After Insurance Issues Are Settled

There's a new man here to see you, said Joyce, the nurse at the Toronto homeless shelter where I see patients once a week. He just had his leg cut off. Says it hurts a lot. I stepped out of my small examining room and into the hallway of the shelter. Micah was sitting quietly in a wheelchair, his pants already rolled up to reveal his right leg, which had been amputated below the knee. He was a brown-skinned man in his late 50s. He looked tired, and his black hair and mustache were streaked with advancing lines of gray. I introduced myself and asked him what the problem was. My leg's paining me again where they did the operation, he said. And it's leaking. I rolled Micah into the examination room and removed the dressing covering his stump. The tattered gauze had not been changed since his discharge from the hospital 6 days ago, and it was soaked with a thin, yellowish fluid. The dressing emitted the unmistakable, nauseating odor of infection. A line of surgical staples surmounted the reddened and tender ridge of his wound, the edges of which were beginning to pull apart at one end. Micah told me his story. Almost 2 decades ago, he had left his home in the Caribbean and had come to Canada on a temporary visitor's visa. He had stayed on since then, working full-time as a cook at a small restaurant and living in a basement apartment. He smoked cigarettes but didn't drink alcohol and had never used street drugs. About a year ago, Micah had noticed that he was thirsty all the time and went to see a doctor, who had diagnosed diabetes and prescribed him an oral hypoglycemic medication. The doctor's bill was not too bad, but the cost of the pills was more of a problem. After 3 months, Micah thought to himself, Why am I buying this for so much money when I'm feeling okay? He stopped taking the pills, and he never went back to see the doctor. (Canada has a system of universal health insurance that covers almost everyone, including most homeless people, but this coverage does not extend to undocumented workers.) Two months ago, Micah's toes and then his entire right foot began to turn dark purple. After procrastinating for weeks, he finally sought care at the emergency department of a local hospital. By then, the gangrene was far advanced. Dr. Cabot, the admitting surgeon, had no choice but to amputate. Micah lost his apartment while he was in the hospital, as he had no income and little savings. In any case, access to his basement apartment had become impossible now that he was in a wheelchair. Homeless for the first time in his life, he had been discharged to the large downtown men's shelter in which we were presently sitting. When you were discharged, what arrangements did they make for your dressing changes and follow-up? I asked Micah. Nothing, he said. Nothing? I was both surprised and skeptical. They didn't give me nothing but this, he said, producing a neatly folded piece of paper. It was a hospital discharge form, the preprinted kind with spaces to fill and boxes to check. Under the section for Follow-Up Appointments, the spaces for Date and Time had been left blank. In the area for Comments, it read: Follow-up with Dr. Cabot after insurance issues are settled. I stared at the paper with a slight sense of shock. As an American trained in general internal medicine, I had seen many patients without health insurance who had delayed seeking care until their condition had become unbearable. Although I knew that uninsured patients might not be welcome at many hospitals and doctors' offices, it had not occurred to me that someone would have the temerity to tell a sick patient to stay away until he had insurance. Your leg has an infection, I told Micah. You're going to have to go to the hospital right now to get it taken care of. Yeah, I was thinkin' that might be the problem, he replied calmly. I quickly wrote a brief note summarizing Micah's condition, while the staff at the shelter arranged for a taxi to take him to the emergency department of the hospital where I work, only a few blocks away. Five hours later, I received a call from a somewhat irritated-sounding surgical resident. We think it would be better if this gentleman were transferred back to the hospital where his original operation was done, he said. I told him that this would probably be difficult to arrange. Okay, we'll see what we can do, came the reply. The next morning, Joyce called to notify me that Micah was back at the shelter. The surgeons had performed an incision and drainage of his wound in the emergency department, prescribed oral antibiotics, made arrangements for regular dressing changes, and instructed him to return for follow-up in 5 days. Although Micah took the antibiotics faithfully, his infection worsened, and only 2 days later, he had to be admitted to my hospital. He stayed for 12 days of intravenous antibiotics before returning to the shelter. An orthopedic surgeon and an infectious disease specialist saw Micah once a month at the outpatient clinic of the hospital, a Catholic institution with a long-standing tradition of caring for the poor. I monitored Micah's progress during my weekly visits to the shelter. He took a prolonged course of oral antibiotics, and over the next 2 months his stump healed nicely. The shelter managed to arrange for the cost of his medications to be covered, and his diabetes came under reasonably good control. As his clinical condition stabilized, my encounters with Micah became less frequent. He moved into a smaller shelter, which provided him with some welcome relief from the noise and chaos of the shelter where we had first met. A year has passed since Micah's amputation, and he is still homeless. Despite his situation, he is unfailingly pleasant and cheerful whenever I see him. He has not yet been fitted with a leg prosthesis because of his lack of insurance, but the staff at the shelter is trying to gather enough donations to buy one for him. Meanwhile, Micah gets around reasonably well in his wheelchair. For people like Micah who lack health insurance, every illnessa nagging cough, a child with a high fever, or the silent creep of diabetespresents a wrenching dilemma: Seek treatment and face the resultant bills, or delay treatment and hope that the problem will take care of itself. As physicians, we eventually see the patients who have chosen the latter option after they've experienced a resulting health catastrophe. However, we are insulated from the plight of others who have made the decision to forgo health care. Perhaps they have heard a clear, although unspoken, message: Our care is reserved for only those who can afford it.