“The pain is in my heart. I want you to send me to a heart specialist so that I can have an angiogram and have this taken care of right away.”
Stephan’s deep, subdued tones, deliberate cadence, icy eyes, and furrowed forehead made it clear that this 59-year-old black man from Oakland was accustomed to tossing aside the short end of the stick to get what he needed. His lovely younger wife Tamara looked at me anxiously. It was exactly a week before the Thanksgiving holiday.
I cautiously but firmly pushed the area along the left posterior aspect of his neck, which made him grimace. He’d had excruciating knifelike pain in his left upper chest, left neck, and left arm for almost a week now. Two days before coming into the office, he’d had a temperature of almost 105 degrees. This was his first visit to me with this problem.
“Something bad is going on here,” I confirmed. I looked back and forth between their attentive faces. “But the problem’s in your neck, not your heart.”
Stephan didn’t buy it initially, but after ten minutes of explaining why inadequate blood flow to the heart causes intermittent symptoms, without significant fever or focal tenderness, he understood that the problem was in his neck. I could not persuade him, though, that this was an emergency and that he needed to go to the hospital to get an MRI scan of his neck. I knew he was insured through a health maintenance organization. It would be difficult for me to get approval for a prompt MRI, because the next week would be cut short two days due to the holiday. They would, however, allow an urgent MRI to be ordered through the emergency department.
“It’s not my heart, so I’m not going to the hospital to wait for five hours in the emergency room,” he concluded. We wouldn’t be negotiating this any further, despite my contention that he might have a life-threatening cancer or infection affecting the area next to his spinal cord.
I reluctantly wrote out a prescription for oral morphine and for gabapentin, a medicine for nerve pain, to help him get through the night, and they agreed to come back to the office the following day, or to the emergency room before that if anything changed for the worse.
Because I split time between offices in Alameda and Berkeley, I was not in the Berkeley office the next day when he came back, so his appointment was with David, the other family practice physician in our office. When David told him again that this was not a situation where it was safe to wait for insurance authorizations, Stephan grabbed his medical chart from David’s hands and stormed out the door. He was heading to the hospital, just a block from our office.
Carol, our clever, lovable office manager with a mischievous grin that reminds me of my five-year-old daughter, and Kathryn, a high-level administrator in our practice, saw him leave. They devised a plan. They went to the emergency room, where Carol was able to retrieve Stephan’s office chart. They safely delivered it back to its home location, and it seemed our mission had reached a successful conclusion.
Stephan ruined that illusion a short time later when he appeared again in the Berkeley office waiting room, having been thrown out of the emergency room for what had been perceived as belligerent behavior. I wondered why someone couldn’t have seen that extra efforts should have been made to help this man experiencing torture-level pain. Meanwhile, Carol took the time to calm Stephan down enough to escort him back to the emergency room.
Our local emergency department consistently impresses me with the high level of compassionate and competent care they give my patients, but not this time. When to my surprise and horror Stephan surfaced again with his wife Tamara the following Wednesday morning, heavily sedated but otherwise untreated, I knew we would have to assemble our collective machetes and bulldozers. Carol and Reggie, our designated referral chief and premedical student, whose dry sense of humor and fondness for pranks keep us all on our toes, started making phone calls to the MRI facilities listed under Stephan’s independent provider association’s (IPAs) radiology providers, knowing that we needed to find a facility that would squeeze in this one-hour test on the day before Thanksgiving. The IPA informed us that we had to find a facility before they would give us an authorization, while the facilities expected us to give them the authorization number before they would schedule the test.
The closest facility to our office said that their staff would be leaving early, at 3:00 p.m., and they did not have any openings before then. Over the ensuing two hours, we found two facilities that would do the test. But each time, when we called the IPA for authorization, they informed us that, although each facility was on the approved list of providers, they could only do X-rays, ultrasounds, and CT scans for patients in the IPA. They were not covered for MRI scans. The only place we could get an authorized MRI scan turned out to be the one that was closing at 3:00 p.m.
Reggie finished explaining this to me at 2:40. I knew I had only one hope, and that was to call the radiologist at the local facility.
“Jim,” I pleaded, after describing my patient, “I know you all want to go home, but sometimes we have to do what needs to be done, and you are the only person who can help him right now.”
“Can he get here in five minutes?”
I knew Stephan was at a pharmacy just down the street.
“Yes,” I said.
“Send him over.” Reggie called the IPA and got the authorization. Carol called Tamara. Ninety minutes later, Jim paged me.
“He has an eight-centimeter abscess right next to the left side of his lower cervical and upper thoracic spinal cord,” Jim explained. “He needs immediate surgery.”