in the morning, alone. A broken child and his parents were on their way in an ambulance. We had promised to provide “a higher level of care,” but the only doctor who could give that care just killed it. What was my plan? I was the doctor, after all. I had no idea.
In the end, all we could do was give the child morphine (a lot of it) and antibiotics, hoping we could keep him comfortable. Still, every time he moved just a little, he howled in pain. We hoped he wouldn’t lose his leg to some flesh-and-bone-eating infection. And so we waited until morning, when we would ask our teaching attendants to delicately negotiate with the surgical group to please come in and take a look.
What did I learn that night? Certainly nothing about the preoperative and postoperative management of children with femur fractures. No, I learned how even in the dead of night, in the presence of a child suffering, the bottom line can override the Hippocratic Oath.
Such is our peculiar institution called American healthcare. We have gobs of money, the best technology, plenty of specialists, and spend the most money on healthcare in the world. Despite that, a child gets left out in the cold. Whom do we blame? Some would say the surgeon for refusing to play ball. But practically speaking, would you, whatever your job, work for free? In some cases, you can hold patients accountable for being careless with their health — drinking, smoking, eating too many McNuggets — but you can’t prevent unforeseen things.
This is especially evident in pediatrics where children will suddenly develop epilepsy or leukemia, or have an accident. You can blame insurers for their reimbursement games, the American Medical Association for lobbying to maintain the status quo, lawyers for bringing frivolous lawsuits, or drug makers for blocking international imports to keep prices high. The list goes on and on. But in the end, put it all together and it’s a system, a monstrous medical-pharmaceutical-legal-actuarial-industrial complex that’s leaving a lot of people behind.
This is the medical system we have. It reminds me of the scene from Godfather II:
“There was this kid I grew up with; he was younger than me. Sorta looked up to me, you know. We did our first work together, worked our way out of the street. Things were good, we made the most of it. During Prohibition, we ran molasses into Canada… made a fortune, your father, too. As much as anyone, I loved him and trusted him. Later on he had an idea to build a city out of a desert stop-over for GI’s on the way to the West Coast. That kid’s name was Moe Greene, and the city he invented was Las Vegas. This was a great man, a man of vision and guts. And there isn’t even a plaque, or a signpost or a statue of him in that town! Someone put a bullet through his eye. No one knows who gave the order. When I heard it, I wasn’t angry; I knew Moe, I knew he was head-strong, talking loud, saying stupid things. So when he turned up dead, I let it go. And I said to myself, this is the business we’ve chosen; I didn’t ask who gave the order, because it had nothing to do with business!”
What’s the connection? It’s the flatness. The coldness. The refusal to allow a human aspect of a very human situation, the murder of a friend, interfere with the business. That’s our medical system. It’s about money. We made a system that is about caring for sick and injured people into a system that is all about getting paid. And don’t get me wrong. Doctors, nurses, they all deserve to get paid and need to get paid, and they need and deserve to be paid well. Nurses are under-paid as it is. But this is the system we’ve chosen; don’t ask who refused to give treatment, because it has nothing to do with business.
And this is why we need universal single payer health care. Because medicine shouldn’t be conducted like the Mafia conducts business.
Ugh. And damn. My late stepfather was a gp & surgeon, and he never turned anyone away who needed help. He gave hundreds of thousands of dollars in unpaid care over his lifetime, to people who had bad insurance or no money. No, he did not become rich, but that was not why he became a doctor. Yes he complained about the miserly behavior of insurance companies—especially after trying to get them to cover such refused items as an emergency tracheotomy.
But he never turned anyone away, he would have had harsh and foul language for any doctor refusing care like that.
So I am not in favor of letting doctors off the hook in this situation simply because we have an incredibly stupid financial system for our healthcare now. You don’t want to get up in the night to care for someone who is suffering, be a dermatologist, or be a pathologist–or a librarian. Don’t piss on your oath. And don’t hide behind the insurance companies and our (cruel and unfair) health care system.
Yes, I would work for free in those cases. Pro bono…there is even a name for it. Every individual in the “system” makes choices. That surgeon’s was dead wrong.
Just remember folks…if you are a majority in the town I live in (and in this case, the minority around here is white), then you will be screwed!! Don’t get me started about not being a citizen, because many in this majority are!
“F” it all!