Fabulous Prizes

I have decided to institute a series of competitions in the field of health care. These will be unpublicized and participants will not be made aware that their performance is being monitored, except for unpredictable posts in which I will award unsolicited recognition and, occasionally, cash prizes.

This week's award, granted for the Least Flattering Response to a Conflict of Interest Between Patient Care and Hospital Finances, goes to a local tertiary academic medical center. The winner will remain nameless here, although they will receive a plaque in the mail crediting them, which they may display in the main lobby of their hospital building or some other prominent place.

A month or so ago I saw a new patient, Sra. B, in my clinic. She is an immigrant from Mexico, and she had previously been followed by the transplant surgery unit of the academic medical center I mentioned. She had had utterly intractable diabetes, which had been complicated by end-stage renal failure and a variety of other unpleasant associates of high blood sugar. She is only in her early thirties and has a young child, so clearly this was a disaster. I say that she "had" diabetes, (you don't normally get to say this about people who aren't dead; in general once you've got it, you've got it) because she was the lucky recipient of a combined kidney-pancreas transplant (See fig. 1).

The first kidney/pancreas transplants were performed in the late seventies, and have become more common since although they are by no means considered a standard therapy for diabetes. This is a stunningly ambitious surgery. While kidney transplantation has actually become rather straightforward the pancreas is loathed and feared by everyone, particularly people who have to touch it. It has been described by surgeons as having the consistency of "tissue paper stuck together with spit" and is notorious for its capacity to digest itself and kill its owner in response to the most trivial provocations. It has this propensity because it manufactures the bulk of the enzymes which take the enormous, totally unusable polysaccharides, proteins, and fats we all eat and turn them into small, usable fragments which can be absorbed and turned into fluttering eyelashes and babies' bottoms and other nice things. Clearly, this is a locus of extreme hazard since there isn't really any difference, from the point of view of a proteolytic enzyme, between a fish eye you ate at a cocktail party to demonstrate your gonzo panache and the eye you use to see with. Both, to the pancreas, are offensively baroque, decadent blights which fairly cry out to be reduced to their component macromolecules. Pancreatitis ensues when any part of the pancreas' remarkably fragile system for protecting you from your own concentrated digestive juices is interrupted, which can often happen without any trauma at all. You have a little too much to drink, your calcium level gets a little too high, or you get stung by a scorpion, and all of a sudden your pancreas starts leaking enzymes into its own substance and dissolving itself. Caustic fluids leak out into your abdomen, and produce what is basically a large, internal burn. Pancreatitis can become a self-reinforcing crescendo of inflammation which generalizes to involve the entire body, and it routinely kills people despite maximal medical therapy. The pancreas is the body's self-destruct button.

So just touching this thing is a bit iffy; to take one out of a dead person and stick it in somebody with a defective one in the hopes of curing a lifelong and debilitating affliction takes real chutzpah. And, astonishingly, it works - transplant patients are not only cured of their diabetes and no longer need dialysis (so long as the transplant takes) but often see regression in other complications of diabetes, something which isn't seen to any really exciting extent with any other therapy.

The trade-off is that transplant recipients have to take potent immunosuppressive drugs for the rest of their lives to prevent their immune system, (our bodies' haematological Gestapo,) from picking up on minor genetic differences in the graft and destroying it. These drugs are not benign; some of them cause birth defects so reliably that it's generally recommended that patients take the oral contraceptive pill while on them, no matter what other form of birth control they use. All of them, by design, suppress your immune system which increases your susceptibility to infection. (The Gestapo metaphor is vitiated by the fact that, unlike Germany under the Third Reich, your body really is constantly beset by malevolent, genetically impure monstrosities who want to infiltrate, usurp, and destroy you. At the cellular level, a paranoid police state actually is usually in your best interests; if your cells are doing nothing wrong, they have nothing to hide...). Some of these drugs have narrow therapeutic indices and need monitoring of their concentration in plasma to insure that they aren't dangerously diluted or toxically concentrated. Laboratory tests indicating kidney and pancreas function need to be monitored regularly to catch any incipient rejection of the transplant early. When a patient who is highly motivated, disciplined, and ready to learn a lot about their condition comes together with a healthcare provider who is ready to make a serious, ongoing commitment to ensuring the best possible outcome for them, this operation can be a stunning demonstration of the god-like power of scientific medicine.

People who perform these surgeries select their patients very carefully to try to maximize the probability that things will go well for them; you do not, obviously, want to do something like this to someone who never takes pills or misses appointments or has no fixed address or is just basically perverse and bloody minded, because you'll end up making things worse than they were before you intervened. Now, instead of diabetes and renal failure, the patient will have diabetes, renal failure, transplant rejection, and various drug toxicities.

Sra. B is covered by a subset of Medicaid which only covers emergencies, and to some extent palliative care, and for which anybody is eligible, regardless of immigration status. It doesn't, however, cover chronic care - like the kind you need to monitor immunosuppression and transplant viability over a lifetime. The academic medical center funded the actual transplant, probably because it was part of a study, or because the kidney-pancreas transplant unit enhances its prestige, or perhaps as a purely charitable gesture. Medicaid definitely does not cover this kind of operation. (Medicaid doesn't even cover insulin dosing pens that make clicking noises so that blind diabetics can dose their insulin accurately.) Moreover, I am sure the transplant was not her idea - she could never have afforded it, and I don't think she even understands exactly what they did to her.

So she had the surgery, and they followed her for a while, but then she lost her emergency Medicaid funding which, in any case, would have eventually stopped paying for her care there. At this point, they were presented with a conflict between the center's financial interest and their duty of care to the patient. And it's because of the choice they made that they win this week's award. They could have said, "You know, we're the ones who suggested that this lady have this surgery, and we did it to her, for free; so really, we've incurred a moral obligation to see it through, regardless of whether we make our money back." This would have been the "right" answer. Instead, the transplant unit told her to arrange further follow-up at my hospital, (which has a mandate to treat all residents of the county regardless of their ability to pay but, glaringly, does not have a transplant surgery unit,) and she found her way into my primary care clinic. They decided that it was more important to use her slot for an insured patient than it was to provide optimal medical supervision of potentially dangerous medical circumstances which, let's remember, they created. The also decided that they were comfortable with the risks they assumed on her behalf by referring her management to someone who has been practicing medicine for exactly one year as of last Thursday, and who (like most of his seniors who have significantly more experience) doesn't know much about the chronic use of dangerous immunosuppressive drugs in transplant surgery patients.

As I mentioned, there are stringent protocols for evaluating people as candidates for transplant surgery - they have to be reliable, easy to locate, reasonably intelligent, compliant with medical instructions, etc., and if they're not they never make it onto the waiting list. This experience has made me think that we should impose similarly stringent criteria on institutions that want to perform this kind of dramatic intervention. For instance, we might require that they state explicitly their understanding that the intervention they propose creates potential dangers which persist for the entire life of their patients; that, given this, they assume a contractual obligation to provide lifelong follow-up care regardless of changes in their patients' ability to pay; and that, should it become necessary, they only transfer their duty of care to facilities staffed by persons of comparable specialist training. This doesn't seem like a lot to ask. After all, it's really just a specific application of a general principle articulated in the Hippocratic Corpus some twenty-five hundred years ago: "to help, or at least do no harm".

Sra. B is doing well. I got the transplant unit to give me an official list of her medications and tell me what lab tests I should be monitoring and how often. I got our "Utilization Review" department to pay for her to go see them when one of these tests appeared to be going in the wrong direction, and for her subsequent admission and treatment for transplant rejection. I've managed, through cajoling, wheedling, and appeals to higher principles a follow-up appointment for her there to make sure everything is going all right, although I had to agree to order all lab tests at my hospital and fax them the results. The ignominy of doing their clerical work, I have to say, has tempered some of the boundless pride I felt at the implication that I was transplant surgeon material contained in the original "referral," but if it means they'll pay attention to her, I guess I'll survive. There's an older doctor here who likes to say, of situations like this, "I'm Board-Certified in grovelling, whining, and guilt-tripping."

I'm seeing her on a weekly to monthly basis at the moment. She always comes to clinic with her daughter, who is nine years old and extremely vigilant about her mother's health. She is also incongrously knowledgeable about the workings of the Medicaid program, since she often has to act as a translator. She stays on top of things and remembers to follow questions up when her mother forgets. Somewhat strangely, I think, she wants to be a doctor when she grows up.