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Paul Gross


It all begins one Sunday morning when Mrs. Morris, a 75-year-old retiree with a heart condition, trips on her way out of church. She falls flat on the sidewalk, can't get up, and ends up in our Bronx emergency room. A CT scan shows a pelvic fracture, and she's admitted to our inpatient team.

When I join the family medicine residents to see Mrs. Morris the following day, she can't get out of bed. She's got short, unruly white hair and a gee-whiz expression that charms us. "What a pain!" she says. Given how close she lives to the brink--terrible circulation has cost her one heart attack and several toe amputations--I'm impressed with her good cheer.

Things looks promising. Follow-up studies confirm that the fracture won't require surgery, and in the afternoon a physical therapist pilots her through a few wobbly steps.

The next morning we come to Mrs. Morris's room and find her peering at a novel. "I think it would be great fun to be a secret agent, don't you?" she says to me.

We make arrangements to transfer her to a rehabilitation facility, where therapy will get her walking again.

All goes smoothly until a hospital discharge planner hands me a slip of yellow paper. "Call this doctor," she says. "Insurance is denying the admission."

Uh-oh. I feel a sudden chill. A beast--Denial of Care--lurches over the horizon.

Looking glumly at the phone number, I recall a bout with the beast two days prior: puzzling over three different identification numbers on a patient's insurance card; navigating an automated telephone menu; waiting on hold; being told by a live person to call a different number; then being told at that number to try yet another number; and finally, being informed that neither my patient nor myself were in the insurance computer system.

This time, I'm in luck--sort of. The phone picks up right away, only it's not the doctor I want; it's someone else's voicemail. Did I dial right? I try again and get the same not-who-I-want message asking for the patient's insurance number, which of course I don't have.

Hanging up, I say a bad word. Then I go looking for Mrs. Morris's chart which, when I find it, doesn't seem to have her insurance information. I pause, frustrated; then someone interrupts me with a question about another patient.

Later that day, Meg, our social worker, comes over. "We've got a bed for Mrs. Morris, but her insurance is denying rehab. They say they're having trouble reading the therapist's note."

The beast again.

I don't picture it as a giant or troll. Rather, I imagine this maker of mayhem as a robot. Its iron torso shields a maze of electronic wires. Its taunting voice recites, "Your call is very important to us." Claim forms geyser from its metal fists and flutter around its blank face.

Armed with pens, telephones and determination, we all--health professionals and patients alike--leap to the challenge. The beast barely stirs. It's got all the time in the world.

Meg interrupts my reverie by grabbing a phone to locate the therapist with deficient penmanship. Failing that, she tries to wheedle another therapist into writing a note. Meanwhile, I find Mrs. Morris's insurance number, call the voicemail again and leave a message.

Time passes; the workday draws to a close.

Hospital day number three dawns. "You're still here!" I say to Mrs. Morris with attempted enthusiasm. "Well, the food's good," she says.

I leave another voicemail message.

That afternoon, I get a return call from a doctor with a soft, quavery voice. I wonder if she gets yelled at a lot. I sit down and take a deep breath.

"I understand that you're denying this admission," I say civilly.

"Well, according to the x-rays there wasn't anything requiring surgery, so it's not clear that the hospitalization was required."

Who, I wonder, would send a 75-year-old cardiac patient home with a broken pelvis at 10:30 on a Sunday night?

"She was in pain," I say. "She's got heart disease. She couldn't walk." I forget to mention her missing toes.

"I'll pass that along," she says half-heartedly. "They'll take it into consideration. You can always appeal..." At the thought of another telephone safari, I feel my foot start to jiggle.

"She couldn't walk," I repeat.

 

Hours later, I run into Meg. "Mrs. Morris is leaving!" she says. "They approved rehab--and the admission, too."

I'm pleased. After only a minor skirmish, the beast has clanked back to its lair. But I'm also annoyed. We've been giving Mrs. Morris excellent care. Why the hassle?

As a family physician and as a patient, I'm genuinely curious about this beast, Denial of Care. Mrs. Morris's story seems innocuous, but the same tale played out many times daily all over the country suggests something more profound at work.

How big is this beast? How many hours a day do we, as patients or health providers, grapple with it? How does this struggle affect the care we give and receive? On a deeper level, how does it square with our nation's spirit and soul?

And why doesn't it generate more notice? Have we simply come to accept it? Are we numb to its affronts?

Or is the opposite true: that each rebuff hits a raw nerve, producing cries too painful to voice--or too angry to listen to?

As Pulse's editor, I hope that we can use one another's stories as yardsticks to take the beast's measure. I hope we can find plain, heartfelt words to describe disquieting fairy tales where giving and getting proper care demands a fight--and sometimes doesn't happen at all, despite our best efforts.

I hope, too, that our stories can illuminate and build on our strengths--our compassion, courage and resourcefulness--so that we can one day bring this beast to heel and our health care system back home to us.


About the author:

Paul Gross MD is founding editor of Pulse--voices from the heart of medicine.

Story editor:

Diane Guernsey