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The Art of Medicine

Balancing the books

Godfrey, Alexandra MS, PA-C

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Journal of the American Academy of PAs: July 2014 - Volume 27 - Issue 7 - p 57
doi: 10.1097/01.JAA.0000450816.67072.3b
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How much is a chest X-ray? And all that blood? Gracious God, how much that gonna cost me?” My patient's eyes widen as the tech draws the rainbow.

My patient, a 68-year-old woman, did not plan on an ED visit, and she's trying to find order in the chaos. Undoubtedly, she looks more stylish than most, but that offers little help in a crisis. She wears a fine red wool suit, and on her lap she holds a leopard skin bag that matches her shoes perfectly. Her head is a mass of finely braided plaits. Clenched in her right hand is a small wooden cross that she keeps close to her heart. Her brow furrows with worry, and her eyes brim with anxiety and suspicion. Her lips are set together tightly. She doesn't know whether to curse or to cry. I suspect that like many of my patients, she fears medical debt, bankruptcy, and loss of self-worth. Before I can answer, she extends her hands to the heavens dropping her cross on the floor. “The Lord is my shepherd, I shall not want. He makes me lie down in green pastures; he leads me beside still waters; he restores my soul. He leads me in right paths for his name's sake.”

She looks like she is asking for mercy. I want to tell her there's no sin in sickness. I pick up the cross and place it in her upturned palm. She lifts her head and in her eyes I see her thanks.

I say to her, “I am not sure what the cost will be to you. I doubt a chest X-ray would cost more than $200. The cost of an X-ray is dependent on your insurance, co-insurance, copay, deductible, and on the number and type of views done. It may cost you very little or nothing.”

“Two hundred dollars! I shall skip the chest X-ray.”

I don't want her to skip the chest X-ray. I believe it is important. She presented via EMS from church with chest pain and syncope. She was standing in the pews, praising the Lord, when an elephant walked across her chest. She went down suddenly in her Sunday best. She arrived in the ED pale, hypotensive, and diaphoretic.

“You can skip it,” I reply. “But the chest X-ray is an important part of the evaluation of your chest pain. A chest X-ray gives us important information about diseases of the heart, lungs, airways, esophagus, and chest wall. I would worry we are missing something important if we skip it. I want to keep you safe.”

“I think I was just tired, but I am no doctor. Do you think I have something seriously wrong? Could this be my heart?” She presses the cross to her left breast.

I try to think of a reassuring answer. I decide on the truth.

“Your chest pain could have a serious cause such as your heart. We evaluate patients in many ways and blood tests and X-rays are important. I cannot see the structure of your heart by looking at you, nor can I see changes in your blood.”

My patient sighs. “Even though I walk through the darkest valley, I fear no evil; for you are with me; your rod and your staff—they comfort me....” She stops. Her eyes flicker, a new question: “How many X-rays?”

“Typically, we take two views, posterior to anterior, and a lateral (side) view. These two views allow us to see your thorax better and localize lesions more accurately.”

I sound like a textbook. She answers me from her book.

“You prepare a table before me in the presence of my enemies; you anoint my head with oil; my cup overflows. Surely goodness and mercy shall follow me all the days of my life, and I shall dwell in the house of the Lord my whole life long.”

I give her a gentle smile; then nod my agreement. Her body relaxes, and the tears that once pressed hot behind her eyes now roll down her cheeks. She consents to the remainder of her workup. We both realize that even though we grew up in different cultures and have different spiritual beliefs, we speak in the same tongue.

An illness or accident frequently generates expenses that patients do not anticipate and are unprepared or unable to pay. The sensible patient asks questions, and the sensible provider learns to answer them. Sometimes this won't be easy. Sometimes we may feel professionally and personally challenged, but in struggle we may find opportunities for growth and connection; a chance to transform the clinical encounter and offer our patient the best and most human medicine we can.

© 2014 American Academy of Physician Assistants.