Thread by @jkwillettmd

If ever you’ve found yourself wondering “why did they wait so long?!” regarding a patient with delayed presentation for an illness, consider this.

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Just after Thanksgiving last year, I started feeling under the weather. I was tired all the time. I chalked it up to working a long string of shifts and upped my caffeine intake. After all, I told myself..."I never get sick"!

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Then, I started spiking fevers. I lost my appetite. I could feel something was wrong, but I couldn't put my finger on it. I convinced myself it was viral and that it would pass with time and rest. I continued stacking antipyretics.

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Over the span of a week, I got worse instead of better. I still convinced myself it would improve on its own. I thought of the cost of a doctor's visit, blood tests, or imaging. Then I took another Tylenol and went back to bed.

Why didn't I just go see a doctor?!

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Well, here's the kicker.

I didn't have health insurance.

Let's let that sink in. I was a doctor without health insurance.

How did I let that happen, you are probably asking? I'm getting there.

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In the transition from one job to another, my old insurance lapsed and when I was prompted to sign up for new insurance with my new employer, I was told that it wouldn't go into effect until January 1st. I didn't question it. I was healthy. I'd be ok.

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A colleague suggested I get covered under COBRA. I looked at the costs. With student loan payments & living expenses, I was flabbergasted by the prices. I opted to go uncovered for two months - November and December. It seemed logical.

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So here I was. Knowing something was wrong, but talking myself out of getting seen because I knew the bill would be more than I could handle at the moment. Telling myself "it will probably be fine".

Our patients do this ALL. THE. TIME.

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I don't have to tell you how this story progresses. As you probably guessed, I ended up in my own ED when I collapsed, septic from a huge right-sided pneumonia. And, in tears, I had to explain when a colleague asked "why did you wait so long?"

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And you may be thinking the same. Why DID I wait so long?

Let me share my hospital bill with you.

The total is $10,282.34

This is for one ED visit. I requested IV medications be changed to PO when possible & refused some additional tests and meds. I refused admission because I knew I would never be able to afford it. And I KNOW the healthcare system. Most of our patients do not.

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Now that I have your attention with how ludicrous this is, let me bring your focus back to our patients - because this story isn't really about me, even though I led you in that direction.

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Consider a single-income family in the US. I say single-income because about 1 in 4 children are being raised by a single parent currently, and this number is rising. The average median income for a single-income family is in the range of $35,000.

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Now consider that mom/dad gets sick. They know they should go to the hospital. But who will take care of their children? Who will drive them? And how will they pay for a bill that will likely be 1/3 or more of their total annual income?

This is why they wait.

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We talk about improving access to healthcare. We talk big about health literacy and education and outreach. And these things matter, sure. But until we address the cost of healthcare, a huge barrier to care will remain.

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Do you know the costs of the lab tests you're ordering? Does this play into your medical decision-making process?

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If you're ordering a test, know why you are ordering it. An abnormal value should either give you a diagnostic clue or change your treatment plan.

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The next time you feel frustrated because a patient "should have come in earlier", remember that medicine is intertwined with social factors. This impacts us as physicians, how we treat our patients, and how our patients lives will change because of this treatment.

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