Happy Friday! This week was so busy that I am going to take the unprecedented step and highly recommend you check out our Morning Briefings for the past few days. So many compelling, interesting stories didn’t make the cut for the Breeze, but they’re worth reading.
On to what you may have missed!
Well, this one you probably didn’t miss unless you were in the middle of the woods sans cellphone service: Alabama Gov. Kay Ivey signed legislation that effectively bans all abortions and criminalizes the procedure. The uproar that followed was immediate and ferocious — especially from 2020 Democrats who all but tripped over each other to denounce it as “shameless” and “outrageous” — but is the bill actually the threat to Roe v. Wade that it so dearly wants to be?
The measure is destined for the courts, certainly, but that doesn’t mean it will make it to SCOTUS. One likely outcome: The justices can simply refuse to take it up, leaving in place the lower courts’ decision (which will probably be that the law is unconstitutional). Chief Justice John Roberts is known for favoring incrementalism over sweeping decisions that would overturn nearly 50 years of precedent on a hot-button social issue.
But you need only four votes to get a case on the docket, which has court-watchers eyeing newbie Justice Brett Kavanaugh. His appointment helped galvanize the anti-abortion movement in the first place, but in the past he’s talked seriously about needing a compelling reason to overturn precedent. So far, he has disagreed with the hard conservatives more than people expected. So, the future for Alabama’s law remains uncertain.
What seems more likely is that the high court will instead look to less extreme, but still restrictive state laws (such as bills dictating the disposal of fetal remains and an 18-hour waiting period after state-mandated ultrasound examinations) that are heading toward them even as we speak.
No matter how it plays out, you can pretty much guarantee this is going to be a Big Deal on the campaign trail.
House Democrats took advantage of their newfound power by tying a vote on reining in high drug prices to legislation shoring up the health law. The bill is destined to die, of course, but the move forced their Republican colleagues to go on record voting against something that voters care very, very deeply about.
They also foreshadowed a potential subpoena with letters to Attorney General William Barr. Five powerful committee chairmen said that they’ve been asking since April 8 for documents connected to the Justice Department’s decision to stop defending the health law but haven’t received a sufficient response. They’re giving DOJ two more weeks before they consider “alternative means of obtaining compliance.”
Surprise medical billing is truly the darling of Capitol Hill recently with all the attention it’s getting. Multiple variations of bipartisan duos and groups are working on introducing legislation to combat the issue. The most recent bill unveiled would protect patients from the surprise costs, and let an outside arbitrator settle any disputes between hospitals and insurers. Other proposals have instead favored a rate-setting method to solve payment issues.
Attorneys general from 44 states have filed suit against pharma companies over allegations that “the generic drug industry perpetrated a multibillion-dollar fraud on the American people.” The lawsuit implicates 20 pharma firms following an investigation into allegations that the companies sought not only to maintain their “fair share” of the generic drug market through agreements with one another but also to “significantly raise prices on as many drugs as possible.”
Washington state took a big step this week in approving the creation of a public option — which would essentially look like a state-sponsored health plan. But now comes the hard part: making it work.
And don’t call it a game changer quite yet, experts say. Even sponsors of the legislation acknowledge the state plans may save consumers only 5-10% on their premiums. Still, the rollout will likely be watched closely as the progressive universal health care push grows stronger.
(If you feel like you need a refresher on all these terms — join the crowd, amiright? — this one from NYT’s Margot Sanger-Katz is great.)
Rural hospitals, which sometimes fight literally hour by hour to afford to stay open, are in a crisis in this country, as evidenced by two amazing pieces this week on what happens to a town when one dies.
“If we aren’t open, where do these people go?” asked one hospital worker in The Washington Post’s coverage.
“They’ll go to the cemetery,” another employee answered. “If we’re not here, these people don’t have time. They’ll die along with this hospital.”
Think this measles outbreak is big? (It is, by the way!) How about the one in 1990, which had more than 27,000 cases? In the past few months, I’ve read and written about the record 963 cases from 1994 more times than you can count but had noidea that just four years earlier it was that much higher. If you’re as intrigued as I was about how that changed, dive into NPR’s historical look at what exactly was going on at the time, and how public officials made so much progress so quickly.
• There’s a pretty serious debate going on right now about fair distribution of donated livers. A new rule that went into effect this week and then was immediately blocked by a judge would give the organ to the sickest patient within 500 nautical miles. But advocates in the Midwest and South say that’s unfair.
KHN senior correspondent Sarah Jane Tribble is interviewed on NPR’s “Morning Edition” about the challenges faced by rural communities when their hospitals close. She is spending a year following Fort Scott, Kan., as it copes and recovers from the loss. Listen to the conversation here:
And read the first installment of the series, “No Mercy,” here.
Emergency room patients increasingly leave California hospitals against medical advice, and experts say crowded ERs are likely to blame.
About 352,000 California ER visits in 2017 ended when patients left after seeing a doctor but before their medical care was complete. That’s up by 57%, or 128,000 incidents, from 2012, according to data from the Office of Statewide Health Planning and Development.
Another 322,000 would-be patients left the emergency room without seeing a doctor, up from 315,000 such episodes in 2012.
Several hospital administrators said overcrowding is a likely culprit for the trend. California emergency room trips grew by almost 20%, or 2.4 million, from 2012 to 2017.
Moreover, ER wait times also increased for many during that time period: In 2017, the median ER wait time for patients before admission as inpatients to California hospitals was 336 minutes — or more than 5½ hours. That is up 15 minutes from 2012, according to the federal Centers for Medicare & Medicaid Services. The median wait time for those discharged without admission to the hospital dropped 12 minutes over that period, but still clocked in at more than 2½ hours in 2017.
California wait times remain higher than the national average. In 2017, the median length of a stay in the ER before inpatient admission nationwide was 80 minutes shorter than the median stay in California. Four states — Maryland, New York, New Jersey and Delaware — had even longer median wait times.
The growth in patients leaving California ERs prematurely was faster than the growth in overall ER encounters. About 2.4% of ER trips in 2017 ended with patients leaving the ER against medical advice or abruptly discontinuing care after seeing a doctor, compared with 1.8% in 2012.
“Most patients are sick but not critically ill,” said Dr. Steven Polevoi, medical director of the emergency department at UCSF Helen Diller Medical Center at Parnassus Heights. “Emergency care doesn’t equal fast care all of the time.”
When a patient leaves the ER after seeing a doctor but before the doctor clears them to leave, the Office of Statewide Health Planning and Development classifies that encounter as “leaving against medical advice or discontinued care.” The definition includes encounters in which a doctor carefully explains the risks to the patient and has the patient sign a form, but also instances in which the patient simply discontinues care and bolts out the door.
Patients leaving the emergency room too soon “are deliberately putting themselves at more risk for morbidity and even mortality,” Polevoi said — a point echoed by other physicians.
Dr. Veronica Vasquez-Montez, emergency room medical director at Good Samaritan Hospital in Los Angeles, said she sometimes finds herself having “tough conversations” with sick patients intent on leaving the ER, often citing pressing responsibilities.
“If you die from this,” she tells them, “you are good to no one you are caring for.”
One of her recent patients was at high risk for a major stroke but insisted he needed to leave the ER to take care of his pet.
“Guess what he came back for? A major stroke,” said Vasquez-Montez, also a clinical assistant professor at the University of Southern California’s Keck School of Medicine.
Compared with all ER patients, those leaving against medical advice were more likely to be men; people ages 20 to 39; and uninsured or on Medi-Cal, the government insurance program for the poor, state figures show. They were also more likely to complain primarily of non-specific symptoms such as chest pain or a cough.
Fresno, Shasta, Yuba, Kern, San Bernardino and Tulare counties had the highest proportion of ER encounters in 2017 that ended with patients leaving against medical advice or abruptly discontinuing care. Each of those counties recorded more than 4% of ER patients leaving too soon, state figures show.
From 2012 to 2017, the number of emergency room encounters in Fresno County increased by almost 95,000, or 37%. At Fresno’s Community Regional Medical Center, about 9% of ER encounters ended with a patient leaving too soon, more than three times the statewide rate.
Community Regional Medical Center is one of the busiest hospitals in the state. It recently instituted a “Provider at Triage” program that puts caregivers in the lobby area with patients, said Dr. Jeffrey Thomas, the hospital’s chief medical and quality officer. The hospital’s internal data now show fewer than 2% of patients leaving against medical advice or abruptly discontinuing care.
“When patients bring themselves into the ED, they are seen in about 5 minutes by a qualified registered nurse and, on average, are seen by a provider within 30 minutes of arrival,” Thomas said in a statement.
When a sick patient is about to leave the emergency room, doctors should determine why he or she wants to go, make sure the patient is capable of making a sound decision, involve friends and family, explain the course of treatment and, if nothing works, arrange for speedy follow-up care, said Dr. Jay Brenner, emergency department medical director at Upstate University Hospital-Community Campus in New York and co-author of several studies about patients leaving against medical advice.
“When someone requests to leave,” Brenner said, “it needs to be a priority that ranks just below a cardiac arrest.”
Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.
Walmart Inc., the nation’s largest private employer, is worried that too many of its workers are having health conditions misdiagnosed, leading to unnecessary surgery and wasted health spending.
The issue crystallized for Walmart officials when they discovered about half of the company’s workers who went to the Mayo Clinic and other specialized hospitals for back surgery in the past few years turned out to not need those operations. They were either misdiagnosed by their doctor or needed only non-surgical treatment.
A key issue: Their diagnostic imaging, such as CT scans and MRIs, had high error rates, said Lisa Woods, senior director of benefits design for Walmart.
So the company, whose health plans cover 1.1 million U.S. employees and dependents, has recommended since March that workers use one of 800 imaging centers identified as providing high-quality care. That list was developed for Walmart by Covera Health, a New York City-based health analytics company that uses data to help spot facilities likely to provide accurate imaging for a wide variety of conditions, from cancer to torn knee ligaments.
Although Walmart and other large employers in recent years have been steering workers to medical centers with proven track records for specific procedures such as transplants, the retail giant is believed to be the first to prod workers to use specific imaging providers based on diagnostic accuracy — not price, said employer health experts.
“A quality MRI or CT scan can improve the accuracy of diagnoses early in the care journey, helping create the correct treatment plan with the best opportunity for recovery,” said Woods. “The goal is to give associates the best chance to get better, and that starts with the right diagnosis.”
Walmart employees are not required to use those 800 centers, but if they don’t use one that is available near them, they will have to pay additional cost sharing. Company officials advise workers that they could have more accurate results if they opt for the specified centers.
Studies show a 3% to 5% error rate each workday in a typical radiology practice, but some academic research has found mistakes on advanced images such as CT scans and MRIs can reach up to 30% of diagnoses. Although not every mistake affects patient care, with millions of CT scans and MRIs done each year in the United States, such mistakes can have a significant impact.
“There’s no question that there are a lot of errors that occur,” said Dr. Vijay Rao, chairwoman of radiology at the Thomas Jefferson University Hospital in Philadelphia.
Errors at imaging centers can happen for many reasons, including the radiologist not devoting enough time to reading each image, Rao said. The average radiologist typically has only seconds to read each image, she said. “It’s just a lot of data that crosses your eye and there is human fatigue, interruptions, and errors are bound to happen,” she added.
Other pitfalls: the technician not positioning the patient correctly in the imaging machine or a radiologist not having sufficient expertise or experience, Rao said.
Employers and insurers typically do little to help patients identify which radiology practices provide the most accurate results. Instead, employers have been focused on the cost of imaging tests. Some employers or insurers require plan members to use free-standing outpatient centers rather than those based in hospitals, which tend to be more expensive.
Woods said Walmart found that deficiencies and variation in imaging services affected employees nationwide. “Unfortunately, it is all over the country. It’s everywhere,” she said.
Walmart’s new imaging strategy is aligned with its efforts over the past decade to direct employees to select hospitals for high-cost health procedures. Since 2013, Walmart has been sending workers and their dependents to select hospitals across the country where it believes they can get better results for spine surgery, heart surgery, joint replacement, weight loss surgery, transplants and certain cancers.
As part of its “Centers of Excellence” program, the Bentonville, Ark.-based retail giant picks up the tab for the surgeries and all related travel expenses for patients on the company’s health insurance plan, including a caregiver.
Sampling Imaging Centers’ Work
Covera has collected information on thousands of hospital-based and outpatient imaging facilities starting with its previous business work in the workers’ compensation field.
“Our primary interest is understanding which radiologist or radiology practices are achieving the highest level of diagnostic accuracy for their patients,” said Dan Elgort, Covera’s chief data science officer.
Covera has independent radiologists evaluate a sampling of patient care data on imaging centers to determine facilities’ error rates. It uses statistical modeling along with information on each center’s equipment, physicians and use of industry-accepted patient protocols to determine the facilities’ rates of accuracy.
Covera expects to have about 1,500 imaging centers in the program by year’s end, said CEO Ron Vianu.
There are about 4,000 outpatient imaging centers in the United States, not counting thousands of hospital-based facilities, he estimated.
As a condition for participating in the program, each of the imaging centers has agreed to routinely send a sampling of their patients’ images and reports to Covera.
Vianu said studies have shown that radiologists frequently offer different diagnoses based on the same image taken during an MRI or CT scan. Among explanations are that some radiologists are better at analyzing certain types of images — like those of the brain or bones — and sometimes radiologists read images from exams they have less experience with, he said.
Vianu noted that most consumers give little thought to where to get an MRI or CT scan, and usually go where their doctors send them, the closest facility or, increasingly, the one that offers the lowest price. “Most people think of diagnostic imaging as a commodity, and that’s a mistake,” he said.
Rao applauded the effort by Walmart and Covera to identify imaging facilities likely to provide the most accurate reports. “I am sure centers that are worried about their quality will not be happy, but most quality operations would welcome something like this,” she said.
Few Guides For Consumers
Consumers have little way to distinguish the quality of care from one imaging center to the next. The American College of Radiology has an accreditation program but does not evaluate diagnostic quality.
“We would love to have more robust … measurements” than what is currently available, said Dr. Geraldine McGinty, chair of the college’s board of chancellors.
Facilities typically conduct peer reviews of their radiologists’ patient reports, but there is no public reporting of such results, she said.
Covera officials said they have worked with Walmart for nearly two years to demonstrate they could improve the quality of diagnostic care its employees receive. Part of the process has included reviewing a sample of Walmart employees’ health records to see where changes in imaging services could have caught potential problems.
Covera said the centers in its network were chosen based on quality and price was not a factor.
In an effort to curtail unnecessary tests, Walmart, like many large employers and insurers, requires its insured members to get authorization before getting CT scans and MRIs.
“Walmart is on the leading edge of focusing on quality of diagnostic imaging,” said Suzanne Delbanco, executive director of the Catalyst for Payment Reform, an employer-led health care think tank and advocacy group.
But Mark Stolper, executive vice president of Los Angeles-based RadNet, which owns 335 imaging centers nationally, questions how Covera has enough data to compare facilities. “This would be the first time,” he said, “I have seen or heard of a company trying to narrow a network of imaging centers that is based on quality instead of price.”
Woods said that even though the new imaging strategy is not based on financial concerns, it could pay dividends down the road.
“It’s been demonstrated time and time again that high quality ends up being more economical in the long run because inappropriate care is avoided, and patients do better,” she said.
FORT SCOTT, Kan. — A slight drizzle had begun in the gray December sky outside Community Christian Church as Reta Baker, president of the local hospital, stepped through the doors to join a weekly morning coffee organized by Fort Scott’s chamber of commerce.
The town manager was there, along with the franchisee of the local McDonald’s, an insurance agency owner and the receptionist from the big auto sales lot. Baker, who grew up on a farm south of town, knew them all.
Still, she paused in the doorway with her chin up to take in the scene. Then, lowering her voice, she admitted: “Nobody talked to me after the announcement.”
Just a few months before, Baker — joining with the hospital’s owner, St. Louis-based Mercy — announced the 132-year-old hospital would close. Baker carefully orchestrated face-to-face meetings with doctors, nurses, city leaders and staff members in the final days of September and on Oct. 1. Afterward, she sent written notices to the staff and local newspaper.
For the 7,800 people of Fort Scott, about 90 miles south of Kansas City, the hospital’s closure was a loss they never imagined possible, sparking anger and fear.
Reta Baker, president of Mercy Hospital, began as a staff nurse in 1981 and “has been here ever since.” The hospital closed at the end of 2018.(Christopher Smith for KHN)
“Babies are going to be dying,” said longtime resident Darlene Doherty, who was at the coffee. “This is a disaster.”
Bourbon County Sheriff Bill Martin stopped before leaving the gathering to say the closure has “a dark side.” And Dusty Drake, the lead minister at Community Christian Church, diplomatically said people have “lots of questions,” adding that members of his congregation will lose their jobs.
Yet, even as this town deals with the trauma of losing a beloved institution, deeper national questions underlie the struggle: Do small communities like this one need a traditional hospital at all? And, if not, what health care do they need?
Sisters of Mercy nuns first opened Fort Scott’s 10-bed frontier hospital in 1886 — a time when traveling 30 miles to see a doctor was unfathomable and when most medical treatments were so primitive they could be dispensed almost anywhere.
Now, driving the four-lane highway north to Kansas City or crossing the state line to Joplin, Mo., is a day trip that includes shopping and a stop at your favorite restaurant. The bigger hospitals there offer the latest sophisticated treatments and equipment.
Visitors to Mercy Hospital Fort Scott would pass a tall white cross as they drove down a winding driveway before arriving at the front door. Sisters of Mercy nuns founded the hospital in 1886, and the newest building, constructed in 2002, honors that Roman Catholic faith with various fixtures and stained-glass windows.(Christopher Smith for KHN)
Mercy flew its flags at half-staff in December in honor of former President George H.W. Bush, who died Nov. 30. (Christopher Smith for KHN)
And when patients here get sick, many simply go elsewhere. An average of nine patients stayed in Mercy Hospital Fort Scott’s more than 40 beds each day from July 2017 through June 2018. And these numbers are not uncommon: Forty-five Kansas hospitals report an average daily census of fewer than two patients.
James Cosgrove, who directed a recent U.S. Government Accountability Office study about rural hospital closures, said the nation needs a better understanding of what the closures mean to the health of people in rural America, where the burden of disease — from diabetes to cancer — is often greater than in urban areas.
What happens when a 70-year-old grandfather falls on ice and must choose between staying home and driving to the closest emergency department, 30 miles away? Where does the sheriff’s deputy who picks up an injured suspect take his charge for medical clearance before going to jail? And how does a young mother whose toddler fell against the coffee table and now has a gaping head wound cope?
There is also the economic question of how the hospital closure will affect the town’s demographic makeup since, as is often the case in rural America, Fort Scott’s hospital is a primary source of well-paying jobs and attracts professionals to the community.
The GAO plans to complete a follow-up study later this year on the fallout from rural hospital closures. “We want to know more,” Cosgrove said. The report was originally requested in 2017 by then-Sen. Claire McCaskill (D-Mo.) and then-Rep. Tim Walz (D-Minn.), and has been picked up by Sen. Gary Peters (D-Mich.). Here in Fort Scott, the questions are being answered — painfully — in real time.
At the end of December, Mercy closed Fort Scott’s hospital but decided to keep the building open to lease portions to house an emergency department, outpatient clinic and other services.
Mercy Hospital Fort Scott joined a growing list of more than 100 rural hospitals that have closed nationwide since 2010, according to data from the University of North Carolina’s Cecil G. Sheps Center for Health Services Research. How the town copes is a window into what comes next.
An empty operating room at the closed hospital(Christopher Smith for KHN)
Unused hospital equipment is stored for shipment to other hospitals in the nonprofit Mercy health system.(Christopher Smith for KHN)
While some parts of the building are still in use, vast, empty halls and workstations abound at Mercy’s closed Fort Scott hospital. (Christopher Smith for KHN)
‘We Were Naive’
Over time, Mercy became so much a part of the community that parents expected to see the hospital’s ambulance standing guard at the high school’s Friday night football games.
Mercy’s name was seemingly everywhere, actively promoting population health initiatives by working with the school district to lower children’s obesity rates as well as local employers on diabetes prevention and healthy eating programs — worthy but, often, not revenue generators for the hospital.
“You cannot take for granted that your hospital is as committed to your community as you are,” said Fort Scott City Manager Dave Martin. “We were naive.”
Indeed, in 2002 when Mercy decided to build the then-69-bed hospital, residents raised $1 million out of their own pockets for construction. Another million was given by residents to the hospital’s foundation for upgrading and replacing the hospital’s equipment.
“Nobody donated to Mercy just for it to be Mercy’s,” said Bill Brittain, a former city and county commissioner. The point was to have a hospital for Fort Scott.
Today Mercy is a major health care conglomerate, with more than 40 acute care and specialty hospitals, as well as 900 physician practices and outpatient facilities. Fort Scott is the second Kansas hospital Mercy has closed.
Tom Mathews, vice president of finance for Mercy’s southwestern Missouri and Kansas region, said Fort Scott’s steady decline in patients, combined with lack of reimbursement — as well as the increasing cost of expenses such as drugs and salaries — “created an unsustainable situation for the ministry.”
But Fort Scott is a place that needs health care: One out of every four children in Bourbon County live in poverty. People die much younger here than the rest of the state and rates for teen births, adult smoking, unemployment and violent crime are all higher in Bourbon County than the state average, according to data collected by the Kansas Health Institute and the Robert Wood Johnson Foundation. Ten percent of Bourbon County’s more than 14,000 residents, about half of whom live in Fort Scott, lack health insurance. Kansas is one of 14 states that have not expanded Medicaid under the Affordable Care Act and, while many factors cause a rural closing, the GAO report found states that had expanded Medicaid had fewer closures.
Dr. Katrina Burke checks Randall Phillips during an exam at Mercy Hospital in Fort Scott, Kan., in December. “Up in the city, a lot of doctors don’t do everything like we do,” Burke says of the variety of patients she sees as a family practice doctor who also delivers babies. (Christopher Smith for KHN)
Burke, a family practice physician, also delivered babies at Mercy Hospital before it closed. “A lot of my moms are single moms … they don’t have good resources to even get to their OB appointment,” says Burke, who adds that she’s worried about how her patients will get to another hospital 30 miles away when it’s time for the baby to come. Burke delivered 85 babies last year. (Christopher Smith for KHN)
The GAO report also found that residents of rural areas generally have lower household incomes than their counterparts in bigger cities, and are more likely to have limitations because of chronic health conditions, like high blood pressure, diabetes or obesity, that affect their daily activities.
The county’s premature birth rate is also higher than the 9.9% nationwide, a number that worries Dr. Katrina Burke, a local family care doctor who also delivers babies. “Some of my patients don’t have cars,” she said, “or they have one car and their husband or boyfriend is out working with the car.”
By nearly any social and economic measure, southeastern Kansas is “arguably the most troubled part of the entire state,” said Dr. Gianfranco Pezzino, senior fellow at the Kansas Health Institute. While the health needs are great, it’s not clear how to pay for them.
Health Care’s ‘Very Startling’ Evolution
Reta Baker describes the farm she grew up on, south of town, as “a little wide place in the road.” She applied to the Mercy school of nursing in 1974, left after getting married and came back in 1981 to take a job as staff nurse at the hospital. She has “been here ever since,” 37 years — the past decade as the hospital president.
It has been “very startling” to watch the way health care has evolved, Baker said. Patients once stayed in the hospital for weeks after surgery and now, she said, “they come in and they have their gallbladder out and go home the same day.”
With that, payments and reimbursement practices from government and health insurers changed too, valuing procedures rather than time spent in the hospital. Rural hospitals nationwide have struggled under that formula, the GAO report found.
Acknowledging the challenge, the federal government established some programs to help hospitals that serve poorer populations survive: Through a program called 340B, some hospitals get reduced prices on expensive drugs. Rural hospitals that qualified for a “critical access” designation because of their remote locations got higher payments for some long stays. About 3,000 hospitals nationwide get federal “disproportionate share payments” to reflect the fact that their patients tend to have poor or no insurance.
Fort Scott took part in the 340B discount drug program as well as the disproportionate share payments. But, though Baker tried, it could not gain critical access status.
When Medicare reimbursement dropped 2% because of sequestration after the Budget Control Act of 2011, it proved traumatic, since the federal insurer was a major source of income and, for many rural hospitals, the best payer.
Then, in 2013, when the federal government began financially penalizing most hospitals for having too many patients returning within 30 days, hospitals like Fort Scott’s lost thousands of dollars in one year. It contributed to Fort Scott’s “financial fall,” Baker said.
Baker did her best to set things right. To reduce the number of bounce-back admissions, patients would get a call from the physician’s office within 72 hours of their hospital stay to schedule an office visit within two weeks. “We worked really, really hard,” Baker said. Five years ago, the number of patients returning to Fort Scott’s hospital was 21%; in 2018 it was 5.5%.
Meanwhile, patients were also “out-migrating” and choosing to go to Ascension Via Christi in Pittsburg — which is two times larger than Fort Scott — because it offered cardiology and orthopedic services, Baker said. Patients also frequently drove 90 miles north to the Kansas City area for specialty care and the children’s hospital.
“Anybody who is having a big surgery done, a bowel resection or a mastectomy, they want to go where people do it all the time,” Baker said. Mercy’s Fort Scott hospital had no cardiologists and only two surgeons doing less complicated procedures, such as hernia repair or removing an appendix.
Last year, only 13% of the people in Bourbon County and the surrounding area who needed hospital care chose to stay in Fort Scott, according to industry data shared by Baker.
There were no patients in the hospital’s beds during one weekend in December, Baker said, adding: “I look at the report every day. It bounces between zero and seven.” The hospital employed 500 to 600 people a decade ago, but by the time the closure was announced fewer than 300 were left.
Fort Scott City Manager Dave Martin stands in the middle of the city’s historical main street, which connects to one of the first military outposts built in the United States. Martin, who feels angry at Mercy for abandoning the community, says, “We really thought that we had a relationship.”(Christopher Smith for KHN)
That logic — the financial need — for the closing didn’t sit well with residents, and Mercy executives knew it. They knew in June they would be closing Fort Scott but waited until October to announce it to the staff and the city. City Manager Martin responded by quickly assembling a health task force, insisting it was “critical” to send the right message about the closure.
Relations between Mercy and the city grew so tense that attorneys were needed just to talk to Mercy. In all, Fort Scott had spent more than $7,500 on Mercy Closure Project legal fees by the end of 2018, according to city records.
Will Fort Scott Sink With No Mercy?
When Darlene Doherty graduated from Fort Scott High School in 1962, there were two things to do in town: “Work at Mercy or work at Western Insurance.” The insurance company, though, was sold in the 1980s, and the employer disappeared, along with nearly a thousand jobs.
Yet, even as the community’s population slowly declined, Martin and other community leaders have kept Fort Scott vibrant. There’s the new Smallville CrossFit studio, which Martin attends; a new microbrewery; two new gas stations; a Sleep Inn hotel, an assisted living center; and a Dairy Queen franchise. And the McDonald’s that opened in 2012 just completed renovation.
The town’s largest employer, Peerless Architectural Windows and Doors, which provides about 400 jobs, bought 25 more acres and plans to expand. There’s state money promised to expand local highways, and Fort Scott has applied for federal grants to expand its airport.
Baker and some of the physicians on Mercy’s staff have been busy trying to ensure that essential health care services survive, too.
Baker found buyers for the hospital’s hospice, home health services and primary care clinics so they could continue operating.
Burke, the family care doctor, signed on to be part of the Community Health Center of Southeast Kansas, a federally qualified nonprofit that is taking over four health clinics operated by Mercy Hospital Fort Scott. She will have to deliver babies in Pittsburg, which is nearly 30 miles away on a mostly two-lane highway that has construction workers slowing traffic as they work to expand it to four lanes.
Burke said her practice is full, and she wants her patients to be taken care of: “If we don’t do it, who’s going to?”
Mercy donated its ambulances and transferred emergency medical staff to the county and city.
And, in a tense, last-minute save, Baker negotiated a two-year deal with Ascension Via Christi hospital in Pittsburg to operate the emergency department — which was closed for two weeks in February before reopening under the new management.
But she knows that too may be just a patch. If no buyer is found, Mercy will close the building by 2021.
This is the first installment in KHN’s year-long series, No Mercy, which follows how the closure of one beloved rural hospital disrupts a community’s health care, economy and equilibrium.
In a new set of rules, the Trump administration wants to let not just doctors but almost any health care worker or organization decline to provide, participate in or refer patients for any health service that violates their conscience or religion.
Also this week, the Trump administration is ordering prescription drugmakers to include list prices in their television ads for nearly all products.
And there’s yet another entry in the growing group of bills aimed at overhauling the nation’s health system. This one is “Medicare for America.”
This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Jen Haberkorn of the Los Angeles Times and Alice Miranda Ollstein of Politico.
Also, Rovner interviews Joan Biskupic, author of “The Chief: The Life and Turbulent Times of Chief Justice John Roberts.” Biskupic talks about the behind-the-scenes negotiations that led to the 2012 decision upholding the constitutionality of the Affordable Care Act.
Among the takeaways from this week’s podcast:
Robert Pear, who died this week, was the dean of health policy reporters and will be remembered not just for the many front-page stories he produced for The New York Times, but also as a generous and kind colleague who helped mentor many reporters new to the beat.
The Trump administration’s announcement last week of new regulations to protect health care workers from having to do anything they believe violates their religious beliefs is a stronger policy than past Republicans have adopted. But it follows other efforts to expand past conservative policies, such as the current administration’s more stringent Title X family planning rules.
The administration’s new rule requiring drugmakers to add list prices to their TV ads could confuse some consumers, since few of them actually pay that price. Their insurers often negotiate better prices, and other factors, such as geography and type of pharmacy, affect the consumer’s bottom line.
President Donald Trump this week told Health and Human Services officials to work with Florida on its plan to import drugs from Canada to take advantage of lower prices there. HHS Secretary Alex Azar said he would see if it can be done without jeopardizing the safety of the drugs. That is the rub that his predecessors have used to stop importation efforts, dating to the 1990s.
The increasing interest in Democratic proposals such as “Medicare for All,” which would set up a government-run health care system, and “Medicare for America,” which would offer a government-run option for consumers and businesses, suggests that a public option is not the political hot potato it was during the debate setting up the ACA. It’s also not clear whether consumers are ready to give up their current insurance.
Tennessee is getting ready to ask federal officials for a major change in its Medicaid system. The state wants to switch to a block grant, in which its federal funding would be limited but would come with much more flexibility for spending. The proposal is likely to end up in court because advocates for the poor argue the change would cut off services to some people and would violate laws that have defined Medicaid.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:
Private health insurance plans in 2017 paid more than twice what Medicare would have for those same health care services, says a sweeping new study from Rand Corp., a respected research organization.
Its study, which examines payment rates by private insurers in 25 states to 1,600 hospitals, shines light into a black box of the health industry: what hospitals and other medical providers charge. It is among the first studies to examine on such a wide level just how much more privately insured people pay for health care.
The finding: a whole lot. The difference varies dramatically across the country. And as national health expenses climb, this growing gap poses a serious challenge for lawmakers. The Rand data suggests a need for market changes, which could come in the form of changes in industry behavior or government regulation, in order to bring down hospital prices in the private sector. “If we want to reduce health care spending,” said Christopher Whaley, a Rand economist and one of the paper’s two authors, “we have to do something about higher hospital prices.”
Put another way, if, between 2015 and 2017, hospitals would have charged these health plans the same rates as Medicare, it would have reduced health spending by $7.7 billion.
The national discrepancy is staggering on its own. But the data fluctuated even more when examined on a state-by-state level.
In Indiana, private health plans paid on average more than three times what Medicare did. In Michigan, the most efficient of the states studied, the factor is closer to 1.5 — the result, the study authors said, of uniquely strong negotiating of the powerful UAW union, historically made up of autoworkers.
The difference between Medicare and private coverage rates matters substantially for the approximately 156 million Americans under age 65 who get insurance through work-sponsored health plans, researchers said. For them, higher hospital prices aren’t an abstraction. Those charges ultimately translate to individuals paying more for medical services or monthly premiums.
That’s especially true for the increasing number of people who are covered by “high-deductible” health plans and have to pay more of their health care costs out-of-pocket, said Paul Ginsburg, a health economist at the Brookings Institute. He was not associated with this study.
The gap between Medicare and private plans — and how it plays out across the country — underscores a key point in how American health care is priced. Often, it has little to do with what it costs hospitals or doctors to provide medical care.
“It’s about how much they can charge, how much the market can take,” said Ge Bai, an associate professor at the Johns Hopkins University Carey Business School who studies hospital prices but was not affiliated with the study.
The paper’s authors suggest that publishing this pricing data — which they collected from state databases, health plans and self-insured employers — could empower employers to demand lower prices, effectively correcting how the market functions.
But, they acknowledged, there’s no guarantee that would, in fact, yield better prices.
One issue is that individual hospitals or health systems often have sizable influence in a particular community or state, especially if they are the area’s main health care provider. Another factor: If they are the only facility in the market area to offer a particularly complex service, like neonatal intensive care or specialized cardiac care, they have an upper hand in negotiating the price tag. In those situations, even if an employer is made aware that Medicare pays less, it doesn’t necessarily have the ability to negotiate a lower price.
“Employers and health plans in a lot of cases are really at the mercy of big, must-have systems. If you can’t legitimately threaten to cut a provider or system out of the network, it’s game over,” said Chapin White, a Rand policy researcher and Whaley’s co-author. “That’s when you come up against the limits of market-based approach.”
It wasn’t always this way, said Gerard Anderson, a Johns Hopkins health policy professor and expert in hospital pricing, who was also not involved with the study. Anderson began comparing Medicare prices to that of private insurance in the 1990s, when they paid virtually the same amount for individual services.
Since then, private health plans have lost the ability to negotiate at that same level, in part because many hospital systems have merged, giving the hospitals greater leverage. “Most large, self-insured corporations do not have the market power in their communities to take on the hospitals even if they wanted to do so,” Anderson said.
The RAND findings come as Democrats campaigning for 2020 are reopening the health care reform debate. Single-payer advocates argue, among other points, that covering everyone through a Medicare-like system could bring lower prices and increase efficiency to the rest of the country, or at least give the government leverage to negotiate a better price.
That’s certainly possible, but it isn’t guaranteed. Under single-payer, Anderson said, the challenge would be to make sure Medicare doesn’t simply end up paying more, or that cuts aren’t so dramatic that hospitals and doctors go out of business.
And there’s the political calculus, Ginsburg of Brookings noted. Hospitals, doctors and other health care industries are all influential lobbies and could successfully ward off any efforts to lower prices.
“It’s one thing to have regulatory control of prices. It’s another to set them low enough to make a difference,” he said.
Other strategies, such as a “public option” — which would allow people to opt into a government-provided plan but preserve multiple health care payers — could also make a difference, he said. Lawmakers on the state or federal level could limit what hospitals are allowed to charge for certain medical services, as Maryland does.
Some states have taken smaller-scale approaches, too, by tying their payment rates to a percentage of Medicare, rather than negotiating case by case. In Montana, state employees get coverage that pays about 230% of the Medicare rate on average — an arrangement that saved the state more than $15 million over two years.
For its part, the American Hospital Association, an industry trade group, points to the importance of lowering the cost of prescription drugs or reducing overuse, among other things.
Policy fixes are debatable, White said. But the data makes one point clear: From an efficiency standpoint, the current system isn’t working.
“There are right now the secret negotiations between health plans and hospitals,” and the system is “dysfunctional,” he said.
It was early morning in an operating theater at Providence Hospital in Portland, Ore. A middle-aged woman lay on the operating table, wrapped in blankets. Surgeons were about to cut out a cancerous growth in her stomach.
But first, an anesthesiologist — Dr. Brian Chesebro — put her under by placing a mask over her face.
“Now I’m breathing for her with this mask,” he said. “And I’m delivering sevoflurane to her through this breathing circuit.”
Sevoflurane is one of the most commonly used anesthesiology gases. The other big one is desflurane. There are others too, like nitrous oxide, commonly known as laughing gas.
Whichever gas a patient gets is inhaled, but only about 5% is metabolized. The rest is exhaled. And to make sure the gas doesn’t knock out anyone else in the operating room, it’s sucked into a ventilation system.
And then? It’s vented up and out through the roof, to mingle with other greenhouse gases.
The two frequently used gases are fairly similar medically; sevoflurane needs to be more carefully monitored and meted out in some patients, but that’s not difficult, Chesebro said.
And that bothered Chesebro. He grew up on a ranch in Montana that focused on sustainability.
“Part of growing up on a ranch is taking care of the land and being a good steward,” he said.
Now he lives in the city with his three kids and has gradually started to worry about their environmental future.
“When I look around and I see the stewardship on display today, it’s discouraging,” he said.
“I got depressed for a while, and so I hit the pause button on myself and said, ‘Well, what’s the very best that I can do?’”
He spent hours of his own time researching anesthesiology gases. And he learned desflurane is 20 times more powerful than sevoflurane in trapping heat in the Earth’s atmosphere. It also lasts for 14 years in the atmosphere, whereassevoflurane breaks down in just one year.
Opening a big, black notebook filled with diagrams and tiny writing, he showed how he computed the amount of each gas the doctors in his group practice used. Then he shared their carbon footprint with them.
“All I’m doing is showing them their data,” Chesebro said. “It’s not really combative. It’s demonstrative.”
“I wish I had known earlier,” Hartmeyer said. “I would have changed my practice a long time ago.”
Hartmeyer said he was stunned when Chesebro explained that his use of desflurane was the greenhouse-gas equivalent of driving a fleet of 12 Hummers for the duration of each surgical procedure. It’s “only” half a Hummer if he uses sevoflurane. Hartmeyer noted that outside the operating room he drives a Prius, a hybrid electric car.
“You try to be good,” he said. “You take shorter showers or [don’t] leave lights on, or whatever else. But you know there’s always more that we could probably do. But this was, far and away, a relatively easy thing that I could do that made a huge impact.”
The anesthesiology carts that get brought into operating theaters tend to have a row of gases to choose from. Hartmeyer was able to switch pretty much overnight.
Other anesthesiologists made the switch, too. And it didn’t hurt that sevoflurane is considerably cheaper.
Hartmeyer’s change saved his hospital $13,000 a year.
When Chesebro shared his findings with the anesthesia departments at all eight Providence Health hospitals in Oregon, they prioritized the use of sevoflurane. They now save about $500,000 a year.
She said several hospitals around the country have tried to make this shift, but with mixed results. Some just gave anesthesiologists the information and not much changed. Other hospitals took desflurane away, but that left many anesthesiologists feeling disrespected and angry.
Chesebro succeeded, she said, because he chose to persuade his colleagues — using data. He showed doctors their choice of gas plotted against their greenhouse impact. And it helped that he showed them over and over, so doctors could compare their progress to their peers.
“Providing ongoing reports to providers is the best way for this movement to catch on and grow,” she said. It can reinforce over time, she added, not just what their carbon footprint is, but also what progress they’re making.
“We clinicians are very much focused on taking care of the patient in front of us,” she said. “We tend to not think about what’s happening to the community health, public health — because we’re so focused on the patient in front of us.”
In an emailed statement, one of the largest manufacturers of both the anesthesia gases — Baxter International — said it’s important to provide a range of options for patients. The company also said inhaled anesthetics have a climate impact of 0.01% of fossil fuels.
“The overall impact of anesthetic agents on global warming is low, relative to other societal contributors, especially when you consider the critical role these products have in performing safe surgical procedures,” the statement reads.
It’s a fair point, Chesebro said, but he has a counterargument.
“Well, if it’s there, it’s bad. And if I can reduce my life’s footprint by a factor of six … why wouldn’t you do it?’”
The surgery Chesebro was involved in that morning at Providence was a success. Chesebro estimates that by using sevoflurane on his patient, the amount of greenhouse gases produced was the same as in a 40-mile drive across the Portland region. If he’d used desflurane instead, he said, it would have been like driving the more than 1,200 miles from Seattle to San Diego.
Now Chesebro’s hospital bosses are hoping other doctors will follow his lead, research their own pet peeve and maybe solve a problem no one’s thinking about.
Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.
Could ‘Aid-In-Dying’ Stem Tide Of Senior Suicide?
“Lethal Plans: When Seniors Turn To Suicide In Long-Term Care” (April 9), by Melissa Bailey and JoNel Aleccia, was a significant, interesting, thoughtful article with wonderful stories and solid information. However, the emphasis seems to be on the role of caregivers and various involved institutions to create “safer” environments to foster prevention of elder suicides through better assessment, better trained and more empathetic caregivers, and stronger monitoring and/or oversight.
To me, assessment is the vital piece of the puzzle. If the suicide drive is triggered by depression or other mental health issue, then treatment, well-trained personnel, monitoring, etc. are all on point, with the hope that the suicide ideation will subside as life improves.
However, if loving, thoughtful and professional interactions with the elder reveal that physical or emotional suffering has become unbearable subsequent to a serious, life-threatening illness, the issues involved are very different. They should now be addressed in a patient-centric manner in keeping with the underlying principle of self-determination.
In the article, these issues are only vaguely alluded to, as if medical aid-in-dying is an insubstantial fad or a “rare” policy exception. On the contrary, almost 20% of the U.S. population has legal access to aid-in-dying now that New Jersey’s new aid-in-dying law will take effect Aug. 1.
I wonder about the differences in elder suicide rates in Oregon and Washington, where medical aid-in-dying has been legal for decades. And I wonder if candid, loving discussions about advance care planning and sharing among loved ones about the value of longevity vs. quality of life, etc. are part of the solution. At least it would keep suicide survivors from unending questions, recriminations and flat-out guilt that may be undeserved.
So, my challenge to the incredibly capable and terrific authors is to try and tie these threads together and make the focus about informed decision-making, advance care planning, policies that maximize options (including medical aid-in-dying) and the inevitability of death for the elderly. We all die. Thanks for caring so much.
— Barak Wolff, NM End of Life Options Coalition, Santa Fe, N.M.
Elaborating on her tweet, reader Sharon Moon told KHN: “This is going to become more and more pressing as baby boomers age. I was in risk management in hospitals. In my view, hospitals err on the side of not reporting things. There is a huge culture of retaliation and seeking to sweep problems under the rug. … I can only imagine the way it is in nursing homes that are largely for-profit and without as many M.D.’s to speak out for patients.”
Who can blame them? We have lost our humanity. A nursing home chain owner (4 profit and private) hosted Trump’s CA fundraiser. We need to turn away from money and towards community.
Kaiser Health News’ “Lethal Plans: When Seniors Turn To Suicide In Long-Term Care” was an interesting and informative piece on a topic that deserves more public exposure. Thank you for writing it. But would it be possible for KHN to change its style and use the “Dr.” honorific when referring to psychologists? There are many people who describe themselves as psychologists without having a doctorate. And there are other mental health practitioners who are not psychologists at all — social workers and counselors, for example — who are frequently referred to in news accounts as “therapists,” just as a doctoral-level psychologist might be. You may not be aware that psychologists must complete seven years of education, plus post-doctoral work, and that practitioners must go through state licensing. The level of training is on par with doctors of dental surgery, M.D.’s, doctors of optometry, doctors of osteopathic medicine, doctors of podiatric medicine and doctors of veterinary medicine — all of whom are routinely accorded the “Dr.” honorific.
— Kim I. Mills, American Psychological Association, Washington, D.C.
I appreciated Melissa Bailey and JoNel Aleccia’s piece on long-term care suicide. But unclear why you refer to physicians as “Dr.” and not psychologists? Is that KHN editorial policy? Perpetuates stigma.
— Benjamin A. Bensadon, Ed.M., Ph.D., associate professor, University of Florida College of Medicine, Gainesville, Fla.
[Editor’s note: KHN follows Associated Press style for titles and honorifics. Its guideline on medical doctors — with our blanket apologies to Ph.D.’s — reads: “Use Dr. in first reference as a formal title before the name of an individual who holds a doctor of dental surgery, doctor of medicine, doctor of optometry, doctor of osteopathic medicine, doctor of podiatric medicine or doctor of veterinary medicine. … Do not use Dr. before the names of individuals who hold other types of doctoral degrees.”]
After Snakebite, Swift Action (And Taylor Swift) — But Skip Tourniquet
I am the director of The Rattlesnake Conservancy. We are thrilled that you are covering snakebites and educating people without fear-mongering (“Bill Of The Month: Summer Bummer: A Young Camper’s $142,938 Snakebite,” April 30). However, I am concerned that in the radio report on NPR your team mentioned the young lady used a tourniquet and did not mention how dangerous that can be. Many snakebite experts agree that using a tourniquet is dangerous, leading to potentially life-threatening consequences when the tourniquet is removed. Absent loss of life, it also leads to venom accumulation in the limb and significant tissue damage. The best course of action is immobilizing the affected limb and emergency care as soon as possible. No snakebite kits, tourniquets or other devices will help. The only effective treatment for snakebite is antivenom.
The Facebook group “National Snakebite Support” is a crucial tool for anyone who may have been envenomated. The group is staffed by the United States’ top venom specialists and snakebite medical doctors. Their team quickly responds to patients and will communicate with hospital staff on behalf of a patient as needed.
That being said, remember that venom has saved more lives than it has taken. Many medications, including several for blood pressure, arterial clotting and experimental medications, are developed from venomous snakes. For more information, check out our website.
— Anthony Daly-Crews, Buckeye, Ariz.
A hunter weighs in with advice on Twitter:
I’m horribly sad for that family’s financial burden. That’s the biggest reason I wear knee high snake boots…not scared of dying…I’m scared of the bill!!!!
Re: your 9-year-old girl snakebite story: Where was your question about why the girl was wearing open-toed sandals in the woods? Why do you not cover the personal responsibility angle: What did the girl learn? Will she be wearing more protective gear on her return visit this summer?
— Dick Crawford, Anaheim, Calif.
Nothing Like A Good Blood Boiling With My Morning Coffee
I just wanted to convey to the editors of KHN and NPR’s Shots that the “Bill of the Month” series is amazing and I appreciate your work. Normally something I read that gets my blood boiling this easily in the morning is not something I would seek out. However, I appreciate the intent of these articles to call out the ridiculousness of health care charges. What is even more infuriating is the majority of these articles seem to cover individuals who have some sort of health insurance. The reader can only infer what someone without any sort of health coverage would be dealing with!
— Mike Morse, Grand Junction, Colo.
Further Steps To Guard Against ‘Shameful’ Amputations
Thank you for drawing much-needed attention to disparities in unnecessary limb amputations for communities of color (“Diabetic Amputations A ‘Shameful Metric’ Of Inadequate Care,” May 1). While I applaud your article’s focus on diabetes, understanding related diseases like peripheral artery disease (PAD) is just as important.
As a limb salvage specialist in the Mississippi Delta, I know firsthand that African American patients with diabetes are over three times more likely to have their limbs surgically removed — with even higher rates in Mississippi. Sadly, a majority of the estimated 200,000 annual non-traumatic amputations —many stemming from PAD, a complication of diabetes –– can be avoided with the proper care.
Tragically, even though PAD is as serious as cancer, more than 90% of the amputees I have met have never had a diagnostic test for PAD or an appropriate vascular evaluation to salvage their limbs. Most have never even heard of PAD until it is too late.
To stop these troubling trends in my community, I created a team to aggressively screen, diagnose and treat each one of our 10,000 patients early and often. With no institutional or outside financial support, our practice was able to decrease PAD-related amputation rates in the region by 87.5%.
More must be done on the federal level to address America’s “amputation lottery.” The United States Preventive Services Task Force (USPSTF), for example, should change its recommendation for screening at-risk patients including racial and ethnic minorities and low socioeconomic populations who have a disproportionately higher prevalence of PAD and amputation rates. The current recommendation makes the USPSTF complicit in perpetuating current PAD-related amputation disparities in treatment and outcomes.
There also needs to be broad adoption of non-amputation treatment measures such as revascularization in all algorithms for wounds to heal properly before amputation is ever needed. Finally, policymakers should advance a comprehensive strategy that combines increased public awareness, robust screening and better access to multidisciplinary care for at-risk populations. Together, these steps could go far in reducing limb loss, especially among minority communities.
— Dr. Foluso Fakorede, co-chair of the PAD Initiative for the Association of Black Cardiologists and CEO of Cardiovascular Solutions of Central Mississippi, Cleveland, Miss.
This hits close to home: my grandfather, like thousands of Black and Latinx Californians, suffered a lower leg amputation due to lack of access to quality health care and diabetes. Diabetes is a manageable condition and does not *have* to result in amputation. #HealthDisparitieshttps://t.co/miDR4LBfIz
I am 69, Caucasian and was diagnosed with Type 1 diabetes 57 years ago. Both of my legs were amputated above the knee in 2014. My overall health has deteriorated since about 2000: heart disease, heart attack, quad bypass, pacemaker, peripheral circulatory disease. Eyes and kidneys are good.
Types 1 and 2 are vastly different, and while the ultimate goal is the same — normalizing blood sugar — Type 1 must be totally controlled with food, injections and exercise. A change in any one changes the others, often drastically. I am a retired engineer and know how to control my diabetes well, but life is tough. I cannot leave home without wheelchair-access transportation. I eat one meal a day, a casserole of sorts of beaten eggs, green beans and a small can of chicken breast. Every day.
My injection sites are badly worn, from 20 years of porcine insulin, and I must choose sites I formerly avoided, to get consistent uptake. One must roll the dice with every injection, particularly the fast insulins. Knowledge and extreme discipline are the keys to longevity.
— Mike Kemp, McComb, Miss.
A cousin I grew up with had her leg amputated last summer. It forced me to take better care of myself, but the stats & reasons for this surgery make me sad
Reading “How To Fight ‘Scary’ Superbugs? Cooperation — And A Special Soap” (April 12), I wondered: What about other nations? How are they dealing with MRSA and the like? I’ve read that northern European nations and the Department of Veterans Affairs have made excellent progress in decreasing MRSA, or methicillin-resistant Staphylococcus aureus, infections and death rates by screening, isolation and disinfection, while most U.S. health care facilities have not. What is it that other nations (and the VA) are doing to exercise control? Seems they’ve been a lot less freehanded with handing out antibiotics and using antibiotics in low doses in stock animals (chickens, steers in feedlots, etc.). Let’s hear how the rest of the world’s health care systems are dealing with the problem — the U.S. might learn something. Just as we’d do well to adopt a system for providing health care from at least one of 10 other nations, who get better results with less expenditure/capital than the U.S. does.
— Susan Hogg, Newport, Ore.
Clearly dealing with the most dangerous pathogens, but I wonder if the chlorhexidine also kills protective, beneficial bacteria and introduces new risks to the patients and caregivers.
The challenge: A healthy 7-year-old boy suddenly starts having fevers and night sweats. Can you figure out why?
Every month, the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult medical case and solve a diagnostic riddle. This month we present the case of a boy who has fevers topping 102 degrees every night for over a month. His parents sought help from nearly a dozen doctors in two states before a diagnosis was made.
Below I’ve given you the information that was available to the doctors who figured out the cause of the boy’s fevers. It’s up to you to use this information to put his story together for yourself.
As usual, the first person to crack the case gets a copy of my book, “Every Patient Tells a Story,” and, of course, that fabulous feeling you get when you solve a really tough puzzle.
The Patient’s Story
“I think you need to take him back home.” Her brother’s voice was calm, but she could hear an undertone of anxiety even over the poor cellphone reception that was all she could get from rural Colorado. “He needs to see a hematologist. It could be a virus, but it could also be something else.” He didn’t say it, but she knew what he was thinking: cancer.
Her son, just 7 years old and always a little delicate, had been sick for nearly a month. He was fine during the day, but every night he’d spike a fever of 102 or 103.
Even before they’d come to the mountains for a much needed vacation, she’d taken him to see his pediatrician at home in Minneapolis several times. At each visit, the doctor or one of his partners had looked the boy over closely, and each time he’d seemed fine.
It was probably viral, she was told, time after time. But he seemed to be having one viral infection after another.
A Vacation Cut Short
The day before they left for Colorado, the boy’s father took him to the doctor’s office one more time.
Maybe it wasn’t viral, the pediatrician acknowledged, and prescribed a “Z-pak” — a five-day course of azithromycin. Don’t cancel the trip, the doctor reassured him. He’ll get better.
But he hadn’t. While on vacation, his mother took him to a walk-in clinic, where they’d checked his blood. A worried looking doctor told her that he didn’t know what was wrong with her boy. He should probably see a cancer specialist.
Now she was really worried. There weren’t any specialists anywhere near the bucolic town where they were staying. That’s when she’d sent the test results to her brother, a researcher in immunology. He wasn’t a doctor, but he passed the results to friends who were, and they were worried, too.
Thin and Pale
The family headed home right away, but the 4th of July was coming. They couldn’t get in to see a hematologist until Tuesday.
By now the boy was starting to look sick. He was pale and had dark circles under his eyes. Small for his age — consistently in the fifth percentile for height and weight — he now looked even smaller, thinner. He was a quiet child, always had been. Thoughtful and comfortable in the company of adults, as so many only children are. Even now he never complained.
Nothing hurt. He was simply tired. His fevers started coming a little earlier, peaking a little higher. His mother noticed a cough and wheezing sometimes. Always a picky eater, with these intermittent fevers, very few foods seemed appealing. She tried to hide the terror she felt when he seemed to be fading as she watched.
A Long Line of Specialists
The hematologist examined the boy and sent off more blood. Definitely not cancer, he said. He suggested seeing a gastroenterologist.
The gastroenterologist got an M.R.I. of the child’s digestive system. Nothing there. He noticed the boy’s wheezing and gave him an inhaler, then referred mother and child to a rheumatologist and an infectious disease specialist.
It seemed to the parents that this had to be an infection, but the earliest they could get in to see the infectious disease doctor was the following week. For the boy’s mother, the delay now seemed intolerable.
It had been five weeks since the fevers first started. In that time, the boy had lost nearly 10 pounds. They’d seen eight doctors in two states. They’d all been very nice, thorough, thoughtful, but had no answers.
By the weekend she was desperate. The boy needed to be in the hospital. Couldn’t they see how sick he was? She couldn’t wait for the specialist. She took him to the emergency room of the big university hospital.
The E.R. doctors, like all the doctors they’d seen so far, were kind and thoughtful, and so gentle with her delicate son. But like all the other doctors, they had no answers. They prescribed another inhaler for the boy’s wheezing, since the first hadn’t helped. They also urged her to see the infectious disease specialist. His appointment was just a couple of days away.
TB or not TB?
The boy was sitting quietly between his parents watching a video on his tablet when Dr. Bazak Sharon and the infectious disease fellow he was training entered the exam room. Dr. Sharon’s first thought was that the child looked as if he had tuberculosis.
He’d seen a lot of TB in this clinic, but it was usually among immigrant families who had traveled to Minneapolis from countries where the disease was common. Like this boy, kids with TB were usually thin, sickly looking, pale and quiet. But based on what his fellow told him, the child had no exposures that would put him at risk for this disease. He’d only been out of the country once – to Canada. He’d visited the beaches of South Carolina and the deserts of Arizona, and most recently the mountains of Colorado. But TB was rare in all these locales.
Dr. Sharon introduced himself to the child, who looked up immediately and smiled. How do you feel, he asked the boy? His temperature had been recorded at 103 degrees. I feel good, he’d answered pleasantly. Does anything hurt? No.
His heart was beating rapidly – nearly 140 beats per minute, but that was probably due to the fever. There were several enlarged lymph nodes in the child’s neck and his groin, though none under his arms. Otherwise his exam was unremarkable.
Dr. Sharon had reviewed the blood tests that had already been done but wanted to see if anything had changed. And given that the only localized complaint was cough and wheezing, he wanted to get another chest X-ray.
Reviewing those studies that night, Dr. Sharon saw that the boy was slowly getting worse. He saw patients at that clinic only once a week and was reluctant to wait that long before having him seen again. He thought they needed an answer much sooner than that.
The note from the patient’s visit to the hospital.
To the Hospital
Dr. Sharon called the family the next morning. He’d reached out to one of his friends and colleagues, Dr. Abraham Jacob, who could see them. They should go to the University of Minnesota Medical Center Fairview, where Dr. Jacob would orchestrate a thorough workup. That would be the fastest way to get an answer.
Based on the assessment by Dr. Jacob and his resident and the recommendations from Dr. Sharon, the team reached out to specialists in hematology-oncology and in rheumatology. And since his chest X-ray was abnormal and he had enlarged lymph nodes, they wanted to get a CT scan as well.
Here are the notes from the pediatrics department.
Breathing Through a Straw
It was the results of the CT scan that really got things moving. It was the middle of the day when the resident was paged by the radiologist. The pictures showed that the lymph nodes in the boy’s chest were so swollen that they were pressing on the trachea – the breathing tube – so that it was almost completely cut off. Essentially he was breathing through the equivalent of a cocktail straw.
Any additional swelling could cut off the boy’s breath completely. You can see an image from the CT scan here.
This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.Credit
A normal trachea in a child this age is four to six times the size seen in the scan. The image added even more pressure to make a diagnosis and treat the child before he got sicker.
Solving the Mystery
A diagnosis was made within the next 24 hours. Can you figure out what the boy had, and how the diagnosis was made?
The first person to offer the correct answers to these two questions will get a copy of my book and that sense of triumph that comes from nailing the right diagnosis when it really matters.
Rules and Regulations:Post your questions and diagnosis in the comments section below. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.
A 37-year-old man was admitted to a hospital several months ago with seizures. His M.R.I. was frightening, showing a brain full of holes. Medication controlled the seizures, but the drugs were just Band-Aids on a big, undiagnosed problem.
The patient was not particularly alarmed (which in itself was fairly alarming). His brain was riddled with infection or tumor, but all he wanted to do was get out of the hospital and go back to his life.
By all accounts, it was a troubled, isolated, drug-ridden existence in a fleabag hotel, a life free from anything resembling regular medical care. Still, he was ready to be on his way.
The only way to diagnose his problem was a brain biopsy. “Anything to get out of here,” the patient said, and signed a consent form.
The biopsy was performed uneventfully, and small specimens of the abnormal tissue were sent to the lab for a diagnosis. That was on a Friday.
By Monday, everyone was ready for an answer. By Tuesday, it was hard to tell who was more impatient, the patient pacing the hallways or his doctors pestering the lab.
On Wednesday, with the specimens still being processed and another weekend looming, the case had attracted the notice of the administrators known in hospital vernacular as the discharge police.
Within minutes, it seemed, the patient was out of that expensive acute-care bed and on his way to the subway, clutching a thick sheaf of instructions, appointment slips and prescriptions, still without a diagnosis, brain full of holes, but free at last.
Your reaction to this story will almost certainly depend on your understanding of the word “hospital.” The word has connotations of care and comfort dating to the Middle Ages, but its meaning is changing so quickly that even the people who work in one cannot agree on what it is.
Once hospitals were where you found a doctor when you suddenly needed one; now doctors are all over the place, from big-box stores to storefront clinics. Hospitals were where you were headed if you were very sick; now you can heed your insurer’s pleas and choose a cheaper emergency center instead.
Hospitals were where you stayed when you were too sick to survive at home; now you go home anyway, cobbling together your own nursing services from friends, relatives and drop-in professionals.
Once hospitals were where you were kept if you were a danger to yourself or others. They still serve this function — although, perhaps, the standards for predicting these dire outcomes have tightened up quite a bit.
These days, it may be easier to define hospitals by what they are not. They are not places for the sick to get well, not unless healing takes place in the brief interval of time that makes the stay a compensated expense.
Hospitals are definitely not places for unusual medical conditions to be figured out, not if the patient is well enough to leave.
Like the hospital, the patient with holes in his brain was also a puzzle of ill-defined words. He was very sick, yet not all that sick. Whether he could survive at home depended strongly on the meaning of “survive” and “home.”
He was well enough to be an outpatient, but he was far from well, and had never managed to be a successful outpatient. He was not suicidal, at least not in any immediate sense. The big holes in his brain made it even less likely that he would adhere to the complicated instructions for his new outpatient life.
But then again, a hospital is a place where hope reliably springs eternal.
The patient’s young doctors certainly hoped for the best for him. They gave him a slew of prescriptions, and expressed their hopes that he would take the pills and keep his far-flung appointments, at one of which his brain biopsy report would be retrieved and his medications adjusted accordingly.
Not so long ago, the multiple ambiguities of this patient’s case would have kept him in the hospital until at least some of the uncertainty had been resolved. In fact, it would have been considered close to malpractice to let a patient like him out the door. Now it is considered downright medieval to keep him in.
I’m sure you would like to know what happened to the patient. His doctors would, too, but he is missing. His phone goes unanswered. The name of an emergency contact is blank in his records — he refused to provide one.
It’s anyone’s guess if he filled his prescriptions. He kept none of the appointments made for him.
The results of his biopsy showed a perfectly treatable condition, an infection that the pills he was sent home with should have helped. Perhaps he got better, perhaps not.
The young doctors will never know if they managed his case correctly — that’s “manage” in its medical sense. In the word’s other senses (“succeed despite difficulty” among them), they now have a reasonably good sense of how they failed.
The minute I got on that bus, I knew I was in trouble. The driver sat at the stop just long enough to miss the green light. Then he inched along till he missed the next light and the one after that. He stopped at every stop even though not a soul was waiting.
The 20-minute trip to work stretched to a half-hour, then longer. I was late, late, late.
But this was a driver with a mission, clearly way ahead of schedule and trying to get back on track. He was very early; now I was very late. We were two people with competing, mutually exclusive agendas, and the one in the driver’s seat was bound to win.
A half-hour later, still sweating from racing the last five blocks on foot, with patients piling up in the waiting room, I became the one in the driver’s seat, with the mission and overriding agenda. Woe betide those with competing plans.
Just like that driver, I work under two mandates. One is professional: getting my passengers from point A to point B without breaking the law or killing anyone. The other one is less exalted but generally far more visible: I run according to a schedule that I ignore at my peril.
“She’s running late,” they mutter out in the waiting room. And indeed, she runs late for exactly the same reasons your bus runs late: too many slow-moving passengers lined up to board. Not enough buses or drivers. A person in a wheelchair requiring extra attention. Horrible traffic.
Not only does she often run late, but your poor driver — er, doctor — can run only so late before disaster ensues. She has obligations not only to you and your fellow passengers twitching in annoyance, but to a host of others, including the nursing and secretarial staffs and the cleaning crew at the end of the line. She can’t pull that bus in at midnight if everyone is supposed to leave by 7 p.m.
So when there is enough work to last till midnight, my agenda shifts, and not so subtly. Everyone can tell when I begin to speed. Every visit is pared down to the essentials. All optional and cosmetic issues are postponed, including most toenail problems and all paperwork. Chatting is minimized.
As a bus driver once said to me when I was foolish enough to start a conversation about his speed: “Lady, just get behind the white line and let me drive.”
Medicine is full of competing agendas. Even at the best of times, the match between the doctor’s and the patient’s is less than perfect, sometimes egregiously so. Some residents are now trained specifically in “agenda setting,” the art of successfully amalgamating all concerns.
But when it’s all about speed, an advanced skill set is required.
A patient has been waiting weeks for his appointment, anxiously rehearsing his lines. Bad luck that he showed up on a day I need him in and out in 19 minutes. He spends his first 18 unwisely, pretending everything is fine, making small talk, not quite mustering the courage to say what’s on his mind.
Then just as he is being ushered gently to the door, he pauses. “Oh, by the way …”
“Oh, by the way” is an infamous schedule buster. It means something bad: a suspicious lump, a sexually transmitted disease. Further, it is so common that an entire literature now addresses the “oh, by the way” phenomenon and how to tame it.
One favored tool is: “What else?” That question, asked by the doctor early in the visit, is intended to probe the patient’s agenda before it trumps the doctor’s.
As one set of researchers wrote: “The ‘what else?’ technique uncovers pertinent fears and anxieties up front and prevents an ‘oh, by the way, I have been having some chest pain’ from surfacing at the end of a visit.”
In other words: My agenda is to adopt your agenda, and then rework it so that I can drive on. Brutal, perhaps, but effective.
Very rarely do things work out for me the way they did for that driver who made me so late to work. Occasionally I have so much time that I can dawdle along the route.
I remember clearly the last time that happened. “How’s work?” I began. “What are you doing for exercise?” “Any hobbies?” “Your family, are they well?” I progressed rapidly through seatbelts, bike helmets, family medical history, end-of-life preferences — every single stop my bus typically has no time to make.
Every answer was “fine,” “yes,” or “I dunno.” Then the patient stood up: “Look, I have places to be. Are we done?”
We were two people with competing, mutually exclusive agendas. But that time the one in the driver’s seat lost.
The Challenge: Can you figure out what is wrong with a lively 67-year-old gardener who develops a daily fever and shaking chills along with chest pain and a dry cough?
Every month, the Diagnosis column of The New York Times Magazine asks Well readers to solve a real-life diagnostic mystery. Below you will find the details of a case involving a retired maker of surgical supplies who starts having daily fevers along with chills, chest pain and a dry cough.
I’ll give you the same information the doctor was given before he made this diagnosis. Will you be able to figure out what’s wrong?
As usual, the first reader to submit the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” and the pleasure of puzzling out a tough but fascinating case.
The Patient’s Story
“NoNo says he doesn’t feel good,” the 9-year-old girl said of her grandfather, handing her mother the thermometer. The woman dried her hands on her apron and took the device. She squinted at the little electronic numbers. Just under 102 degrees.
Her father had been sick for weeks. Feverish, weak, not eating. It was late summer and the tomatoes and eggplants in the garden were ripe, but he hadn’t even walked through his garden for days, so she knew he wasn’t feeling well. But this was the first time he’d admitted that something more serious might be going on.
It was about time. She’d taken her 67-year-old father to several doctors over the past two months. They’d looked him over and given him antibiotics, but it hadn’t helped.
“Tell NoNo that if he’s feeling sick he’s got to go to the hospital,” she told the little girl. She darted back to her grandfather’s room then quickly returned. “He says he’s ready to go.”
The woman wasn’t sure exactly when her father had started to get sick, but six or seven weeks earlier she had noticed that he was no longer the first one out of bed. Instead of being up and out before 7 a.m., he wouldn’t get up until late morning. And he started to have strange shaking chills each afternoon and evening, followed by a fever — regular as clockwork.
He looked sweaty and pale. She asked him what was wrong, but he said he was fine. Or sometimes he’d say he felt a little tired. After an hour or two the fever would pass and he’d just look tired, but the next day, or sometimes the day after, the fever would be back.
The First Diagnosis
The woman first took her father to his regular doctor. Knowing how much he loved to work in his garden, the doctor figured he probably had Lyme disease. It was summertime, and Lyme was common in the area of Connecticut where they lived. Plus, he practically took root in the half-acre garden back behind the house where he lived with his wife and their children and grandchildren.
This was the first summer the woman could remember where her father wasn’t out in his garden every single day. This year it seemed that whole weeks would go by when he did nothing but look out the window at his beautiful handiwork.
Her father took antibiotics for the presumed Lyme. It didn’t help.
A Second Diagnosis
When the patient went for a follow-up visit, he told his doctor that his stomach was bothering him a bit. So he was referred to a gastroenterologist. That doctor diagnosed Helicobacter pylori – a bacterium tough enough to survive the acid environment of the stomach that can cause pain and ulcers.
He took two weeks of treatment for that — three medications to kill the bug, and one to neutralize the acid they thrive in. That didn’t stop the daily fevers, either.
Recently the man’s wife noticed that he’d developed a dry cough. Was this a pneumonia? His doctor gave him yet another antibiotic. And he was still taking that pill when he agreed to go to the emergency room.
So three generations — wife, daughter and granddaughter — got in the car with the man they loved and drove to the hospital where the daughter worked.
The emergency room was quiet when they arrived, and after explaining that the patient had been having fevers for weeks, the patient and his entourage were taken into the back so he could be seen right away.
He did have a fever but otherwise looked pretty healthy. The doctors there seemed to focus on the cough and fever. They figured he had a pneumonia that wasn’t responding to the antibiotics he was taking. And when a chest X-ray failed to show any sign of pneumonia at all, the doctors sent him home.
The next day, the man felt no better. His daughter was distressed. Her father was sick. Antibiotics weren’t working. And he was getting worse.
She called his primary care doctor again. He was also worried, he told her. But he didn’t know what to suggest.
What if she tried a different emergency room?, she suggested. They had gone to Yale-New Haven Hospital initially because that’s where she worked, but what if they went to the smaller branch of the hospital, St. Raphael’s Hospital, less than a mile away. They had different doctors there, and the hospital had a different feel — local and friendly rather than big and academic. Maybe they would find a doctor there who could help them figure out what was going wrong. It was unorthodox, the doctor told her, to shop around emergency rooms. And it wasn’t clear what another E.R. visit might do. But he was also worried about the patient, and it was certainly worth a try.
Another E.R. Visit
So early that evening they all got back into the car and drove to the St. Raphael campus. The E.R. was bustling when the family came in. Once again he had a fever – 101.6 degrees. His family explained how sick he’d been, how tired. And yet when the doctor examined him, he seemed well enough. He couldn’t find anything abnormal beyond the fever.
The labs told a slightly different story. His red blood cell count was low. So were his platelets – a type of blood cell that helps blood to clot. What was particularly strange was that these two findings had been checked the day before at the other E.R. and had been fine. And there was some evidence that he had some liver damage.
And when tested for viral hepatitis — a common causes of abnormal liver tests — he tested positive for hepatitis A and possibly hepatitis B as well.
He was admitted to St. Raphael’s Hospital because of his worsening anemia and viral hepatitis.
The next morning, Dr. Neil Gupta saw the patient. Hearing the patient’s story, and the diagnosis of hepatitis A infection, was a little puzzling. Patients with hepatitis usually have mild flu-like symptoms, with a loss of appetite, nausea and vomiting, plus fatigue, low-grade fever and a generalized sense of being unwell. Certainly this patient didn’t feel well, but he had no nausea, no vomiting. And his fever came in spikes. The pattern didn’t really match.
Dr. Gupta sat down with the patient’s family and reviewed all the symptoms and the timeline. Then he reviewed all the labs. He sent off a bunch of tests.
They say if all you have is a hammer, everything looks like a nail. I wonder, then, why my toolbox often seems so inadequate for fixing my patients.
I open one recent afternoon in clinic with a middle-aged man I’ve come to know well. He’s drunk. His breath smells of alcohol and he slurs his words. He tells me his brother’s in jail, his mother died, and he punched a neighbor who tried to steal his wallet. In the past year, he’s been admitted to the hospital countless times for everything from falling to getting injured in a fight to failing to take his medications.
“High risk for readmission,” an automated email plops into my inbox each time he’s admitted. Thanks, I’m on it.
I search for mental health and substance use resources we haven’t yet exhausted. I speak briefly with a psychiatrist and case manager and a social worker who is arranging transportation back to the housing he’s in danger of being thrown out of.
“Maybe we increase his mood-stabilizer?” I offer, mostly just to say something. When all you have is a hammer…
The afternoon doesn’t get easier. I see a patient whose heart failure had been in good control with a telemedicine service that had checked his weight at home and adjusted his medications accordingly. But the service has been cancelled, and now he’s in our clinic, gasping for air as fluid fills his lungs.
He’s followed by an older man who’s been on opioid painkillers for a decade — and who I now suspect is selling extra pills on the street. I’m running 45 minutes late by the time I greet an understandably frustrated woman who, a computer alert informs me, is overdue for her first colonoscopy. She balks when I bring it up, and I don’t have the words or the time to convince her otherwise.
The afternoon was not unusual. At the end of most days, I find myself searching for nails that I can hammer.
Part of the problem is the tool kit we assemble during medical training. We’re educated largely in a biomedical framework. We diagnose disease with textbook knowledge and prescribe medications because those are the hammers we have.
But consider the skills I would need to be more effective in just this one clinic session: understanding social issues that contribute to health; marshaling support resources like case management, social work and rehabilitation centers; exploring my patients’ values and goals and encouraging behavior change; leading interdisciplinary care teams; employing new technologies and methods of patient engagement like telemedicine; and appreciating how health systems fit together to influence an individual patient’s care — from home care and community centers to clinics and hospitals. None have traditionally been emphasized in medical education — and, unsurprisingly, doctors in training like myself are often ill-equipped to practice in today’s health care environment.
Medicine has long been a discipline predicated on memorization, which made sense in a world of textbooks, microscopes and information monopoly. But rooting medical training primarily in knowledge acquisition is increasingly insufficient and inefficient. In an era of big data, Google and iPhones, doctors don’t so much need to know as they need to access, synthesize and apply. We’re increasingly asked to consider not just patients, but communities. We’re expected to practice not as individuals, but as team members. And now — liberated from carrying every diagnostic and treatment detail around in our heads — we have both the responsibility and the luxury of deciding what a doctor should be in the 21st century.
Some medical educators are trying to figure it out, with a greater emphasis on new technologies, collaborative care, wellness and community health.
The new Dell Medical School at the University of Texas, Austin, which enrolls its first class in June, is hoping to revolutionize medical education. The school plans to focus on helping students understand how health systems, communities and social issues contribute to individual health through a variety of innovative methods.
Instead of traditional lecture halls, Dell’s students will learn in collaborative workspaces with a curriculum that emphasizes team-based management of patients. They’ll take weekly classes with pharmacy, nursing, social work and engineering students. Dell’s “Innovation, Leadership and Discovery” program affords students an entire year to pursue projects related to population health and delivery system redesign.
Dell also features a unique collaboration with the university’s College of Fine Arts — known as the Design Institute for Health — to bring design thinking to health care. Here students will learn to think about everything from better hospital gowns and more hospitable hospital rooms to how patients access services online and how to make waiting rooms obsolete.
“It’s an incredible gift to start from scratch,” said Dr. Clay Johnston, the school’s first dean. “We can start by looking at where the biggest gaps and problems are. Then say, O.K., given those needs, what should doctors and the medical system look like in the future?”
The health system Kaiser Permanente recently announced its own plans to open a medical school in 2019, in Pasadena, Calif. The medical school, like the health system, will emphasize integrated care, the latest medical evidence and new technologies like online doctor visits.
“We recognize the importance of providing care in alternate settings,” says Dr. Edward Ellison, who is helping to oversee the creation of the school. “We’ll take care of you when you’re sick. But we’ll also help you stay healthy when you’re home.”
While most medical schools are trying to get students out of lecture halls and into hospitals, Kaiser Permanente hopes to get students out of hospitals and into communities. Students will visit patients in their homes to see how they live and what behavior change looks like in living rooms instead of hospital rooms. They’ll also be trained as emergency medical technicians — riding in ambulances alongside other medical professionals, responding to accidents, violence and trauma in their communities.
The American Medical Association, for its part, has provided over $11 million to established medical schools to reimagine their curricula and better prepare students for a rapidly evolving health care environment.
Older physicians, medical educators, policy makers and patients will continue to debate what doctors should be taught and what they should know. But the deeper question is how doctors can learn to think — to solve problems that can’t be solved with the tools we currently have. Because ultimately, there’s no better hammer than that.
Dhruv Khullar, M.D., M.P.P. is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter:@DhruvKhullar.
When the emergency room doctor pulled the blanket aside, looked at my elephant-size inflamed leg and said, “Whoa!” I knew that wasn’t a good sign.
Nor was the reaction of the emergency room nurse, who glanced down at my bizarrely swollen extremity, then started nervously backing away.
Health care practitioners are trained not to show their feelings, but there are clearly times when things look so bad that even they can’t hide their reactions.
I was in the emergency room at Los Robles Hospital in Thousand Oaks, Calif., because a few days earlier I had undergone what was supposed to be a relatively straightforward outpatient procedure to remove a skin growth on my leg. A couple of days after the surgery I felt fine. The surgeon told me I could drive whenever I was up for it, so we took our grandchildren to the Magic Castle in Hollywood. Running from room to room to see the different sleight-of-hand acts, I no longer felt fine. Now I felt a searing knife-like pain in my leg, which soon began to swell in size.
I went back to see my surgeon, who looked a little concerned. You have an infection, she said. Take these two antibiotic pills, schedule a Doppler scan for the next day, and all should be well.
That night, my leg got even bigger; from the waist down one side of me looked like I weighed 350 pounds (I’m not even half that.) My wife and I spoke to the surgeon, who was vague. “You could go to the E.R. if you want,” she said. “Or wait.”
I went and was admitted immediately. That night, a Doppler study showed no life-threatening blood clots. With no beds available, I was kept in the emergency department overnight, taking catnaps while trying to blot out the screams and moans from down the hall, before being given a room, and intravenous antibiotics, the next morning.
“This is very serious,” said Dr. Barry Statner, the infectious disease specialist who came to see me the next day in my hospital room. “We’ll cure you,” he said while firing questions at me about my medical history. “But you need to know, this is very serious.” I wondered if I was going to lose my leg.
For the first time in my life, I had entered the world of the powerless sick. Like most people, I had long heard about the dangers of contracting infections in hospitals or surgical centers, but I never took them seriously. I assumed that, except for the worst cases, such as those caused by improperly disinfected scopes and other instruments, they were little more than a minor annoyance.
In fact, infections kill, and they do so regularly, even to people who are otherwise healthy.
“There are diseases that can take a regular healthy person and destroy them within hours,” Dr. Statner told me. “You don’t get a second chance. People don’t realize how rapid and lethal infections can be.”
I count myself as somewhat lucky. My wound was infected with a relatively run-of-the-mill strain of Staphylococcus aureus, and after a week in the hospital, followed by two weeks hobbling around the house, where a nurse visited daily to pack my wound with prodigious amounts of gauze, I was on the road to recovery. I was fortunate it wasn’t one of the more serious infections that lurk around hospitals, like MRSA, a “super bug” strain of Staph that is resistant to most antibiotics, or C. difficile, which can cause months of relapsing and severe diarrhea.
No one knows how my infection happened. It was the first, and only, case of this type of infection at the surgical center that year, I was told by Dr. Richard Hoberman, the medical director and the anesthesiologist who had put me under general sedation during my surgery. Clearly shaken by what happened to me, he unexpectedly popped in to my hospital room early in my stay to apologize.
My infection resulted in my being “the subject of several very uncomfortable meetings with the hospital administration” and a five-page written report, Dr. Hoberman said. (They passed on sharing a copy of that report with me.)
Hospitals are anxious to reduce hospital-borne infections, to reduce deaths and improve their reputations. There are also immediate financial incentives: Medicare may penalize hospitals for infections acquired in the facility.
The medical center I’d gone to for my surgery, associated with Los Robles Hospital, practices all the well-known standard forms of infection prevention: constant washing of hands; sterilizing equipment; giving patients preoperative antibiotics; cleaning operating room surfaces and thorough cleaning at night. In addition doctors are not allowed to enter the operating room wearing the same scrubs they wear in the street. To prevent the spread of microbes, cellphones and jewelry are banned, as well as ties.
But infections still happen. While most infections happen at the time of surgery, according to Dr. Statner, they can occur in the hospital room as well. A break in the skin, a lapse in the handling of a paper surgical cover, lackluster cleaning, intravenous lines or catheters that remain in too long — all can result in infection.
In the end, stamping out infections depends on the vagaries of human behavior. “Medical care is done by people. There can be gaps in quality. People must remember to do certain things,” said Dr. Arjun Srinivasan, the associate director for health care associated infection prevention programs at the C.D.C.
“Far too many Americans get sick in the hospital,” said Dr. Thomas R. Frieden, director of the C.D.C. “The importance of making care safer cannot be overstated.” One limitation is that the C.D.C. can only recommend, not mandate, practices to reduce infection, he said. And because hospitals are owned by various corporations, it can be a challenge to know how effectively patients are being protected in any one hospital. If a patient is moved from one hospital to another across town, he said, it “can cause problems,” given that one hospital may have less rigorous infection-reduction policies than another.
Hospitals are experimenting with new disinfection techniques. For example, some disinfecting machines using ultraviolet light are so powerful that no one is allowed in the room when they are in operation. And routine measures like thorough hand washing, and having patients thoroughly shower using chlorhexidine before surgery is helping bring infection rates down in the United States in recent years. In the three to six years before 2014, depending on the type of infection, the rate of surgical-site infections has dropped by 17 percent, C. diff by 8 percent and hospital-borne MRSA by 13 percent, according to the C.D.C. However, there was no change in the rate of urinary tract infections caused by catheters between 2009 and 2014.
Infection rates have dropped even more steeply in Britain, where total MRSA reduction from 2004 is now 80 percent, according to Dr. Mark Wilcox, the head of medical microbiology at Leeds Teaching Hospitals and the head of the C. difficile task force for Public Health England. Leeds Hospital used to see 15 to 25 MRSA infections per month; now it gets five per year, he said.
Dr. Wilcox attributes their success in part to having a coordinated, single health system for the entire country. To encourage hygiene, National Health Service hospitals post current infection rates on boards that can be seen by doctors, patients and visitors. Hospitals are “obsessional” about hand hygiene, Dr. Wilcox said. To do the best cleaning job, health workers must be “bare below the elbows,” with no watches on the wrist. Lab coats, while making a doctor look professional, are also banned, as they can brush up against patients and transfer bacteria from one patient to the next.
Hospitals that fail to meet infection reduction targets are visited by a “hit squad improvement team” that demands a new plan, Dr. Wilcox said. Those that fail lose the right to decide how to spend some of their annual budget.
“A decade ago, people would say that only a small proportion of infections are preventable,” said the C.D.C.’s Dr. Srinivasan. “Now we know that a large proportion are preventable. We’ve turned that paradigm on its head.”
On Thursday, we asked Well readers to take on a challenging case. A 38-year-old man who traveled to the mountains of Colorado for his brother’s wedding suddenly became ill. He had fevers and chills, chest pain, a severe headache and a sore throat. There was so much going on that it was really tough to see what might be underlying it all. More than 400 of you offered your diagnoses, but no one got it completely right. I had to choose two winners, each of whom was the first to get at least part of it right.
The correct diagnosis was:
Lemierre’s disease caused by an invasive strep infection
One of the winning answers came from Dr. Hediyeh Baradaran, a chief resident in the radiology department of Weill Cornell Medical Center. She recognized that an invasive strep infection could cause both the inflamed heart muscle diagnosed at one hospital and the abscess found at the other. She didn’t mention the Lemierre’s. That diagnosis was offered by Dr. Ariaratnam Gobikrishna, a cardiologist with Montefiore Medical Center in the Bronx.
In 1932, Dr. André Lemierre reported on 20 patients he’d seen who became ill with a sore throat and then went on to develop a clot in their jugular vein. The clot was infected with bacteria, and the disease spread from the jugular to the lungs, bones, brain and other organs when tiny pieces broke off, seeding the infection throughout the body. The illness came to be known as Lemierre’s disease, or syndrome.
Lemierre’s is rare, most commonly seen in teenagers and young adults. And it is frequently misdiagnosed, at least initially. In one study of hospitalized patients, a correct diagnosis of Lemierre’s was made, on average, five days after admission.
Most of the time the infection is caused by an unusual bacterium called Fusobacterium necrophorum, but it has been associated with other bugs as well. And no matter which bacterium caused it, in the era before antibiotics, Lemierre’s was practically a death sentence, with 90 percent of patients dying. Even now, it’s not a disease to be taken lightly. Up to 18 percent of patients will die of the infection.
However, it wasn’t some rare infection behind this man’s illness. Blood cultures drawn at Anna Jaques Hospital in Newburyport, Mass., where the patient went after returning home, revealed an underlying disorder that is much more common and much less feared: strep throat. There are millions of cases of streptococcal infections in this country every year, usually in the throat or on the skin. But in a tiny fraction of these cases, the bacterium will invade the surrounding tissues and cause a life-threatening illness, as it did with this man.
Both the Lemierre’s and the myocarditis were caused by this strep throat gone wild. This kind of invasive infection must be treated with antibiotics. This patient was taking an antibiotic, doxycycline, because the doctors were worried initially that he might be suffering from some kind of tick-borne infection, but that antibiotic is ineffective against most types of strep.
How the Diagnosis Was Made
After the patient’s flight back from Colorado to Boston, he had ended up in Massachusetts General Hospital, where he’d been diagnosed with myocarditis, or inflamed heart muscle. He began to feel a little better and returned home, but after a day he began to feel worse again. He was pale and sweaty, the way he’d been in the mountains. And the shaking and fevers were back. His headache was terrible, almost as bad as it had been in the hospital, where it had brought the man to tears — something his wife had never seen before.
The patient’s wife called Mass General several times with her concerns; the doctor who’d cared for the patient there suggested she take him to a local hospital. And that’s when she turned to her husband and gave him a choice: She could drive him to the hospital or she could call an ambulance, but he was going to go to the hospital – and he was going to go now.
At the Anna Jaques emergency room, the couple met Dr. Domenic Martinello. He heard their complicated story of traveling to Colorado and feeling sick, then returning to Boston and feeling sicker; then going to Mass General and getting a diagnosis of myocarditis, but not getting better. After a quick exam, Dr. Martinello decided to focus on the most prominent symptoms at that moment: the headache, the neck and throat pain, and the fever.
Scanning the Head and Neck
He would start with a CT scan of the head, he told the patient and his wife. And if that didn’t provide an answer, he would get a CT scan of the neck. And if he still had no answer, he would get a lumbar puncture, or spinal tap. One of those tests, he was certain, would provide the answer.
The head scan was completely normal. There was no tumor, no blood clot and no sign of increased pressure. That was important because Dr. Martinello suspected that the patient had some kind of meningitis, and if the scan had shown increased pressure, he wouldn’t be able to do a spinal tap. But as it turned out, a spinal tap wasn’t needed.
The emergency room doctor wanted the CT of the patient’s neck because it was swollen and tender. The patient had told him he had a sore throat, yet when the doctor looked in his throat he saw nothing. Could there be an abscess seeded deep in his oral pharynx from some earlier infection? Is that what was causing his throat and neck pain?
The arrow is pointing to a clot (darker gray) within the jugular vein (lighter gray).Credit
It was the right question, though the result was not what Dr. Martinello expected. There was a small abscess. More worrisome, there was a blood clot in the patient’s jugular vein, on the patient’s right side. He had Lemierre’s disease, a rare infection that Dr. Martinello had seen only once before. You can see the clot in the CT image shown here.
Transferring to a Bigger Hospital
Now that Dr. Martinello knew what was making this man so sick, he was worried that his small community hospital was not prepared to care for him. They didn’t have the kind of specialists he needed on call 24/7. It seemed clear that the patient needed a hospital with more resources. So Dr. Martinello arranged for the patient to be transferred to a sister hospital, Beth Israel Deaconess Medical Center in Boston.
Identifying the Bug
Dr. Andrew Hale was the infectious disease specialist on duty the night the patient arrived at Beth Israel. When the patient and his wife arrived at the B.I. emergency department, Dr. Hale hurried to meet them. He spoke to husband and wife and reviewed their complicated history of the past week or so. But he also learned that both children had come down with strep throat while their father was at Mass General. It was an important discovery since, although unusual, it was well known that strep could cause Lemierre’s, He ordered another set of blood cultures and started the patient on broad-spectrum antibiotics.
Because the patient had been started on intravenous antibiotics while at Anna Jaques, there was a good chance that these cultures wouldn’t grow anything, but he needed to try. He also knew that Dr. Martinello had drawn blood cultures from the patient before he had started on the intravenous antibiotics, and was optimistic that these cultures would show what the bugs were. Identifying the bacteria that were causing the infection was important so that the antibiotics could be more narrowly targeted.
The cultures from Anna Jaques grew out Strep pyogenes, the most common cause of strep throat. The patient continued on antibiotics for six weeks and started a three-month course of a blood thinner to keep the clot from growing or spreading.
How the Patient Fared
That was a year ago. The patient is completely recovered. It was kind of funny, he told me recently. Even though his throat was painful, the sore throat seemed insignificant compared to the shaking chills, the fever, the headache. “I thought of it as kind of a sidebar, when in fact it was the main event,” he said.
Both he and his wife have read up on the illness and come up with a new family motto: Take strep seriously.
A radio producer investigating cancer costs once asked me, “What is another year of your life worth?” During my flummoxed silence, she informed me that experts mention the figure $50,000. Can patients like me — older people with recurrent disease — estimate the expense of a future year of cancer treatment to decide whether it’s worth it?
I began to understand the origin of the number when my nephew sent me an article in The New England Journal of Medicine, “Updating Cost Effectiveness.” Its authors explain: “For more than two decades, the ratio of $50,000 per quality-adjusted life-year (QALY) gained by using a given health care intervention has played an important if enigmatic role in health policy circles as a benchmark for the value of care.”
Used by economists, the QALY calculates quality and quantity of life to judge the monetary worth of medical inventions. Since my cancer was diagnosed in 2008, I have wondered how to make this reckoning within our for-profit health system. So with misgivings I set aside the plight of the uninsured and began considering not generic measurements of cost-effectiveness but how much I — as an insured patient — had paid for one year of cancer treatment.
It turned out to be impossible. Never — during four years of operations, radiological interventions, and cycles of chemotherapy — had I been informed beforehand about the cost of any consultation, procedure, equipment or drug. Nor did I understand what would be covered by insurers and (when I got older) Medicare or what would have to be paid out-of-pocket.
After the consultation or procedure, I received impenetrable statements from providers, stamped in large letters, “This Is Not a Bill.” They were followed by cryptic printouts from the hospital that clearly were bills, although next to many entries the word “pending” appeared.
Now, given my erratic bookkeeping, I cannot calculate what I ended up spending.
The camouflaging of cancer costs poses an unprecedented problem. There is no analogue in life — including the approach of death — in which I remain so ignorant of expenditures. Although I have ascertained what cremation, a grave site, and a marker cost, I have no idea what the costs of my treatments amounted to.
During those same years, I could not predict treatment complications that required subsequent procedures and outlays. When an operation necessitated another, the bills multiplied. Humbled by my own unknowingness, I took to heart Kierkegaard’s insight that we must live life forward, even though it can only be understood backward.
Obviously, I was in neither the physical nor the psychological state needed to adjudicate the paperwork. Dazed, frightened and depleted by the alarming threat to my mortality and the debilitation of treatment, I demoted the bills to a nasty irritant. An excellent job with good benefits buffeted me from facing what less lucky people confront: a financial crisis triggered by cancer treatment.
Stints in the hospital enlighten many patients about prohibitive co-pays and costs above coverage ceilings for the large sums charged by surgeons, anesthesiologists, radiologists and oncologists; for operating and hospital rooms, tests and scans, medicine and equipment as well as a box of tissues. The title of an article in The Oncologist about the financial distress of insured patients speaks volumes: “The Financial Toxicity of Cancer Treatments.”
Add to these expenditures exorbitant out-of-network fees, the loss of wages resulting from treatment-related appointments and disabilities, the cost of travel to and from the hospital, and the need to hire child care or housekeeping or elder care assistance. All these combined payments can be staggering.
As for the new cancer drugs, pharmaceutical companies apparently charge whatever the market will bear. A new type of medication, a PARP inhibitor similar to the one I receive in a clinical trial, has been approved by the Food and Drug Administration for recurrent ovarian cancer patients. Lynparza, produced by AstraZeneca, costs about $11,000 a month. That would come to $132,000 a year. After a media flap a few years ago over Zaltrap — doctors at Memorial Sloan Kettering boycotted it, saying it was no more effective than a less expensive drug — its producers cut the price in half.
No wonder, then, that people with cancer are more likely to go bankrupt than other Americans. The authors of The New England Journal of Medicine article conclude that the QALY has been underestimated. For a single threshold now, they would suggest either $100,000 or $150,000 per QALY.
Whatever the estimate, a crude ratio of cost effectiveness, like the QALY, seems presumptuous. How can qualitative factors (nausea, fatigue) be converted into quantitative numbers? How can general calculations account for individual variations (my preference for fatigue over nausea) or overriding personal beliefs and principles about what constitutes a valuable existence?
Yet it would help patients like me to participate in sober public conversations on these issues since many of us are aware that individual decisions about medical costs sidestep vexing social questions of why they are inflated and how they will tax our children and grandchildren. At the least, more transparent communications would alleviate widespread fears that living life forward could trip us backward into penury.
For the past three years, the clinical trial in which I participate has covered most cancer-related expenses. When the drug in my trial fails, I want to have some say about whether another year of my life is worth the cost of treatment. But it will take a change in the current way of doing medical business to make that possible.
The Challenge: Can you figure out what is wrong with a 38-year-old man who suffers from fevers, insomnia and night sweats after traveling to the mountains of Colorado to be his brother’s best man?
Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a real-life medical mystery. Below you will find the story of a 38-year-old marketing executive from the Boston area who suddenly becomes sick when he takes his family to his brother’s destination wedding in the Rockies. Within a day of their arrival, the man begins to feel sick, though the rest of his family feels fine.
As usual, the first reader to offer the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” along with that feeling of satisfaction that comes from solving a difficult but really cool case.
The Patient’s Story
“Either you are getting in the car with me to go back to the hospital, or I’m calling an ambulance,” the woman announced. “It’s totally up to you.”
Her husband, 38 and never sick a day in his life, had been desperately ill for more than a week. He’d just gotten out of the hospital that morning, and after being home for less than 12 hours he was worse than ever. Though she couldn’t bring herself to say it out loud, she was worried he might be dying. And though he didn’t say anything, so was he.
It had started at his brother’s wedding, one of those destination events in the mountains of Colorado. And almost from the moment he stepped off the plane, he’d started to feel awful. His head ached. So did his body. His eyes were puffy, and his whole face looked swollen. He couldn’t eat, and he couldn’t sleep. When he went to bed that first night, he tossed and turned, though he felt exhausted. In the morning, when he dragged himself out of bed, the sheets were soaked with sweat.
Just the Altitude?
At first he wrote it off as altitude sickness. The resort was 11,000 feet above sea level, and he’d never been this high up. Though his wife and the kids felt fine, there were others in the wedding party who were feeling the effects of the altitude as badly as he did. One of the bridesmaids fainted at the rehearsal dinner. And an elderly aunt had to leave before the wedding.
The day of the wedding it snowed – in May. The kids were thrilled. His wife took them sledding. He’d spent the day in bed, trying – mostly unsuccessfully — to get some sleep. That afternoon the wedding service seemed to last forever. The tuxedo felt like a straitjacket. There was a pressure in his chest that made it hard to breathe. But he’d stood at the front of the church, proud to be best man to his younger brother.
After the service, the photographer led them outside, trying to capture the spring blossoms covered with snow that made the setting so extraordinary, and he worked hard to exhibit an enthusiasm he was too sick to feel.
By the time he made it to the dinner reception, his whole body shook with violent chills, and his head was pounding. His collar felt so tight he could hardly swallow. He’d been working on his toast for days, so his wife talked to the D.J. and changed the order of the toasts so that he could give his toast early. After completing it, he made his apologies, went back to the hotel and climbed into bed.
Feeling Worse and Worse
He figured he’d feel better when they got to the lower altitudes of Denver, where they’d arranged to spend their last night. But he didn’t. Even when he traveled back to Boston, down at sea level, he didn’t feel any better. He had some business in the city so was staying at a hotel while his wife took the two kids back to their home, an hour away. She was worried but he reassured her he’d be O.K.
But that night, alone in his hotel room, he felt so bad he began to get scared. If this was altitude sickness, he should be better by now. Everything he read on the Internet said so.
Finally he could take it no more. He went to the front desk and asked for a taxi and went to the closest emergency room, at Massachusetts General Hospital.
An Inflamed Heart
Because of his chest tightness, the doctors at Mass General ordered an EKG. To his surprise, it was abnormal, and he was rushed to the cardiac care unit. He hadn’t had a heart attack; they were sure of that. But something had damaged his heart.
After dozens of tests, the doctors told him he had something called myocarditis, an inflamed heart muscle, though they couldn’t tell him why. For three days they searched for the cause of injured muscle. Myocarditis is often due to a viral infection, but the doctors wanted to make sure they didn’t miss anything treatable.
At the top of their list, they worried that he had picked up some kind of tick-borne infection while in rural Colorado. None of the tests came back positive, but they sent him home to finish up a week of the antibiotic doxycycline, just in case.
In the hospital he felt a little better. His chest didn’t hurt, and his heart wasn’t racing. His fever went down. On his way home he felt like he was on the mend. His wife wasn’t so sure. And a couple of hours later, when she looked in on him again, she was frightened by how sick he looked.
He was pale and sweaty – the way he’d been in the mountains. And the shaking and fevers were back. His headache was so bad that he was crying with pain, something she’d never seen before. She called Mass General. The doctor there said that if she was worried she should bring him right back. But the prospect of an hour-long drive seemed daunting. She decided to take him to the local hospital one town over.
So, did he want her to call an ambulance, or should they go by car?
Back to the Hospital
The patient’s wife dropped off the kids at a friend’s house, then drove him to Anna Jaques Hospital in Newburyport, Mass. It was late by the time they arrived and the emergency room was quiet.
Dr. Domenic Martinello knocked at the entrance to their hospital cubicle. The patient’s wife looked up expectantly, her face tight with exhaustion. The patient lay motionless on the stretcher; his eyes were sunken, and his skin hung off his face as if he hadn’t eaten much recently. His voice was soft but raspy, and every time he swallowed, his lips tightened in a grimace of pain.
Together, husband and wife recounted the events of the past few days: the wedding, the fevers, headaches, pain in his chest, in his neck and in his throat, the four days in the hospital in Boston.
It was certainly a confusing picture, and Dr. Martinello wasn’t sure what to make of the diagnosis of myocarditis. But the patient had no chest pain now, only the headache, sore neck and painful throat.
He quickly examined him. The patient’s skin was warm and sweaty, and his neck was stiff and tender, especially on the right. He was going to approach this systematically, he told the couple. First he would get a head CT, then a scan of the neck, and then he would do a lumbar puncture – a spinal tap. He felt optimistic that one of those tests would give him an answer.
“Tell me,” my patient’s daughter asked at the other end of the phone line. “Is she stable?”
I wasn’t sure how to answer.
My patient hadn’t been home in nearly three months. It had all started to come apart in the fall. Until then, she’d been a healthy 90-year-old who lived alone and cooked all her own meals, played tennis in the summer, binged on movies in the winter. But then there was a strange pain in her back, a visit to an urgent clinic and a harrowing ambulance ride to the emergency room. A tear had developed in the wall of her aorta, one of the main vessels carrying blood from the heart. In a windowless conference room, the doctors told my patient’s family that without emergency surgery, she would most likely die.
To her family’s relief, the surgery went well. But there were complications – first pneumonia, then kidney failure, delirium, profound weakness. After two weeks she hadn’t died, but she hadn’t recovered, either. Because she was still dependent on the ventilator, her doctors took her back down to the operating room for another procedure, a tracheotomy, cutting a small hole in her neck to serve as a more permanent connection for the ventilator. Because patients with tracheotomies can’t eat using their mouths, at least not at first, she returned from the O.R. with another new tube, a feeding tube in her stomach.
Another few weeks passed in the I.C.U. It seemed that as soon as one infection got under control, another developed. From time to time, my patient’s delirium seemed to clear – when she was strong enough to breathe through the tracheotomy without the ventilator, she could speak with her family and offer one-word answers to questions. Her whisper was so soft they could barely hear her. On other days she was scared and wild-eyed, hands bound with soft “mitten” restraints to keep her from pulling out the feeding tube that delivered the thick white liquid slurry pumping from a bag on an IV pole above her head directly into her stomach.
One day, her family learned that she had a bed at another facility, called a long-term acute care hospital. This was good news, her doctors told the family. It meant that this weak, intermittently delirious woman who looked nothing like the spry 90-year-old who’d come to urgent clinic some months before didn’t need the I.C.U. any longer. They were cautiously optimistic.
In this new hospital, she did get better. Some days she managed to stay off the ventilator for eight hours, then 12, then a day, then two. Her tracheotomy was removed and the hole in her neck started to heal. Her delirium lifted, replaced by a dull, lifeless gaze. Her kidneys improved. And then, things stopped getting better. Time slowed. There she was – neither dead nor truly alive – stuck, it seemed, in limbo.
One Saturday, she spiked a fever. Her breathing grew ragged. Back in the E.D. she was intubated once again, then sent up to the I.C.U., where her daughter called us to ask, “Is the stable?”
I debated about how to respond. The ventilator was delivering sufficient oxygen. Intravenous med drips were acting directly on her heart to keep her blood pressure at an acceptable level. Her kidneys were functioning to make urine.
But behind the façade of stability was a more dire truth: she might never get better. With her constellation of ventilation dependence, infections and delirium, she had what doctors call “chronic critical illness.”
Her story isn’t unique; there are about 100,000 chronically critically ill patients in the United States at any one time, and with an aging population and improving medical technologies, this number is only expected to grow. The outcomes of these patients are staggeringly poor. Half of the chronically critically ill will die within a year, and only around 10 percent will ever return to independent life at home.
Chronic critical illness is not something I learned about in medical school, or something that many doctors even talk about. One reason might be that the care for the chronically critically ill quite literally takes these patients out of our view – they move, as my patient did, from hospital to long-term care and back again, accompanied by a growing stack of medical records as things slowly fall apart.
In the early moments of critical illness, the choices seem relatively simple, the stakes high – you live or you die. But the chronically critically ill inhabit a kind of in-between purgatory state, all uncertainty and lingering. How do we explain this to families just as they breathe a sigh of relief that their loved one hasn’t died? Should we use the words “chronic critical illness”? Would it change any decisions if we were to do so? Here, I find that I am often at a loss.
I was quiet on the other end of the phone line that night. Was my patient stable? For the moment, she was. But with each event like this one, and there would be more, my patient would move further from the hope of ever reclaiming that life she had had in the fall: living in her own home, watching movies, cooking. I felt that I could see the weeks and months spooling out, a moment of calm, a new emergency. But this wasn’t the time to tell her daughter, not on the phone, not tonight.
And so I told her the truth – one truth, at least. Her mother was critically ill, but stable for the night.
Daniela Lamas is a pulmonary and critical care fellow at Brigham & Women’s Hospital in Boston.
Friday night in the emergency department is about what you’d think.
It starts off slow: a middle-aged man with a middling pneumonia; an older nursing home resident with a urinary tract infection that is making her delirious. Then come two heart attacks at the same time, followed by a drunken driver with a head bleed and half his rib cage fractured. At midnight, in roll the inebriated members of a bachelorette party that has not gone, one assumes, according to plan.
Amid the chaos, I break off to greet a thin, older man, quietly bundled up on a hallway stretcher. I look over his chart and prior scans. His prostate cancer has grown through several chemotherapy regimens. His spine is full of tumor and he’s been vomiting everything he eats or drinks for weeks. He can’t move the left side of his body after a recent stroke.
He smiles a charming, crooked smile. “It hasn’t been the best month of my life.”
“I’m sorry to hear that.”
I ask him about his symptoms, when they started, how bad they’ve gotten. He asks me where I went to medical school and if I have a girlfriend. I ask him if he’s dizzy and whether there’s blood in his stool. He tells me he emigrated from Greece 50 years ago, almost to the day. He won a scholarship to M.I.T. and studied electrical engineering. There he met his wife — “a fantastic cook” — and started his first company.
Now, decades later, he’s alone — in a crowded emergency room, on a Friday night, his wife dead, his two sons overseas, a nurse visiting him once a week at home to help him with some medicines and make sure the various tubes coming out of his body aren’t infected.
I ask him when he last moved his bowels.
“Son, I’m dying. I’m alone. One day you’ll learn there’s more to a good death than how often I move my bowels.”
I am better at many things than I was when I started my journey to become a physician more than a decade ago. But I am not sure that understanding patients as people — and placing them in the context of their long, messy, beautiful lives — is one of them.
Doctors are trained first to diagnose, treat and fix — and second, to comfort, palliate and soothe. The result is a slow loss of vision, an inability to see who and what people are outside the patient we see in the hospital.
As we acquire new and more technical skills, we begin to devalue what we had before we started: understanding, empathy, imagination. We see patients dressed in hospital gowns and non-skid socks — not jeans and baseball caps — and train our eyes to see asymmetries, rashes and blood vessels, while un-training them to see insecurities, joys and frustrations. As big data, consensus statements and treatment algorithms pervade medicine, small gestures of kindness and spontaneity — the caregiving equivalents of holding open doors and pulling out chairs — fall by the wayside.
But all care is ultimately delivered at the level of an individual. And while we might learn more about a particular patient’s preferences or tolerance for risk while explaining the pros and cons of a specific procedure or test, a more robust, more holistic understanding requires a deeper appreciation of “Who is this person I’m speaking with?”
In Britain, a small but growing body of research has found that allowing patients to tell their life stories has benefits for both patients and caregivers. Research — focused mostly on older patients and other residents of long-term care facilities — suggests that providing a biographical account of one’s past can help patients gain insight into their current needs and priorities, and allow doctors to develop closer relationships with patients by more clearly seeing “the person behind the patient.”
In the United States, Medicare recently began paying doctors to talk with their patients about end-of-life planning. These conversations allow patients to discuss and explore their preferences about a slew of complex medical interventions, including clinical trials, transfers to the intensive care unit, use of mechanical ventilation or feeding tubes, and the desire to die at home or in the hospital. These discussions, too, may benefit from a biographical approach, in which patients are able to elaborate on what is and has been most important in their lives. To better serve patients, we need to see not only who they are, but also who they were, and ultimately, who they hope to become even at the end of life.
How much more effective would we be as diagnosticians, prognosticators and healers if we had a more longitudinal understanding of the patient in front of us? If we saw not just the shrunken, elderly Greek man on the emergency room stretcher in front of us, but also the proud teenager flying across the Atlantic to start a new life half a century ago?
The emergency room is, by its nature, an arena designed for quick thinking and swift action. There are certainly other places, times and circumstances more conducive to probing goals-of-care discussions and lengthy forays into the internal lives of patients.
Still, there is always some moment of grace and meaning we can help patients find in the time they have left, a moment that recalls a time when they felt most alive — even if it’s just a fleeting conversation about gyros and electrical circuits in a busy emergency room, late on a Friday night.
Dhruv Khullar, M.D., M.P.P. is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter:@DhruvKhullar.
His wife assured me he was the life of the party, the kind of guy “you pay to stop talking.” But her description only added to the concerns I had about my patient, a drowsy older man with gnawing abdominal pain. He listlessly told me he had noticed his stool was darker than usual, a sign of bleeding from the G.I. tract “Doc,” he could barely get the words out, “I didn’t think nothing of it till I started feeling woozy. Then I thought a lot of it.”
Dr. Dhruv KhullarCredit Tom Fitzsimmons
As a medical resident, a doctor-in-training who leads much of the day-to-day patient care in the hospital, I’m among the first to see patients. Along with my team, I assume the bulk of the logistical duties of admitting new patients – interviewing them and their families, writing orders, calling consultants, scheduling appointments and responding to sudden changes in their clinical condition. When I started residency, I personally carried out most of these tasks. Now, as I progress in my training, I’m increasingly supervising younger residents doing them.
For this patient, our team immediately stopped any home medications that could further lower his blood pressure — in his case Lasix, a “water pill” that removes extra fluid in patients with heart failure. We rushed him to the endoscopy suite, where doctors placed a clip on the site of the bleeding. I was impressed with how rapidly he recovered. His wife, it turned out, was right. He did talk, a lot. I even took a small measure of satisfaction at my quick recognition and management of his condition. Victory.
Not quite. The patient was feeling better and insisted on being discharged, though we had hoped to monitor him in the hospital for another day or so before resuming his medications. Together, we decided it would be O.K. for him to leave, provided he saw his primary care doctor in a few days to restart his medications at the right doses.
I completed the discharge summary, and the patient went home. But he skipped the follow-up appointment. He still hadn’t started his water pill when he finally saw his doctor a week later. By then, fluid had accumulated in his lungs, his breathing had grown labored and I got the dreaded ping on my cellphone: “your patient has been readmitted.”
When we’re notified a patient we discharged has been readmitted, it’s generally a mark of shame, generating a sense that we failed to do enough to restore our patients to good health. But discharging a patient from the hospital is among the most difficult and dangerous aspects of providing medical care. It’s a tumultuous time, when the results of many lab tests may still be pending, medication regimens have been disrupted, and the doctors in charge are often left speculating about whether a patient is truly ready to leave. In the meantime, most patients who are feeling better just want to go home – and they let us know.
One-fifth of Medicare beneficiaries are readmitted within 30 days of discharge, and one-third are readmitted within 90 days. One study found that 20 percent of patients have a complication within three weeks of leaving the hospital — more than half of which could have been prevented or ameliorated. Thankfully most complications are minor, but some can be serious, leading to permanent disability or death. All told, Medicare spends $26 billion annually on readmissions, $17 billion of which is for readmissions that are considered preventable.
Issues crop up after discharge for many reasons. One factor is the process we use to admit versus discharge patients. In teaching hospitals, a junior resident — a year or two out of medical school — typically spends hours interviewing a patient, gathering information and developing a plan. He or she might then discuss the plan with more senior residents before ultimately presenting the case to the attending physician in charge. Together, they all examine the patient and settle on a plan, which is updated every day.
Contrast this with the discharge process. Ideally, it begins at admission through discussions with case managers and family members. But there’s often a rush toward the end of hospitalization — when a patient wants to leave or a rehab bed opens up — leading to a haphazard set of final conversations, appointments and prescriptions. And because the exact time of discharge is uncertain, the doctor discharging a patient may not be the one who knows the patient best.
It’s also often not clear exactly when a patient should be discharged. There’s no green light that turns on when a patient recovers or crystal ball that predicts what will happen afterward. In the hospital, we constantly monitor a patient’s vital signs, blood tests and clinical condition. But after hospitalization, patients live in a very different environment — and there’s tremendous uncertainty in that transition. Sometimes the difference between discharge today versus tomorrow is a more frustrated patient and higher medical costs. Sometimes it’s a devastating complication that hasn’t yet declared itself.
As patients recover from their immediate illness, the remaining diagnostics and treatments are often completed after discharge. But this is where we struggle most. Research suggests direct communication between hospital doctors and primary care doctors occurs infrequently and that discharge summaries — detailed records of a patient’s hospital course — are often unavailable at a patient’s first post-hospital visit. Almost 30 percent of patients are discharged with a plan to continue workups after hospitalization, but more than one-third of these are never completed. Similarly, more than 40 percent of patients have lab tests pending at the time of discharge — with 10 percent requiring action—but most physicians remain unaware of them.
There are steps that patients, doctors and hospitals can take to improve the transition from hospital to community — and we’re starting to make progress. Post-discharge phone calls, nurse-led discharge planning, visiting nurses, and dedicated “transition coaches” have all been shown to lower readmission rates. Pharmacists reviewing medications with patients can reduce drug-related complications. Ensuring high-risk patients see doctors within a week of discharge can prevent readmissions. Moving forward, greater use of telemedicine and dedicated post-hospital discharge clinics or specialists will be part of the solution.
More seamless transitions from hospital to clinic require recognizing that our responsibilities to patients continue, and sometimes increase, when they leave us. Like many of medicine’s important but often overlooked areas — prevention, screening, care coordination — discharge planning is not widely celebrated. But for patients hoping to stay out of the hospital, it may be what matters most.
Dhruv Khullar, M.D., M.P.P. is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter:@DhruvKhullar.
Is it time for new costumes in the long-running improv act featuring doctor and patient? The white coat and the cotton gown are tattered, under continual assault for their practical deficiencies and outmoded symbolism.
Presumably all garments carry bacteria, including the vestments of priests. The clergy, though, probably tote a less noxious load — and probably change robes more often. Doctors report that they do so only every couple of weeks, long enough for grime to accumulate.
Most American medical schools now bestow a fresh white coat on every new student, a symbol of our exalted professional aspirations. Some American hospitals now discourage those selfsame coats in the name of hygiene. Draw what moral you will. Many pediatricians would no more dress in a white coat than in a gorilla suit, lest they scare the little ones. Some adult doctors, reasoning that we are all children in illness, feel likewise. Some of us just need the pockets.
The best clinician I ever knew was draped in a grayish shabby thing spilling over with scraps of paper, vaguely redolent of his usual weekday lunch of pea soup. Whether you were a patient or a trainee, you didn’t really want him near you, until you quickly figured out that you really did.
One of the worst specimens of doctor I’ve run into wore snowy white, changed daily. You really didn’t want that guy near you, period, as many of his patients ultimately realized, including the ones who took him to court.
The symbolism surrounding patient gowns is just as fraught. They are cheap, demeaning, undignified and chilly. One way to cope is to wear two of them, one opening to the front and one to the rear. Thus encased, the patient is snug and warm, and also extremely well defended from inquisitive fingers and probing stethoscopes. It turns out that actual clothes are far easier to push aside for an examination than are two johnnie gowns firmly knotted together.
But patient gowns are out of style in some places mostly because they clash with the dominant medical fashion these days: doing everything at top speed. People need time and privacy to dress and undress. Medical settings without time or extra space find their stacks of clean gowns going undisturbed.
Instead, patients disrobe incompletely, or sometimes not at all, just opening little portals in their clothing through which what passes for a physical examination can be performed. Such accommodation is regrettable, but necessary to maintain our cruising speed. Call it laparoscopy for the nonsurgeon.
For my professors, the physical exam was a sacred ritual. I sometimes wonder which would distress them more: the thought of treating a rash glimpsed only on a cellphone screen, or the idea of asking a patient to open two shirt buttons under his tie for a quick inspection of that thing on his chest. I’ve been guilty of both.
A couple of months ago, on a frigid winter day, a stolid, silent patient came in because her knee hurt. “Just give me something,” she said. I was sorely tempted, but I couldn’t do it: I had to examine both unclad legs. She cast me a look of pure disgust and hauled herself to her feet.
It took almost 10 minutes for her to peel off the layers of tight, ill-fitting jeans, socks, pantyhose, more socks, more hose, long underwear, down to the arthritic knee. It took another 10 minutes to put it all back on.
My professors would have stepped out to give her some privacy. For some reason, I stayed where I was.
Those 20 minutes were death to the day’s schedule, but invaluable for showing the harried doctor something of the grim labor of everyday life for this patient, a heart-rending discomfort of binding elastic and straining seams she could never have articulated, and, of course, one that would have been invisible with her on display in a hospital gown.
It was the process that educated, not the final tableau.
We are never more human than when we are dressing and undressing, and yet for our medical care, we have, for some reason, decided to posture in front of one another fully costumed, pretending that, encased in our separate roles, we will get to the bottom of the pain.
Perhaps we need not new costumes but new stage directions. Perhaps doctors should routinely watch patients undress and then dress again. Perhaps, for that matter, patients should watch doctors washing their chapped hands yet again and putting on their white coats, checking the pockets for tools, phone numbers, reminders, lists of urgencies, looking at those coffee stains and wincing, vowing to get to the laundry and then forgetting.
Beck Bailey has encountered some health care professionals who were unsure how to treat transgender patients.Credit Kieran Kesner for The New York Times
After a skiing accident in January left him with a smashed knee, Beck Bailey, a transgender man in Greenfield, Mass., spent 15 days in a Vermont hospital undergoing a handful of surgeries. As part of his normal routine, Mr. Bailey gives himself regular shots of testosterone. But the endocrinologist on duty in Vermont told him that patients should not take testosterone post surgery.
Mr. Bailey explained that he couldn’t just stop his hormone treatment. But the doctors were so resistant that he finally had them call his primary care physician, who explained he should resume his usual protocol.
“I don’t expect every doctor in the world to become an expert in trans medicine, but I do think they should be knowledgeable enough to know what they don’t know and pick up the phone and call an expert,” said Mr. Bailey, 51, deputy director of employee engagement at the Human Rights Campaign, an advocacy group for gay, lesbian, bisexual and transgender people.
Mr. Bailey’s experience is echoed by many transgender patients, both those who have fully transitioned and those in the process. Research on nontransition-related medical needs is limited; most medical schools don’t prepare doctors for treating this community.
“What happens once you get past the immediate issues of transition, and you run into problems with diabetes, cancer, with the E.R.?” said Karl Surkan, 46, a professor of women’s studies at M.I.T. and Temple University.
Credit Mark Makela for The New York Times
Mr. Surkan, who is transitioning from female to male, has firsthand experience: He carries the BRCA1 gene and was given a diagnosis of breast cancer. When he inquired about whether testosterone would affect his cancer treatments, his oncologist told him, “It probably would, but we don’t have any data on whether testosterone would cause a recurrence of your cancer. We wish we could help you.”
Indeed, there are few longitudinal studies on hormone use in the trans community. Many doctors aren’t aware that some transgender men may still need pap smears, breast exams and mammograms, and that all transgender women should be screened for prostate problems.
“Many transgender men and women have not had genital affirmation surgery and retain reproductive organs they were born with,” said Dr. Harvey Makadon, the director of education and training programs at the Fenway Institute in Boston and a clinical professor of medicine at Harvard Medical School. “All transgender women still have a prostate gland, and a good clinician will need to learn about the current anatomy and provide appropriate preventive screening and care.”
In addition to medical concerns, many trans patients say they are discriminated against by doctors and other medical staff members who misuse pronouns, call them by incorrect names or house them with people of the wrong gender.
According to a 2010 report by Lambda Legal, 70 percent of transgender respondents had experienced serious discrimination in health care. And a 2011 study of more than 6,000 transgender people by the National Center for Transgender Equality and the National LGBTQ Task Force found that 19 percent said they had been denied health care because of their transgender or gender nonconforming status. Many of them avoided the doctor’s office altogether: 28 percent had postponed getting health care when they were ill or injured, and 33 percent had delayed or not sought preventive care because of their past experiences with doctors.
A 2014 report by the HRC Foundation found that out of 501 hospitals researched, 49 percent did not include both “sexual orientation” and “gender identity” in their patient nondiscrimination policies.
Hospitals, for their part, are often flummoxed. Where, for example, should they put a patient who identifies as female, but is anatomically still male or listed that way on their birth certificate?
Mr. Surkan said that he has been placed in hospital rooms with other women. “It doesn’t bother me as much as it bothers people who are housed with me,” he said. “I do have a friend who is much more masculine appearing who had a hysterectomy, and he was put in the ward with women. That was pretty awkward for everybody.” He has since co-founded the TransRecord, which, together with sites like RAD remedy, act as a kind of clearinghouse for trans people seeking medical care.
In July, a transwoman alleged sex discrimination at Brooklyn Hospital Center after being placed in a room with a male roommate. “We didn’t realize that the individual was transgender,” said Joan Clark, a hospital spokeswoman. The hospital now requires all employees to undergo sensitivity training. “I think it’s made us a better organization,” she said. “They don’t want different treatment, they just want equitable treatment.”
Wrene Robyn, 46, a transwoman in Somerville, Mass., began her transition in 1989, when she changed her name on her driver’s license and Social Security cards, and the gender on her driver’s license from male to female. While she integrates fairly well into mainstream society, she has avoided the doctor for years. “Most trans people don’t go to the hospital, because they’re terrified of the room situation,” she said. “They’re terrified of it all. They don’t want to be misgendered, and they don’t want to explain what they have or don’t have in their pants.”
In April, after a bout of pancreatitis, Ms. Robyn spent a week in Massachusetts General Hospital in Boston, where she was given a single room. “Nobody really asked me what my preference was,” said Ms. Robyn, who works as a software engineer at the hospital and also serves on a transgender care committee there. In addition to worrying about being discriminated against, “What goes through a lot of trans people’s minds is, is this going to cost more? Usually we can’t afford private rooms.” (It was covered by her insurance.)
Some hospitals are now overhauling — or implementing — policies on treating transgender patients. At Mass General, for example, transgender patients are now asked if they prefer a private room or double. “If they are going to be placed in a double room, we ask them how they identify themselves,” said Terri Ogan, a spokeswoman. “If the patient identifies as a woman, they will be placed in a room with a woman. If they identify as a man, they will be placed in a room with a man.”
Transgender patients at Mount Sinai Health System, which encompasses seven hospitals in New York City, have been housed according to their current gender identity, regardless of where they are in their physical transition, since 2013. They can also request a single room. Previously, the hospital always put them in private rooms, but that had drawbacks: Many patients felt as if they were being segregated, and worried that they would be charged extra (they weren’t). “Often the transperson would be delayed or in the E.R. waiting for a single room to open up,” said Barbara Warren, the director for L.G.B.T. programs and policies at Mount Sinai’s office for diversity and inclusion.
Terry Lynam, a spokesman for North Shore LIJ Health System, which has 21 hospitals in New York City, Long Island and Westchester, said that their transgender policy, which was approved in November of 2014, is to treat transgender patients like any other patient. “So, we wouldn’t necessarily give them a private room,” said Mr. Lynam. But, he acknowledged, the issue becomes a bit more complicated with patients who still look like the sex they were assigned at birth. In that instance, if a roommate objects, “We’ll try to accommodate them and move the person who complains,” he said.
Advocates see this as a long time coming. “I’ve been telling hospitals that they really need to think about this and adopt some policies proactively,” said Tari Hanneman, deputy director of the Health and Aging Program at the Human Rights Campaign. “The first time you think about where you are going to put a transgender patient should not be when they arrive.”
The substance user and the hospital are bound by the most ambivalent of relationships. Heavy users — of tobacco, alcohol or harder drugs — see far more of the wards than the average citizen and, it is safe to say, like them even less.
They need hospitals. They hate hospitals. Hospitals make them well and sick at the same time. We are their doctors and nurses, their parents, their arresting officers, parole officers, judge and jury. Needless to say, we are not trained for the last five roles, nor are we particularly good at them.
A single principle guides us: You cannot use your drug of choice on our premises, no matter how much you may need it and prefer it to our proffered alternatives. Around that immutable core swirl large clouds of negotiation, compromise, duplicity, manipulation and general misery for all involved.
On some days it seems as if we spend all our energies managing not the conditions we are trained to manage but the addictions that complicate them.
One patient is tying his shoes as we make our rounds in the morning, and tells us cheerfully that he is going out for a smoke. He’ll be right back. We inform him, not without sympathy, that in our hospital smoking breaks are not allowed. If he leaves for even half an hour he will officially be considered discharged. His bed will be given to someone else, and to resume his medical care, he will have to go back to the emergency room and start the cycle all over again.
We propose a nicotine patch instead, but the nurses have already given him a patch, to no effect. Few other compromises are possible between the smoke-free hospital and the hard-core, implacable smoker. The discussion grows heated. We wind up discharging him on the spot, just a little sooner than we had in mind.
The patient in the next room has been in the bathroom for almost an hour. We need to examine him. We knock on the bathroom door. He yells out that he’s fine.
When he finally drifts out, drowsily readjusting the dressing covering the intravenous line in his arm, he doesn’t look fine. He looks as high as a kite, and come to think of it, the two visitors lounging by his bed do, too. We sigh. No easy compromises will be possible for him.
It was back in the 1980s that most American hospitals became officially smoke-free (and cigarette butts began accumulating in stairwells and side exits). The big exceptions were the V.A. hospitals: In fact, theVeterans Health Care Act of 1992 specifically required V.A. facilities to establish designated smoking areas for clients. In 2008, those areas were all moved outdoors, and most V.A. hospitals still have them.
This policy has been bitterly criticized as the worst kind of tobacco industry manipulation, but it does serve a useful function: It allows medical care to proceed without major interruption. Granted, that care is often for tobacco-related conditions, a cycle that strikes some observers as a common-sense, harm-reduction approach to the real world, and others as completely insane.
Still, smokers pose fewer challenges than intravenous drug users, like that young man who wandered out of his bathroom to face our interrogation. He has an infected heart valve, and is receiving high doses of antibiotics through an intravenous line in his arm, a portal to his bloodstream that is apparently proving too tempting for him to ignore.
He needs antibiotic treatment, and we have no oral options for him. Among other considerations, if his guests keep providing him with substances to shoot into that line, it may well become infected and unusable, and he will get even sicker than he is.
He promises never to do it again.
So now what? We have a set of programmed responses, none particularly satisfying or effective.
We can give him some methadone to keep him from withdrawing. We can screen his visitors or post a watcher at his bedside. Some hospitals transfer patients like him to an expensive intensive care bed for even more careful monitoring. Some make contracts and threaten to kick patients out for violations. (Can we really kick them out, as desperately sick as they are? I’ve never actually seen that happen.)
Addiction experts point out that hospitalizations offer an excellent opportunity to urge addicts into treatment. Unfortunately, inpatient acute care hospital wards are spectacularly ill equipped to provide that treatment, which would require a specially trained, dedicated team of medical and mental health professionals able to treat infection and addiction at the same time, in the same bed, on the same premises. It doesn’t sound like a particularly expensive proposition, but it must be one, because it’s another thing I’ve never seen happen.
Instead, we routinely plan for patients to be transferred to drug treatment programs when they are discharged. Quite a few don’t last that long. Our patient will prove to be one of them: After a few more days, he will suddenly be gone, well enough to walk out of the hospital (and take his intravenous line with him).
Presumably, he will try to make it out in the world until he gets too sick and lands in another hospital, where events will repeat themselves in yet another baffling health care cycle.
The Challenge: A healthy 67-year-old man develops an annoying little cough that, over the course of a week, worsens and nearly takes his breath away. Can you figure out why?
Every month, the Diagnosis column of The New York Times Magazine challenges Well readers with a real-life diagnostic question. In this case, a retired Air Force officer shows up in an emergency room with chest pain so severe he can barely breathe.
I will provide you with the history, data and imaging available to the doctor who made the diagnosis. It’s up to you to make it all make sense.
The first person to identify the cause for these symptoms will win a copy of my book, “Every Patient Tells a Story.”
The Patient’s Story
“I think you’re dying,” the anxious wife told her husband of 38 years. Her 67-year-old spouse sat propped up at the head of the bed. His chin rested on his chest and his face bobbed up and down with each rapid fire breath. He gazed up at her from beneath his shaggy gray eyebrows.
“I’m going … to be … O.K.,” he panted in a whisper.
She didn’t think so, and she wasn’t alone. She had just spoken to one of his oldest friends, and he was worried too, she told her husband. The friend thought they should go to the hospital.
“Now?” the man breathed.
She nodded. He finally nodded in return. He would go.
A Knife in the Back
It all happened so fast. An annoying little tickle that started maybe a week before was now a great wracking cough. Every breath felt like a knife cutting through to his back. The pain was so severe he couldn’t take a deep breath, and he felt like there was so much stuff in his lungs that the little breaths he could take didn’t bring in enough air.
As he sat on his bed struggling to breathe, he suddenly flashed back to a morning many years ago when, as a small child, he’d fallen into the deep end of the pool. He sank to the bottom, arms and legs flailing, the need for breath overwhelming. Suddenly he saw an explosion of bubbles, then felt strong hands lift him up, back into the air. Back where he could breathe.
Now more than 60 years later he felt like he was struggling the same way. This time without the water, but still in need of rescue.
The 30-mile drive from their home to Huntsville Hospital in Huntsville, Ala., was mostly on the interstate, but every tiny bump or dip brought a soft grunt of pain. The man held onto the strap above the window, willing himself motionless.
His wife walked him into the emergency room, then hurried to park the car. By the time she got back he was already in a bed and, with oxygen piped into his nose, a little more comfortable.
Downhill at the Fishing Camp
Dr. Robert Centor, the attending physician on call at the hospital, had heard about the patient the night before and was eager to see him the next morning on rounds.
He’d started off with a little nothing of a cough, the man told Dr. Centor. He mentioned it to his own doctor just before he went out to his fishing camp with some pals. After listening to his lungs, his doctor had pronounced him “just fine.”
But the cough kept getting worse, going from occasional to constant practically overnight. He couldn’t read or eat or sleep. Lying down made it even harder to breathe, so he spent two nights in a recliner. And the friends who’d come to the camp with him got absolutely no sleep because of his persistent hacking.
The third day of their trip, his chest began to hurt. Every breath felt like a dagger. Moving made it worse. So did breathing. He got out of breath just walking to the kitchen. His friends were worried. And, finally, so was he.
As soon has he got home his wife took him to the local emergency room. A chest X-ray showed cloudy white patches over both lungs. He had no fever nor any sign of infection, and so the E.R. doctor figured it was probably his heart. The patient could stay in the hospital and see his doctor there or go home and see her in her office the next day.
It was an easy decision: He’d much rather go home. The E.R. doctor admonished the patient to see his doctor as soon as he could and let him leave.
A Problem Heart?
The patient saw his doctor a couple of days later, and a brief exam convinced her that the E.R. doctor was right: It probably was his heart. It was hard to imagine any other reason for there to be clouds all over both of his lungs. Not too many things could do that. You could see it with a whopping pneumonia – but he had no fever or other signs of infection. Or you could see it with something known as congestive heart failure, which is what the emergency room doc thought he had.
Congestive heart failure reflects a problem not with the lungs but with the muscle of the heart, the doctor explained. It gets injured somehow – maybe because of a heart attack or infection – and suddenly it can’t beat as strongly as it had. Fluid from the blood, which should have been pumped out into the body, was instead backing up into his lungs.
She sent him home on a powerful diuretic to help draw the water out of his chest and arranged for him to have an echocardiogram, an ultrasound of his heart, to confirm her diagnosis.
The diuretic kept him in the bathroom for much of the next two days, but it didn’t seem to help at all. And so his wife, with the support of his friends, finally convinced the breathless man not to wait for the “echo” but to go right then to the big university hospital in Huntsville.
A Healthy Guy, Until Now
As the man and his wife told their story, Dr. Centor took a good look at his new patient. He was tanned and trim – clearly not someone who spent much time being sick. But he coughed frequently, and every paroxysm brought a grimace of pain to his face.
Before this, the man told him, he’d been pretty healthy. He took a medication for high blood pressure and another for his heartburn. A month earlier, he’d had knee surgery, an operation that left him with a big pus-filled wound – red, hot and incredibly painful. So, for the past few weeks his wife had been injecting a syringe full of an antibiotic, called Cubicin, into an intravenous line he had snaking up through his left arm. It was clearly doing its job because, although his knee was still pretty sore, there was no more pus and it looked a whole lot better.
He quit smoking five years ago. He drank sometimes with his pals on special occasions but hadn’t had anything since he started taking the antibiotic. He exercised regularly, at least before the surgery.
The couple had a dog, but no birds or other pets. He had retired five years earlier, but during his career he had been assigned to bases all over the world – especially the Middle East. He spent a lot of time in Afghanistan. And he’d done some time as a pilot in Vietnam, where he’d been exposed to Agent Orange, the herbicide used there that had been associated with many health problems later in life.
Working to Breathe
On exam, the patient’s breathing and heart rate were high and his oxygen level was low – a bad combination.
Dr. Centor gently placed a hand on each side of the patient’s neck and could feel the strap muscles there tense with every breath. These muscles are recruited to help breathing when needed; they pull the rib cage up to help the patient suck in more air. And when Dr. Centor listened to the patient’s lungs he heard a cacophony of tiny snaps with every breath, as if inside his ribs a sheet of bubble wrap was exploding. His knee revealed a well healing surgical scar.
Dr. Centor had already seen the X-ray and CT scan done the day before. You can see the chest X-ray and the CT report here.
The chest X-ray showed cloudy white patches over both lungs.Credit
The CT Report
Reviewing the Notes
The radiologist thought it was an infection, and so the patient had been started on the usual antibiotic combination for pneumonia. But why had this healthy retiree developed a whopping pneumonia – not in part of one lung, which is usually what occurs with pneumonia, but all over, and in both lungs?
Dr. Centor reviewed the notes from the E.R. and from his resident, and the data from the labs. You can see those notes and labs here.
Emergency Room Note
The Resident’s Note
The Lab Reports
Solving the Mystery
What was he missing? Dr. Centor asked himself.
He figured it out. Can you?
Submit your responses in the Comments section. As usual, the first person to figure out the diagnosis gets a copy of my book. And that warm satisfaction that comes from solving a mystery.
Rules and Regulations:Post your questions and diagnosis in the comments section below. The correct answer will appear Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.