The invitation to talk to an informal gathering of his colleagues had come out of the blue. One of the major drug companies in his field had arranged to bring together a score of physicians in an educational opportunity to be held in one of the upper crust restaurants of the city, and get somebody (him, specifically!) to talk to them about the latest guidelines on one of the common diseases of the specialty. This was to be followed by dinner, a sine qua non to lure busy professional people away from home or country retreat on a summer evening to hear about drugs and treatment algorithms. Not a blatantly promotional event, but the company product featured so prominently in the guidelines that it would be the next best thing. The speaker would not have to bend over backwards to praise the sponsor, so his professional conscience would have no particular objections. This even gave him the moral permission to accept the proffered honorarium as an extra bonus. Preparing the lecture should not be particularly difficult: it would give him a chance to review the guidelines, compile a nice slide presentation, throw in some of his favorite jokes, add personal touches from practical experience, perhaps slaughter a few sacred cows along the way, and enjoy a round of applause from his peers. Piece of cake. He readily accepted.
He had known this man for some twelve years. He had first been asked to see him after his coronary bypass operation at age 60, when his borderline lung function had given way, and he had required prolonged assistance to recover. Ever since the patient had visited him once or twice every year from his small country town, an hour’s bus ride from the metropolis. He had given up smoking, and had complied well with his treatment. He was a quiet, polite, undemanding man, with a caring wife. His spirometry kept declining with advancing age: his FEV1 had gone from an initial figure of 45 percent down to 31 on his latest visit, but he plodded on.
When one morning the doctor found him waiting unannounced at his office doorstep in the private hospital where he consulted, he immediately feared the worst. Ashen faced, hypoxic, unable to talk clearly, the patient gave a history of sudden deterioration in his breathing over the last couple of days; he also mentioned a vague pain in his shoulder the previous day did not fit with a routine exacerbation of COPD. Better have a look at his EKG first. It did not take long to realize that he was infracting. A coronary angiogram was arranged without delay. One of the old grafts was found occluded, and he underwent a difficult percutaneous intervention. A couple of hours later his graft was pronounced patent again. Everyone involved heaved a big sigh of relief.
However, having survived the acute cardiac event, the patient now had to face his chronic respiratory insufficiency and almost nonexistent lung resources. He slowly made the transition from Intensive Care to the general ward, and home care with oxygen supplementation was arranged. On the day of his planned discharge he went into pulmonary edema. Instead of home he went into the ICU again. After initial resuscitation he required prolonged invasive ventilation. Soon a pneumonia with a resistant organism supervened.
Inevitably, as his illness dragged on, the ugly head of healthcare cost rose more and more prominently, like a cobra swaying out of a basket. Every so often, in the midst of a discussion on a patient’s course, someone from the family would hesitantly touch the issue of money. Could we find a bed for the patient in a government hospital? This was easier said than done. It involved kid-glove negotiation, use of the old pals’ network, some gentle arm twisting, a trading of favors between departments, and a good measure of luck.
The physician had a poor night’s sleep. His old patient was gradually slipping away. The hospital bed had been secured, but his bill was outstanding, and his family would have to bear the burden. Could he do something about it? Approaching the hospital management for a discount was out of the question: the tight financial circumstances precluded such goodwill gestures, which had been almost the rule in the past. Waiving his own fee was simple enough: he had done it before without second thought. But this was only a tiny fraction of the total expense, which amounted to several hundreds of euros per day. Two weeks of intensive care could easily wipe out a pensioner’s annual income.
In the middle of the night the brain tends to function in strange ways. He recalled that once in the past as a high school student, while half asleep, he had solved a problem in geometry that had been puzzling him throughout the previous day. Now, almost in a dream, he had a flash of inspiration. That very morning he had received a handsome check representing the lecturer’s fee for his talk at the drug-sponsored meeting. This was easy money that had dropped into his lap literally from heaven. He could do without it, and he would feel better in more ways than one: he had never before accepted such gifts from drug firms. It would not cover the whole cost, but it would be a significant contribution, much better than nothing. There was no need for the patient’s family to know: a discount would appear on the bill, assumedly offered by the hospital. He spent the rest of the night tossing and turning in his bed, and thinking of the best way to put the idea into practice.
By daybreak he had made up his mind. Over his morning cup of coffee he rang up the hospital accounts manager and asked for a personal meeting with him at his earliest convenience. Easy come, easy go, he thought. A different sort of investment.
ANTHONY PAPAGIANNIS, MD, MRCP(UK), DipPallMed, FCCP is a practicing pulmonologist in Thessaloniki, Greece. He received his MD degree from the Aristotle University of Thessaloniki Medical School. He trained in internal medicine in Greece and subsequently in the United Kingdom, and specialized in pulmonary medicine. He also holds a postgraduate diploma in palliative medicine from the University of Cardiff, Wales, United Kingdom. He is a postgraduate instructor in palliative medicine in the University of Thessaly, Larissa, Greece. He also edits the journal of the Thessaloniki Medical Association, and blogs regularly.