Supply and Demand

It was around 2pm when I finally finished with Mr. P. His was one of the more challenging upper endoscopies I've done thus far in my training, and the extra time (over 45 minutes to complete what is usually a 20 minute procedure) was well worth it as we had an excellent outcome.

Mr. P is 70, and I met him in the emergency room a few months ago with rapid bleeding from his esophagus leading to vomiting blood and a subsequent quick ambulance ride to the hospital. I was initially called at 1am by the emergency room for the dreaded "we have a bleeder." Within hours we had an endoscope in his stomach, and after removing blood clots, we identified that his esophagus was full of large veins, called varices, which often result from elevated blood pressure in the liver circulation, referred to as portal hypertension. The curious thing about Mr. P was that he had no risk factors for this bleeding. He was not a drinker, had no hepatitis history, no drug use, very few longstanding medications. That night I placed small rubber bands on the recently bleeding veins, a procedure called "banding." And I placed him on medications to help prevent further bleeding. Mr. P did well. We found a cirrhotic, small liver and elevated pressures in the portal veins, but we did not find a cause. He was discharged to home and planned to see me in clinic for further evaluation.

Nothing seemed extraordinary about this story. More than 30% of all cirrhosis is "idiopathic" in nature, which means we don't know the cause. To label something idiopathic, we doctors will first do our best to make a diagnosis. But after enough testing, when we've reached the boundaries of what we know, we have to stop, and often where we stop is knowing the state of affairs (he had a cirrhotic liver and portal hypertension) but not knowing the root of the problem. This is often a huge source of frustration to patients who think we should know more, if not everything. And I don't blame them. Here is something wrong enough with Mr. P's body to hospitalize him. Something so drastic that he surely would have died if we had not intervened, yet the best we can do is describe what we see, with no explanation of how he got so sick. That, to me, presents a terrifying situation for the patient. Could this happen to his children? He asked. Will he bleed again? He wanted to know. Is this the result some strange virus? I wasn't sure.

But Mr. P interests me for reasons beyond his mysterious "idiopathy". After all, many people are told "we just don't know why" by doctors every day. The less arrogant doctors are more willing to put forth that sentence and not assure patients that we will find a cause every time.

In truth, what interested me most about Mr. P was his wife.

Ms. P is 72, from a Mediterranean country. She moved here at age 30 and shortly thereafter met her husband. She raised 3 children for him, and kept "the neatest home." She also was "the best cook in the world." Her specialty, he told me when we all met in my office the first time, "was lemon chicken with rice." I found it immediately interesting that in her presence, beyond these 2 compliments, Mr. P said nothing. In fact, I struggled in my interaction with him to focus on him, as she asked all of the questions, and looked skeptically at me when I told her that he would need two or three more endoscopic procedures to fully band his high grade varices. I explained that he remained a high risk for rebleeding. I explained that we were lucky last time, and that of the rebleeders, up to 25% die from bleeding to death. Her skepticism expanded: "No. No more. He's been through enough." I asked if her rationale was our uncertain diagnosis. She told me she didn't care what we said. When they left, I felt completely defeated. Here is a man I helped to save in the middle of the night just months before- who thanked us profusely when he was an inpatient- walking out of my office, muted by her anger, and possibly going to die if he didn't get additional medical attention.

So the question is: What was I to do next. In truth, what doctors are obligated to do by law, and obligated to do by oath are very different. The law states that we can do no harm, and need to do our best to do good. The oath I swore to (written by my medical school class- most med schools abandoned the not-so-politically-correct Hippocratic Oath 30 years ago) stated that my task was to have the "best interest of the patient in my heart and in my mind." There are few things I actually have to report to authorities. Child abuse is an obvious one. Elderly abuse is less obvious. Elderly Neglect starts to blur the line. And on and on the spectrum of what I observe vs. what I have the power to do continues. But when Mr. P, who clearly can make decisions for himself, decided to become a quiet lamb in the presence of a woman who had her own issues with the medical community and was willing to make him pay for those issues, my hands were tied. Still, I thought and thought. I had one of those dinners at home that night where my wife had to repeat a story because I was so deep in thought. I had one of those end of the day showers where she had to remind me to get out because I stood under the water for 1/2 hour pondering Mr. P- and how I might help him.

The next day I called- hoping to reach him. A lab result had returned normal and it was my excuse to call. But she answered instead, and refused to put him on the phone. She yelled at me for 10 minutes, telling me that no matter what I wouldn't "make money" on her husband. Little did she know that as fellow I make no money on endoscopies performed. So I did something else: I picked up the phone and called his primary care doctor. There I found a kind, caring man who clearly knew Mr. P and his wife well.
"She's beating you up!" he said laughing- "she does that to everyone except me."
"So what's your trick?" I asked.
"25 years of knowing them," he answered. And then I knew I had done the right thing. Within a week she had called to schedule his next endoscopy. And I arranged to be there. As the endoscope passed the first large vein that required banding, and I fired the band successfully onto the vein, I smiled.

I'll never know why Ms. P was so angry. Was it a brittle nurse who yelled at her husband one morning and reminded her of her sister when she was 13? Was it a lifetime of doctors making them pay co-pays and more and more expensive medications that didn't seem to provide all of the solutions she was seeking? Was it cultural differences- where American doctors ask completely different questions than those she is accustomed to? All of these and more probably. Regardless, I don't blame her. She did come to both appointments with him, standing by his side. She was there in the hospital to comfort him. Could I ask more of a wife? Even if her initial decisions weren't in his best interest, she was probably trying. And that is one of the toughest parts of my job- to look past blame and frustration and do what's best regardless of what I'm up against.

And believe me, there are more and more Ms. Ps out there- looking for a way to vent their frustrations with the state of medicine in America- and who better to yell at than the young man in the white coat?