Yesterday I went in to work early to help with the overflow of sick visits. I never do the well child exams, and they hold little interest for me. However, I really dislike having to see three or four patients in an hour and to figure things out, and tie up loose ends in a short time span. In preparation, I come in early look over the patients who are booked and skim through their medical histories. Sometimes I print up patient education information in advance of seeing someone, just based on a hunch. One thing I never look at is insurance coverage.
As I keep saying, I am a very intuitive caregiver. My intuitions are based on experience but also on impressions that come to mind. Last week, I walked by one of the nurses and asked her if she was okay. She said it was nothing that 7 and 1/2 months wouldn't cure and that was great news since she had infertility issues. I looked at her once and said, "Um, there are many babies in there." She told me that she had several eggs implanted. I said, "I feel like you are having triplets." The next day I got an email from this nurse saying she just had an ultrasound, "Just call them the Three Amigos!"
The fact of the matter was that I had worked in high-risk maternity for a couple of years but this was before multiples larger than two were conceived on a regular basis. I just knew she had three beings in there. So along those lines, I looked at my schedule yesterday and saw that my first patient was past adolescence and was coming in for a lump in her breast. I got up, went in to see T., our lead medical assistant and asked her if it was possible to get a breast imaging appointment if we needed it. She walked over to the department, but was then stopped by the local admitting people. This first patient had no insurance. T. asked me what I wanted to do.
Beforehand, I knew that I would discover a mass in this young woman's breast and it would not be run-of-the- mill. I also strongly felt that if I turned her away, she would wait a long time before seeking evaluation again. Recently I worked with an NP, an old friend, who when asked if she would see a patient who presented and had no insurance she glibly said, "No pay, no WAY!" I was shocked, surprised, and horrified but respected her jurisdiction in this case though my esteem was significantly lowered for this co-worker.
I saw the young woman with the breast mass and it definitely warranted visual diagnostic evaluation. The patient had come with her mother and they were worried. After having set up permission with breast imaging beforehand, thanks to T., I called and arranged an immediate ultrasound. I told them in the imaging department that this patient had no insurance, but they deferred to me and it was accomplished. They told the patient and her mother that there was a mass in her breast that needed a biopsy and excision in a timely way.
I returned to pediatrics to see my second patient who was fairly complex, and required four opinions on what I had observed. When I went out into the hall to enlist my fourth expert, T. came running over and said, "Call B. You are in big trouble." I was too busy to make the call at that moment, and busied myself with developing the best plan of care for this second patient. B. came to find me and pulled me out of my exam room.
"Your patient had no insurance!" I said, "Well yes, but she had a problem and I needed to do the right thing." B. said, "There is free care in Boston. You should have sent her for that." My response was that it was my judgment that she needed prompt care. B. was pretty mad at me and there was a lot of give and take in the hallway. But he had to thank me for a medical favor which I had done for him, which went beyond the bounds of regular care. The two scenarios were juxtaposed in my mind, and what I deduced was that everyone deserves adequate care. My time is not not costly and the imaging device was already there. I made the right decision. Finally, I just swept my hand in the air as if brushing the discussion aside and said, " Do what you want B. If I need to answer to more people, I will. If this gets me in trouble, I'll deal with it." He said, "Oh no, you are not in trouble, but this is going to cost the center a lot of money. Please don't do this again."
Hopefully, in not too long a time, everyone will have some form of insurance and this will be a moot point. Meanwhile, word travels fast, and during the course of the day, I got many hugs and pats on the shoulder from my co-workers. I was assured especially by the clinicians that my choices were correct. But too, I am sure I have not heard the last of it from the administrators.
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