Demystifying Medicine One Month at a Time

Horseshoes & Hand Grenades

Well, it was close.

I was fortunate to be selected as a finalist in a national essay contest about the frequently-outrageous-and-almost-never-transparent costs of obtaining medical care.

But I didn’t win any of the big prizes. Out of eight finalists, I got an honorable mention.

It’s not the destination…it’s the journey.

And being selected in the first wave still feels good–like someone out there is listening.

I wrote about this issue previously (complete with embedded video!). The scientific paper that discusses the research we did has been accepted for publication and will be out very soon (look for an update on this blog and a tweet or two).

Here, then, is the narrative version of what inspired the work and how we did it:

[All names and identifying features of characters in this story have been changed.]

Nora, a third year medical student, came to me in moral distress.

Ms. DiFazio, one of the hospitalized patients on her Internal Medicine rotation, was frightened to undergo an invasive (and expensive) medical procedure: cardiac catheterization.

The first year doctor [‘intern’] with whom Nora was paired, Dr. White, vented to her:

“These patients come to us seeking our help and then refuse what we have to offer them,” Dr. White steamed.

At the bedside, the intern demanded to know why Ms. DiFazio refused the procedure. When no reason beyond “I don’t want to” was offered, Dr. White told Ms. DiFazio that there was no longer cause for her to stay in the hospital.

By declining the procedure, Dr. White informed Ms. DiFazio that she would have to sign out ‘against medical advice’ (AMA). To signify this she would have to acknowledge that leaving AMA could result in serious harm or death. In addition, Ms. DiFazio would bear responsibility for any and all hospital charges incurred and not reimbursed by her insurance due to such a decision.

“The threat of a huge hospital bill got Ms. DiFazio to stay and take the test,” Nora related.  “It just seems so wrong to bludgeon a patient this way. Can it possibly be true?”

I’d been out of medical school myself for eight years at that point; until then I’d never heard that patients who sign out against medical advice risk bearing the costs of their hospitalization. What about a patient’s freedom of choice, or as we like to call it in medicine, their autonomy?

I told Nora I didn’t know, but was determined to find out. Ethically, the notion that patients in the hospital must do our bidding or pay the price seemed dubious. Yet in a world of co-pays, deductibles, and ‘preexisting conditions,’ a mere grain of plausibility made this idea seem vaguely credible.

I asked around. To my surprise, many fellow attending physicians told me they had been taught the very same thing. My colleagues had trained at teaching institutions around the country, so I began to see this as a pervasive and widely-held belief.

I straw polled some of our residents, and like Dr. White, found that they almost unanimously believed that AMA discharges incurred financial penalties. Where did they learn this?

From their attendings.

From the nurses.

From the AMA form itself, with language stating that the patient, by signing, acknowledges financial risk.

We needed to find the truth.

Colleagues helped us sift through nearly ten years of AMA discharges from our teaching hospital. And though the results are in press at a medical journal, I can say that out of hundreds of cases of AMA discharges over a decade, in only a handful was the bill was not paid—and that was invariably due to ‘administrative issues,’ not because of the AMA discharge.

I also thought it important to go to the source: I called the insurance companies themselves. I talked with VPs and media relations people from several of the nation’s largest private insurance carriers.

Each of them told me that the idea of a patient leaving AMA and having to foot their bill is bunk: nothing more than a medical urban legend.

They were glad to tell me so, as this was a rare occasion of insurance companies looking magnanimous. One director went so far as to poll his company’s own medical directors—a half dozen of them–and found that several of them had been taught and believed the canard about AMA discharge and financial responsibility. He was happy to set the record straight.

So patients and doctors beware: The next time you or your loved one has decided that it’s time to leave the hospital, don’t let us doctors coerce you into staying by threatening you with the bill.

It simply isn’t true that leaving against medical advice makes it fall entirely upon your pocketbook.

Future Noras should feel empowered to set the record straight with their interns and residents. Most of all, the Ms. DiFazios of the world won’t have to submit to procedures that they don’t wish to undergo.

You can read a press account about the contest winners here. And if you have a story about the costs of care that you’d like to share, I’d love to hear about it.


  1. That is huge. Important. Thank you for sharing!!!

  2. Thanks for sharing. And Mazal tov on the honorable mention…your articles are excellent. I’ve been in health care for 35 years, and I treasure your insight.

  3. Great work, as usual. Congratulations!

  4. I don’t understand. Aren’t patients expected to pay for costs of their hospitalization that are not covered by insurance whether discharged after taking all recommended tests/treatments or refusing them and are discharged against medical advice?

    • glasshospital

      January 22, 2012 at 12:33 pm

      Yes-if there are co-pays or deductibles beyond what’s covered by your insurance, you’re still responsible for them. Whether you’re discharged against medical advice or not.

  5. With the kind of essay that you’ve written, an honorable mention isn’t enough. Well for me, you should get more than that. Maybe I’m telling this because I wasn’t able to know other entries but still, I think you’ve given justice about the topic. Costs of obtaining medical care is a critical issue and I find your essay a good one.

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