Today's prize goes to a previous winner in this series, an institution which for the moment I will refer to as Local University Hospital (LUH). LUH won the first prize I awarded, the (in retrospect somewhat anemically phrased) award for "Least Flattering Response to a Conflict of Interest Between Patient Care and Hospital Finances." Let me briefly recap the situation which landed them this dubious honor: about half-way through my internship I met a patient in clinic who had suffered from intractable diabetes, which resulted in renal failure and a number of other complications. She was referred to the LUH transplant program, where their star team of surgeons and nephrologists elected to perform a kidney-pancreas transplant. The operation was a miraculous success and a credit to her physicians, in that it cured her diabetes and her renal failure simultaneously, thereby massively extending her life expectancy and the quality of life she could be expected to enjoy. So long, that is, as she continued to receive regular follow-up care from a physician experienced in the management of transplants.
As I detailed in my last post on this case, transplants are themselves a disease. The whole point is that they're usually preferable to the disease you used to have, but they nonetheless require constant expert monitoring and frequent titration of life-sustaining medications - not unlike, say, congestive heart failure, coronary artery disease, or diabetes. LUH won the award because after her transplant, the patient no longer needed dialysis and therefore was no longer eligible for Medicaid, the federal insurance program which had covered her treatment, and they responded to her loss of coverage by declining to see her further in their clinic and advising her to follow up at a public hospital. To put it simply, they cured her original disease by giving her a different, far more manageable one, which they then declined to treat, preferring to leave her care to an intern a few months out of medical school with no experience in transplant medicine working at a county hospital (i.e., me).
Since that original post, she has been admitted to LUH twice for episodes of serious transplant rejection (only, I should add, after I had arranged for the County to pay for her admission). Would this have happened if she had been under the care of a transplant nephrologist, rather than an overworked medical resident who only has clinic once a week, and whose clinic is frequently cancelled because he is on-call or post-call? Probably not.
However, these ignominious failures clearly fall under the remit of the original award LUH received back in 2009. Whence this renewed recognition? Well, last time I was on the wards I admitted a second patient with nearly the exact same story. She also developed renal failure young, she also received at transplant at LUH, she also lost her insurance, and whe was also turfed out to fend for herself. During her hospitalization, I finally actually spoke to a transplant nephrologist in the LUH clinic, and asked him (as you might imagine,) some fairly frank questions. Yes, he said, it is the policy of the clinic to refuse further care to people who lose their insurance. Yes, there are a fairly large cohort of people whom they have performed transplants on and who have subsequently lost insurance. Of course, he hastily added, they now screen people financially prior to transplanting them (thank God, by the way, that we don't ration care in this country, like those atheist communists in Europe) and, he went on, they categorically refuse to perform transplants on people whose only coverage is through federal insruance programs which predicate eligibility on dialysis-dependence, and who will thus predictably lose coverage when their renal failure is cured by transplant.
So they no longer transplant people like my first patient. However, this policy change would have made no difference to my second patient, since she had the kind of insurance all Americans are supposed to have and on which our "system" is founded, i.e. insurance through her employer - she was just unfortunate enough to be laid off after getting her transplant.
Given this second case, and the implication of many similar cases, LUH is being awarded an even more prestigious prize, for Grossest Institutional Failure to Recognize And Abide By A Fundamental Principal of Medical Ethics. I am referring, of course, to cumbersomely-named principle of "Nonabandoment," of which a recent Annals of Internal Medicine article has this to say:
In medical ethics, the term “abandonment” has customarily meant unilateral withdrawal by a physician from a patient's care without first formally transferring that care to another qualified physician who is acceptable to the patient. Abandonment means leaving the patient without care. As such, abandonment has been universally condemned as a serious and punishable infraction of both the legal and ethical obligations that physicians owe patients. Its converse, nonabandonment, is therefore a fundamental ethical obligation of physicians once patient and physician mutually consent to enter into a relationship.I think it is hard to make the argument, in either case, that LUH is thinking very hard about their obligations to the patients they transplant. It seems obvious to me that if you intervene in someone's body to create a situation of lifelong dependence on technical expertise which you possess, regardless of their prior situation, you have entered into the kind of relationship which is supposed here. LUH's actions seem to me to be directly analogous to a doctor who intubates a patient in respiratory failure and then neglects to connect them to a ventilator because he isn't being reimbursed to manage ventilators, or a cardiologist who orders a pacemaker implanted but then refuses to monitor its efficacy (or transfer the patient to another cardiologist) when the patient loses their insurance. Anybody who disagrees (e.g. lawyers for the tobacco, pharmaceutical, or arms industries) is warmly invited to post a rebuttal.
The fact is that LUH makes clear by their actions that what they are primarily interested in is the prestige which comes with a transplant program, and the star faculty and grant funding such programs can attract. If they were genuinely committed to the well-being of the patients they operate on, they would not, as the Annals author put it, "[unilaterally withdraw care] without first formally transferring that care to another qualified physician who is acceptable to the patient," which is exactly what I have seen them do twice and what their own physican has told me is a matter of policy. You might answer that there's a limit to how many patients they can continue to treat for free, to which I would reply that there certainly is, and it should be integrally and explicitly related to the number of patients they perform transplants on in the first place.
Their medical negligence in denying people follow-up care is a diffused crime - the responsibility is certainly not only the transplant physician's, but obviously also falls to the administrators who tell them what they have to do - but it's a crime nonetheless.
While I'm at it, I realize that they deserve a second award, which would be for "Most Egregious Failure To Explain The Possible Ramifications Of A Therapeutic Intervention To The Patient." The first patient of theirs I saw, I recently discovered, had visited our gynecology clinic complaining of infertility. Unbenownst to me, (I take full responsibility for not asking insistently enough) she had been trying to get pregnant for several months. Our perinatologist explained to her (in my defense I had already said something to this effect) that one of the medications she takes to suppress rejection is grossly teratogenic (Greek for "productive of monsters") and that it was inadvisable in the highest degree for her to attempt to conceive while taking it. She said that she had never realized that this would be the case, and that had she known she would never have consented to the transplant. This simply augments LUH's already strong contendership for this second award, since they also failed to explain to her that their proposed intervention would make her dependent on transplant specialists for the rest of her life, and that they would refuse to see her if she lost her insurance (which was a predictable consequence of the operation they were about to perform). This award represents a violation of another well-known and often cited principle of medical ethics, i.e. "Informed Consent."
Thus ends another exciting award ceremony. What shining exemplar of modern medicine will next attract the notice of our august panel of judges? Who knows. Fortunately, there is no shortage of candidates. And if you are a reporter who likes to write stories on things like this, I know some transplant surgeons and university administrators who want nothing less than to talk to you.
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