Monday, September 30, 2013

Opening wallets. Helpful or harmful?

Awhile ago I posted this tweet to twitter:

It received 24 retweets and a lot of twittversation around it. A number of doctors give money to patients when they are in need. Too many times the safety net is porous or too difficult for unsophisticated patients to navigate. This week-end I saw this tweet:

The article is really good and is worth a read.

When I was just out of fellowship I saw a young patient in the emergency department with hypokalemia and severe hypertension. We sent an aldo and renin and treated her blood pressure with a number of medications but not spironolactone. I was sure he was going to have primary hyperaldosteronism and starting an aldosterone antagonist would complicate getting selective adrenal vein sampling to diagnose an adrenal adenoma. I set her up for a follow-up appointment and discharged him. He never made it to the follow-up visit. I didn't see him again for years but when he re-presented he still was hypertensive but his kidney's were thrashed. Half a decade of uncontrolled hypertension had taken their toll.

I asked him about why he didn't follow-up. Turns out he lost his job a few weeks after being discharged and didn't have any medical insurance. I regret not giving him the spironolactone prescription.
I know that for $0.13 a day I could have had better blood pressure control than with whatever concoction anyone else threw at him.

He eventually went become one of my dialysis patients. He was morbidly obese and was rejected by the transplant team for that reason. We were discussing what to do next. I was trying to convince him to take charge of his life and lose the weight. He kept making excuses about why he couldn't. At one point he said that he didn't have enough money for a treadmill. I pulled up Craig's List and found a an $80 dollar treadmill for sale I told her her could probably buy it for $40 and gave him $20 to get him halfway there. I know my guilt from the earlier miss influenced my behavior but mainly I was trying to shake him out of dialytic nihilism.

Soon after that, either I switched shifts or he changed units and we lost contact.

The other day I was talking to our transplant nephrologist and he told me that the patient was touched by that gesture. The act of pulling out my wallet and throwing down some cheddar made him feel that he needed to recommit and give a full throated effort to lose weight.

He was successful. He lost the weight, received the kidney and is off dialysis.

Best $20 I ever spent.
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