A sweet little lady came to the emergency department recently. She said she felt short of breath and sweaty at home. In the department, she looked like a rose! Normal oxygen levels, normal labs. Her chest x-ray had a faint area that ‘one might possibly imagine could perhaps be’ a pneumonia. It looked remarkably like her previous film.

But her history was concerning to me, and it was concerning to the resident on call for her physician. We decided to admit her, despite the lack of hard findings. Within two hours, she was short of breath and her mental status had dramatically changed.

But someone might have asked, on first pass, ‘what are we going to do with her in the hospital?’

From the emergency department perspective, I’m well acquainted with the question. Admitting physicians ask it all the time. When diagnoses do not manifest themselves with sufficient clarity, when patients’ complaints lie in the ‘no-man’s land’ of disease, when the only reason to admit is that it just ‘feels right,’ the question is usually, ‘what are we going to do in the hospital?’

I admit, it’s a good question. When the sweet old lady falls and doesn’t actually break anything, but it hurts terribly to walk. When the child is in a dramatic car crash, but has no obvious injury. When the 40-year-old man says, ‘I can’t explain it doc, I just feel like I’m dying!’

We try to be scientific. We crave certainty and answers. And so, when the lab tests and x-rays don’t add up, when they don’t give us the ‘dotted i’s and crossed t’s’ we need, we frequently assume that nothing is wrong. When there are normal cardiograms, normal blood counts, normal x-rays, we assume…normality! And yet, sometimes there’s more. Sometimes, danger is lurking. But the admitting physician reasonably asks, ‘what are we going to do in the hospital?’

I think that it illustrates the remarkable problems of allowing either insurers or government to decide what will be reimbursed. In essence, this illustrates the problem of anyone other than the patient paying for their care. When someone else pays, two problems arise: the payer gets to decide what will be covered, and the recipient of the care has less ownership of their own care…as well as less control.

Sometimes the answer to ‘what will we do in the hospital?’ is simply this: we’ll wait, and watch and see. I’m a big fan of waiting and watching. Physicians now are in the habit of denial. They’re so used to being beaten up by utilization review boards and insurers that they fall into the trap of assuming that, if there is no obvious answer, then there is no serious problem.

It’s not their fault, really. They’ve been denied and harassed so long that they can’t help but take the safest course. Unfortunately, the safest course isn’t always safest for the patient.

It’s odd, I know, to suggest that patients might be safer without insurance. But on some levels, it might be true.

Then, the answer to ‘what are we going to do in the hospital?’ could reasonably be answered by the best person. The doctor, the person in charge of the patient’s care, could say, ‘I think we’ll just keep him, and watch, and see what develops. Even if all the tests are normal!’

Dangerous things may be difficult to discern. And brilliant doctors may be compromised; not by drug companies, but by the power of the dollar as it emanates from third party sources, including governments.

And sometimes, we must be allowed to follow our instincts.

Edwin Leap is an emergency physician who blogs at edwinleap.com.

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