Fighting for treatment

I knew what I had to do next: call an ear, nose and throat specialist. I hesitated because, well, they can be trying. After taking an hour or so to respond to a page, they usually want to know just one thing: Is the air passageway obstructed? If not, send 'em to the office in the morning. If yes, intubate and admit to ICU and they'll see the patient the next day. The most common reason for an ER call is uncontrollable nosebleeding -- a messy, unpleasant affair. So from the ENT doctor's point of view, the ER calls with nothing but trouble.

Worse still, I had on my hands an uninsured patient who might need surgery. There's no overemphasizing the callousness of modern medicine when it comes to patients with no money and no resources, and I feared I'd have to discharge this woman with little more than an empty promise that someone else would see her in a day or two.

Why empty? Because on-call doctors are pros at rigging the game against uninsured patients. Here's how it works: Hospitals receiving Medicare and Medicaid are legally bound to treat all patients -- insured or not -- who turn up at the door. To fulfill this obligation, the hospital enters into an elaborate bargain with specialists. The facility grants them lucrative admitting and operating room privileges; in exchange, the physicians agree to be on call occasionally and treat patients who appear during that shift no matter what their financial circumstances.

On their call day, they have to take all comers, most of whom are uninsured or on Medicaid, which generally pays less than private insurance plans. If the patient needs surgery or immediate treatment, the doctors have to rush to the hospital. If the problem is manageable on an outpatient basis, the specialist is supposed to grant them at least one office visit. But patients discharged with just a name for follow-up often end up right back in the ER in a day or two, unable to make an appointment in anything less than weeks or months. Even fully insured patients can be given the runaround, but their chances of gaining a physician's sympathy are better.

Young doctors just out of residency training happily grab lots of call days for a couple of years so they can establish a reputation with the physician community and build a valuable referral base. In time, the referrals for insured patients pile up, superseding their interest in hits from the ER. That's when they get a little testy about what they see as our 'dumping' patients on them.

One of the first things I do upon starting a shift is scan the call list to see who's on: the good, the bad or the ugly. The ENT doctor on call this particular night was an unknown entity. I recognized his name, but I had never called him before. He returned his page quickly -- an unexpected but positive omen -- and asked, as I knew he would, about her airway.

Please understand: I am willing to lie. It may be in a patient's best interest for me to paint a bleaker picture simply to facilitate admission to the hospital or, at a minimum, to lure the on-call doctor in to make an evaluation. Although this woman was breathing comfortably, the easiest way to force the ENT doctor's hand would have been to report that her trachea was in imminent danger of obstruction. The downside of presenting a false clinical picture is that when they come in they'll think I was either lying or stupid -- and they'll remember it the next time I have to call. So I use this tactic sparingly.

Since this ENT guy had responded so promptly and sounded concerned, I decided to tell the truth. I said she was breathing fine but that the mass was huge and had erupted in a mere two weeks. He mulled it over for a moment. Then he asked me her name and performed the doctor's version of racial profiling. "Southeast Asian?" he said. "High incidence of oropharyngeal carcinomas in that population."

Uh, oh. No way out.

Next Page: Six months to live

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