“The doctor was adamant: ‘This is America, not Sweden,’ he told me. ‘We operate.’”
Below, a physicians assistant (PA) recounts what happened when he was diagnosed with appendicitis.
Andrew T. Gray knew that he could not afford surgery. Ironically, he had just taken a new job as a PA but had not yet filled out all of the paperwork for insurance. Moreover, he had read about a randomized controlled trial done in Sweden suggesting that over 70% of patients did just as well taking antibiotics rather than going under the knife.
Gray’s story originally appeared in pulse- voices from the heart of medicine, a free online magazine that publishes riveting stories and poems written by health care providers as well as patients. All of the them are true, and both the writing and the editing is superb. If you’re not familiar with pulse, see this postwhere I describe how pulse was boron, quote reviews, and link to some of my favorite stories.
I urge everyone to consider subscribing to pulse’s free weekly e-mails. You will receive a story or poem at the end of each week that will brighten your Fridays.
At the end of Gray’s story, I have added a note on research done not only in Sweden, but in the UK, comparing the results when doctors recommend antibiotics before scheduling surgery for patients diagnosed with appendicitis.
Saving My Appendix
By Andrew T. Gray
How did this happen to me? I wondered, looking at him across the ER exam room. How could I, a healthcare provider, not have insurance?
I had woken up that morning with a mildly upset stomach. Nonetheless, I’d gone to my job (begun only six weeks earlier) as a physician assistant at a Beverly Hills HIV clinic. I’d seen patients until lunchtime, then attended a research meeting. The subject was a study of irritable bowel syndrome.
“I need to be in this study,” I joked to a coworker. “My IBS is acting up.”
I don’t have IBS, but I was indeed having crampy stomach pain. I continued to see patients until 3 pm, when the pain became steady: on a ten-point scale, I gave it a six. I left work early.
As I exited the building, my first thought was Freedom! I can get home early, relax, maybe take a nap…
Crawling into bed, however, I realized that my pain had coalesced in the right lower quadrant of my abdomen. Could it be appendicitis?
Panic flooded me. After six weeks at my new job, I now qualified for health insurance, but I’d neglected to fill out the necessary paperwork.
Only an hour after leaving the clinic, I returned. Almost hysterically, I completed and faxed in the insurance forms.
Only an hour after leaving the clinic, I returned. Almost hysterically, I completed and faxed in the insurance forms.
Only an hour after leaving the clinic, I returned. Almost hysterically, I completed and faxed in the insurance forms.
“Go to the emergency room right now,” urged one of my supervising physicians.
I felt it would look better, though, if I didn’t show up at the ER on the day I’d applied for insurance. Because I had no fever, nausea or vomiting, I decided to return to my apartment. I spent a sleepless night tossing and turning.
At 6:30 am, I walked to the large, prestigious nonprofit hospital located three blocks from my apartment.
Waiting for the ER doctor, I recalled that, at some point in my schooling, I’d read a Swedish study about treating appendicitis with antibiotics. Googling the study on my smartphone, I found it:
By the time the ER resident approached, I was ready.
“I don’t have health insurance,” I said calmly. “Can I be treated with antibiotics instead of surgery?”
He pondered what I’d just said.
“I doubt they’re going to let you do that here,” he said finally. “But keep expressing interest.”
When the ER attending physician came in, I repeated the question.
“Absolutely not,” he replied flatly. “This is America, not Sweden. If you have appendicitis, we operate.”
They sent me for a triple-contrast CT scan. The results: early acute appendicitis.
Next I met with the surgical team–a resident and a medical student.
“I’m familiar with the literature about antibiotics in lieu of surgery,” the resident said, sounding annoyed. “But those studies were in pediatric patients, not adults.”
I pulled out my phone. “The study says five hundred and fifty-eight patients. No mention of pediatrics. Seventy-seven percent success rate.”
He turned to the med student. “We have to get the attending.”
The attending surgeon arrived and heard my spiel.
“Seventy-seven percent is a horrible number for a surgeon,” he said firmly. “We’re looking for much better than a seventy-seven-percent success rate.”
“But I don’t have insurance,” I protested.
“Man, you already got a CT scan–your bill is going to be huge anyway,” he said irritably. “This is a simple surgery. I can put you on for four pm.”
I was given a dose of IV antibiotics in preparation for surgery. Once in my hospital room, I tried not to move; it hurt too much. They offered me morphine, but I refused. If I took it, I’d no longer be able to use my pain levels to gauge the seriousness of my situation.
Delores, my nurse, entered the room. One hand held a hospital survey.
“What’s the primary goal with regard to your stay here?” she asked.
“That it be as cheap as possible,” I replied, my spirits sinking. I knew how impossible that was.
Delores looked at me intently.
“Sir, we want you to focus on getting well. Please don’t think about the cost; that can all be worked out once you’re healthy again.”
So many times, I’d heard myself say these very words when a patient expressed concern about treatment expenses.
But now I realized the truth: no one involved in my care actually knew the cost of any of the treatments they were suggesting.
Turning to my phone again, I found a Harvard Medical School article supporting antibiotics for acute appendicitis:
I also found a Cochrane Review:
Nevertheless, when you’re a physician assistant, it’s hard to stand up to an army of MDs telling you that you need surgery. Although I feared that my insurance coverage wouldn’t come through, I resigned myself to going under the knife.
Two friends had come to keep me company, so at least I wasn’t waiting alone. I discussed my concerns with them. They were understanding, but not being in medicine themselves, they weren’t willing to support my attempt to buck the system.
At 5 pm, Delores informed me that emergency surgeries had preempted all the anesthesiologists, and that my procedure would happen as soon as anesthesia was available–”maybe around eight o’clock.”
“Don’t worry,” she said reassuringly. “Appendectomies don’t get cancelled.”
My phone rang. It was another supervisor from work.
“How do you feel?” he asked.
“The pain is five out of ten,” I said. “A little less than this morning.”
“Andrew, get out of there. We’ll schedule you for an appendectomy as an outpatient procedure tomorrow. You’ll save a lot of money.”
Seconds after we said goodbye, I pulled out my IV. My friends, shocked but wrapped up in the drama of the moment, helped me to gather my things, and I walked out of my room and down to the nursing station.
“I’m signing out against medical advice,” I told Delores.
She looked shocked. “Sir, please don’t do this. You could die.”
“I’m not going to die,” I said excitedly, fueled by adrenaline. “If I need to, I’ll come back.” I felt bad for upsetting Delores; I know she was sincerely worried about me.
I texted my supervisor, asking him to call in prescriptions for the antibiotics used in the studies. That night I started taking them.
The next morning, my pain was down to a three. I declined outpatient surgery.
Over the weekend I lay low, and on Monday I worked a full day. On Tuesday night, I attended my regular yoga class with no problem. On Wednesday, I got word that my insurance would be instated retroactively to the first of the month.
Then the bills started to arrive. The full tab for an ER visit, a CT scan, a dose of IV antibiotics and hospital admission came to more than $30,000. That was without an appendectomy.
Two weeks later, I finished my oral antibiotics. Total cost: less than $50.
It’s now six months later. I haven’t missed a day of work, and I feel great.
Had I known that my insurance was active, I certainly would have had that appendectomy. In retrospect, I’m thankful that I didn’t know. A 77 percent success rate may not be acceptable to an American surgeon, but it was good enough for a guy without insurance.
It’s easy to tell a worried patient, “Let’s worry about the cost once you’re healthy,” but having been that patient myself, if only for a day, I know how thoroughly the fear of medical bills can obliterate any concern about health or healing.
Nowadays, when someone asks me how much a treatment costs, I no longer get annoyed.
I go and find out.
About the author:
Andrew T. Gray graduated last December from Baylor College of Medicine’s physician assistant program, where he served as president of his class; he now practices HIV medicine at Pacific Oaks Medical Group in Beverly Hills, CA. An active member of the American Academy of Physician Assistants and the California Academy of Physician Assistants, Andrew has been interested in writing since he majored in English literature as an undergraduate at the University of Texas at Austin. Looking back on the incidents that led to this story, he says, “It’s been six months since my brush with appendicitis, and I’m feeling fine.
A Note from MM on the Research:
It’s worth taking a look at the Harvard Medical School report that Gray mentions. . It summarizes the results of the UK study.
When “researchers from Nottingham University Hospitals in England compiled the results of four randomized clinical trials that compared antibiotics and surgery for uncomplicated appendicitis, here’s what they found”
- Antibiotics alone successfully treated appendicitis 63% of the time
- About 20% of those treated with antibiotics had a return of pain or other symptoms and needed to go back the hospital; some of these had serious infections brewing”
- People who received antibiotics instead of surgery were 39% less likely than those who underwent surgery to have developed complications such as a perforated appendix, peritonitis, or infection around the appendectomy incision.
The research was published in the British Medical Journal (BMJ).”
But as Gray discovered, these studies are not widely accepted in the U.S. The Harvard report concludes: “For now, most doctors will probably continue to recommend surgery to treat an inflamed appendix. But if you find yourself with appendicitis and your doctor suggests trying antibiotics first, he or she isn’t crazy and it just might work.”
Finally, a pulse reader commenting on Gray’s story asks a provocative question. He writes:
“I admire the author’s spiritedness, even if I don’t agree with his decision to leave the hospital against medical advice. However, I’m selecting this piece as one of the readings for our monthly Art of Medicine Rounds because it illustrates how ignorant we are of the economic impact of the care we provide. For all our hand-wringing over health care costs, are any medical schools or specialty boards testing students and physicians on the prices of even basic laboratory tests, imaging, common surgical procedures and the most prescribed medications?”
