“Don’t tell him that!!”

I had gentleman come to my ER the other night complaining of pain in his lower abdomen as well as nausea and vomiting for the past day. He looked pretty uncomfortable and his lower abdominal tenderness was slightly more on the right side raising the concern for acute appendicitis. I wouldn’t say he had a classic presentation – he had no fever or anorexia , and his tenderness did not seem like a slamdunk appy – but his symptom complex was suggestive. In the past patients like this could be monitored for evolution of their symptoms with close surgical follow-up. However in this day of litigation combined with the ease and availability of obtaining a CT scan, it is almost mandatory to perform this imaging study. The majority of modern surgeons won’t even examine a patient unless a CT scan has been obtained. Even in cases of a classic appendicitis presentation when there seems to be no doubt clinically regarding the diagnosis surgeons appreciate the imaging study to prevent operating on the occasional patient who has mesenteric adenitis or right-sided diverticulitis which can mimic appendicitis and do not require surgical intervention. Imaging also helps define any complications such as perforation which assists with operative planning. In the case of my patient there were many reasons to pursue imaging to evaluate the cause of his abdominal pain however he was concerned about the cost. At $7-10K to scan the abdomen and pelvis his concern was understandable. Not to mention the radiation exposure which is not trivial in these CT scans. The patient revealed that he was only able to obtain part-time employment at his factory, and, unfortunately, he was not eligible for health benefits. It is sad that he was willing to work and actually had a job, but thanks to a poorly functioning healthcare system that leaves huge gaps in coverage of our population this patient was going to have accept responsibility for a huge hospital bill. Since the patient’s wife was in the examining room with him, I inquired if she was working and had access to benefits. She responded “I don’t work”. Now come on- it’s easy to blame the system when people are making the effort and still are not covered, but where is the personal responsibility. I suggested to the patient’s wife that she go get a job somewhere like K-mart or target. Maybe it’s not glamorous and the pay isn’t fantastic for low-level positions, but I have relatives and friends who maintain this type of employment solely for the benefits. It might not be worth a pay-cut if you already have a job with good compensation, but if someone is not working then some pay is more than none and the health insurance alone can add several hundred dollars worth of benefits to your monthly salary. Try going out and purchasing health insurance privately as an individual – it’s expensive. I had to pay $250/month for a basic HMO when I was a young healthy waiter struggling to put myself through school. I had to work 3-4 extra shifts each month to afford limited insurance, but at least I was covered. I have never gone without auto insurance, and I think the same thinking should be applied to health insurance. Sure it’s easy to blame the government, but ultimately the individual is responsible. And there are options. When I suggested to my patient’s wife that she get a job I explained that she would probably only have to work 30hours/week to qualify for benefits. She replied “don’t tell him that! I don’t want to work!!”. She didn’t want to work. Even for 30 hours a week. She probably logged in more hours than that watching TV. I mean come on – even if she was raising children she had a husband who was only working parttime and there had to be time to split the household responsibilities and still work for 30 hours/week. This is the not the 50’s when men worked and women stayed at home. In today’s economy anyone who can work should be seeking employment, appreciating the opportunity to earn a living, and contributing to our progress as a society. I always wanted to work, and I started working fulltime when I was 15 years/old. Most of my life I have held down 2-3 jobs simultaneously and gone to school. It is difficult for me to comprehend how someone can not want to work especially when their family has no medical insurance and one medical problem could present financial distress ranging from draining a small savings account to forcing a family into bankruptcy. Unemployment is a luxury only the independently wealthy can truly afford. Think about it.