“Doc, I honestly cannot go to the ER.”
It would be a lie to say I was surprised when my patient with chest pains answered my recommendation so bluntly. It’s a refrain I have heard often the past few weeks.
He is a diabetic, at high risk for having a myocardial infarction, and as I pleaded my case, trying to explain what I thought was best for his health, I found the phrases I invoked familiar as well:
“I am worried about you.”
“I wouldn’t want anything avoidable to happen.”
“Better safe than sorry.”
But these justifications don’t carry the weight they once did because COVID-19 has changed the risk profile of emergency rooms, and I can no longer guarantee that my recommendation to go to the emergency room is purely benevolent.
I will abstain from all intentional wrong-doing and harm. These are the words laid out in the Hippocratic Oath, dating back more than two thousand years. The concept of “do no harm” is as old as western medicine itself.
There may have been a time in the history and practice of medicine when this philosophy was easy to practice. At face value it seems easy enough to abide by today, for at the surface it merely demands that physicians put the wellbeing of the patient before all else.
However, in our current healthcare landscape with a virulent pandemic taking its toll, I find myself grappling with this principle on a daily basis. Not only does my recommendation to seek hospital medical care now risk exposing patients to COVID-19, but it also risks subjecting them to financial burdens they may never be able to recover from.
Even prior to this pandemic, if someone were to sift through my utilization numbers, they would find the number of referrals I made to the ER to be very conservative. This is because I take care of a largely working class population who struggle to pay their out-of-pocket healthcare expenses, even on a good day.
It is part of my daily practice to sit down and look through medication formularies and alternative drug options, to find ways to ration medications and treatments, so that my patients can afford them. Though the majority of my patients are insured, the skyrocketing cost of premiums, co-pays and deductibles means that patients often pay thousands of dollars out-of-pocket before coverage even kicks in.
In the past month, the magnitude of our healthcare crisis has been amplified. As my patients have lost their jobs, so too have many lost their insurance. This past week alone I have offered medication refills and a free telephone visit to a diabetic mother who lost her insurance, and I referred another patient to a free clinic system in another county so he can continue his rheumatoid arthritis injections despite losing his benefits.
So, while talking to my patient with chest pain, trying to help him understand my recommendation for urgent cardiac evaluation, I felt a pang of uncertainty. I was weighing the tangible risks he could incur. The risk of contracting COVID is one shared by patients nationwide — likely explaining the recent plummet in ER visits and the rise of preventable deaths at home.
But the financial risk is one that exists as well — one that I cannot ignore in a time when unemployment rates are surging.
The average emergency room bill in the United States is upwards of $2,000 — significantly more than a single pandemic stimulus check. For a patient without guaranteed income, that bill could be devastating.
The U.S. is unique among developed nations. In the wealthiest country on earth, we watch our fellow citizens die early of preventable diseases and fall into financial ruin simply for getting sick. Every day marks the creation of yet another “Go Fund Me” for an American citizen, facing bankruptcy due to their health bills.
In this healthcare infrastructure, where insurance is often tied to employment, the fact of 30 million newly unemployed Americans is extremely foreboding.
Until we move towards a more equitable and patient-centric model for financing healthcare, I am afraid that many of my patients will continue to defer care, even when they desperately need it.
Dr. Monica Maalouf, a practicing physician in Chicago, teaches Narrative Medicine at Loyola Stritch School of Medicine and serves as Faculty Director of Wellness. Dr. Maalouf blogs at: www.doctoredtales.com
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