The Cost of Medicine

It is obvious that the patient is dying. She is 92 years old with “multiple medical problems”—so many that my tired intern mind can barely list them on morning rounds. “History of metastatic colon cancer, diabetes, advanced dementia, congestive heart failure …” But the family wants everything done—so we do our job efficiently and thoroughly. The attending physician recommends an MRI to clarify the diagnosis of the patient's sudden limb weakness, and I write the order down, then initial it. It feels routine now, this mundane ordering of expensive tests with no questions asked about cost. No more do I feel the sense of wonder and amazement that suffused me when I first started working as a physician in the United States. Like “Medical Disneyland”—as many diagnostic and therapeutic rides as you want. And no lines in this amusement park, Sir! So I ordered them all, the MRIs, the CTs, the PET scans—this was larger-than-life medicine.

But for some reason today, as I order the scan and look into the hazy eyes of this 92-year-old lady with a dying body that all these thousands of dollars will not save, I think back to the boy.

While a medical student in India, I was on call one night in the ER (or “casualty,” as it is known in India), asleep soundly in a room that I was sharing with the intern, when we were awakened by loud knocking on the door. The government hospital could not afford pagers, so the system of choice was Ramappa, the orderly, who was sent to wake up physicians whenever there was an admission. The method was a bit alarming, especially at two in the morning, but it was foolproof—there was no “but my pager didn't go off.” I woke up with my face and scalp …