Gorilla Glue and Heartbreak
“My friend said to tell you everything when I come,” she says as she opens a little zippered bag full of flakes. “My teeth are falling out and I can’t afford a dentist, so I use Gorilla Glue to glue back the pieces,” she says. She was referred to me for severe asthma, but she does not need an asthma specialist. She needs a dentist.
The well-dressed businessman has come back because his asthma is worse again. He has been to the ER or the hospital six times in the last six months. He has allergies, he is on inhalers and asthma medications. “What do you think is going on?” I ask him. “Well,” he says, “ the medications are expensive. I can’t buy them all every month – I wait to buy them depending on how our billings and collections are. I spend $2,000 a month on them.” Advair is $300, at least in the US, Spiriva is another $300, then the others.
“Did you go to your ENT appointment?” I ask a patient at our follow-up. “No,” she says, “I didn’t have the $25 for the copay, but I got paid yesterday so I came today,” she tells me.
“You A? doctor? My kid has rash,” the janitor in the hall tells me. “I’m sorry,” I say, “I’m not a kid doctor, and I am not a skin doctor. You should take him to the pediatrician,” I tell her. She tells me they have health insurance through her husband’s work with a $4,500 deductible. I have no idea what she makes, but at $10/hr a doctor’s visit will likely be two days worth of work.
“I know it may sound strange,” a friend says, “but I have to wait until I’m almost dying to go to the doctor. It’s so expensive, I can’t afford to go too early and have them pat me on the back and send me home.”
“I got sick, so I lost my job, and I lost my insurance,” the patient in the hospital says. “I was one week away from being eligible for benefits, but I got sick and missed it.” I now begin to understand how the infection in his chest was allowed to prosper until the infected fluid completely compressed his right lung and he could hardly draw a breath. Was he holding out for as long as he could in the hopes of being able to go to the doctor insured?
“In Europe there’s a social contract,” my attending tells us. “Healthcare is public, and people take the trade off that they will receive reasonable care, preventative care, vaccinations, and antibiotics, etcetera. But at the end of life, they will not receive every possible intervention.”
I am told, the ICUs in Europe look very different. They don’t have the very elderly patients with multiple medical problems that we have. They have rules about who is allowed to go to the ICU because many people will die despite being admitted, while others will live even if they are are not. We know we spend more money on healthcare during the last six months of life than the rest of a person’s lifetime combined. It is true that when we intervene, we never quite know that we’re intervening during the last six months, though it is also true that often we have a pretty good idea. I don’t have the answers, the questions are big and complex, but surely, there must be a better way for all of us.