What Makes a Difference
Perry A. Klaassen, MD
Oklahoma City, Oklahoma
drklaassen@coinsaccess.org
JAMA. 2007;297:1039.
"Is your wife with you?" asked the gastroenterologist as I entered his office for my postcolonoscopy conference. With that, I knew immediately that I had colon cancer. I remember little else of what he said except that he had set up an appointment for me to see a surgeon at 1 o’clock that same Wednesday afternoon. I didn't have time to go home so I ate a light lunch and met the surgeon at the appointed time. "You have a tumor about the size of a golf ball in your colon, close to the appendix, and we’ve got to get it out of there. I think I can work you into the schedule on Friday."
I had the surgery that Friday. The tumor was removed, along with a section of the ascending colon, the appendix, and the omentum. Of the 16 lymph nodes removed, four were positive for cancer and two spots of tumor were visible on the omentum. That's why it was removed.
About three days after my surgery, the oncologist came to see me. "Since your cancer has spread beyond the colon we would have to call it stage 4, and if we want to be more optimistic we could call it stage 3. In any case, with this staging, you are eligible for a new chemotherapeutic agent along with the usual two that are given."
I had recovered from the surgery very nicely. And so nearly five weeks later a port was placed just below my left collarbone and I started chemotherapy. I was able to tolerate chemotherapy well enough to go back to work.
I received the most efficient care possible. I was 61 years old and had good group health insurance through my workplace. I was a physician in a community health center.
Several months after returning to work, I saw a patient who was my age, with abdominal pain, weight loss, and blood in her stool. She stated that several months earlier she had been admitted to a community hospital through the emergency department because of abdominal pain and weakness. In the hospital she was found to be anemic, and her upper gastrointestinal tract was examined for ulcers. None were found so she had been placed on iron and encouraged to see a gastroenterologist for a colonoscopy as an outpatient.
She supported herself by taking care of her grandchildren so her children could work. She had several children who lived nearby so this arrangement worked very well for her. She delayed making an appointment with a gastroenterologist because she had no insurance and felt she could not afford the test anyway.
A relative who happened to be a patient of mine referred the woman to the health center where I worked because we could accept her as a patient and her payment would be based on her income and the number of dependents in her household.
On examination, I found that she was anemic with significant weight loss, blood in her stool, and a mass in her left lower abdomen. I told her that I was concerned about the possibility of colon cancer and that she needed a colonoscopy as soon as possible.
The earliest appointment that could be arranged was three months later. Prior to this appointment, I saw her once more, and because her symptoms had worsened I was able to arrange an earlier colonoscopy. The biopsy revealed cancer of the colon and surgery was scheduled two weeks later. At surgery the tumor was found to have spread into the surrounding tissue and the liver. It was not possible to remove the tumor. It was definitely stage 4 colon cancer. She was offered chemotherapy but declined it. She said that she could not afford chemotherapy, it would inconvenience her family to take her for therapy, and she did not want to leave her family with a large bill. She was a woman with a strong faith in God, and this sustained her until she died about one year later.
The difference in the outcome of these two similar situations is obvious. I had good health insurance, received optimal care, and 5 years later I not only have survived, but lead a fairly normal life even though I still have cancer and have to have regular treatment. My patient had no health insurance, delayed her evaluation and treatment, and died less that two years following diagnosis of a preventable and treatable disease.
A Piece of My Mind Section Editor: Roxanne K. Young, Associate Editor.
They give me money to put in the bank with 5%. Thanks to the bill pay and ACH's. So easy to manage.
This is absolutely true.
Damn. I will remember next time. any electronics should be charged on AMEX.