Line in the sand

I've lately been forced to learn to practice a new style of medicine. I like to call it "no cost medical care." It may be the ultimate way to lower health care spending...make medical care (or the insurance that usually pays for medical care...or the new wrinkle, rising health insurance deductibles) so expensive that no one can afford it, so no one gets any.
It began before the economic downturn, but now, with real hard times, it's becoming increasingly common...patients can no longer afford any significant aspect of their medical care.
It began insidiously. The first few times it was only that a patient couldn't afford some screening labs, important to their care but nothing life or death.
But then, I started to notice that patients were refusing to have crucial labs or tests, ones necessary to make an important diagnosis or treatment decision. At first, I was so taken aback, even indignant, that I nearly refused to treat the patient's problem.
But after the third or fourth time, I began to incorporate this new limitation into my practice style. It was kind of a throwback to the old days. If I have only a patient's history and physical exam findings, along with a very limited set of available treatments, can I fix what ails them? Often, I could, though it wasn't easy.
On the right day, seen in the right light, if I'm in a particularly good mood, it can be kind of fun...a challenge. How to take care of patients who can barely afford coming to see me, and can't in any way afford typical testing, hospital or ER care, specialist referrals, and certainly not most common medications.
It's certainly not an optimal way to practice, though. Patients are avoiding almost all preventive care, such as mammograms, colon cancer screening, and immunizations. It's a bet that we will begin to lose in the near future as people are diagnosed with late-stage cancers and preventable diseases become more common again.
And I will miss important diagnoses or mistreat simple problems because I didn't have available the basic testing and typical treatments for many problems.
It's already happening, as patients of mine are putting off surgeries for gallstones, infections, and obvious skin cancers.
But it really hit home recently. A very dignified, polite patient came to me for treatment of abdominal pain. I reviewed their chart and found that the problem had been worked up about six months ago, when they were found to have a growth in their abdomen. While the growth may have been a sign of a number of different diagnoses, cancer was certainly a consideration. The patient had decided, due to limited funds (and no health insurance) to defer immediate surgery in the hope that they could find less expensive care in another country. Unfortunately, that option proved also to be too expensive. The pain continued, and maybe a cancer has continued to grow.
This is the line in the sand. I told this patient as much.
Treatment for this patient's problem exists. In a five mile radius from my office, there may easily be 30 doctors who could treat this patient. Definitive diagnosis with follow-up studies and surgery is a simple matter.
It is deplorable that we have a system that denies easily available care to those who need it. It says something horrible about us. It is increasingly difficult to take part in such a system.