A tale of two patients.

Abstract

Two patients come to the emergency department. One flies two hours from a different state. The other drives four hours from a different county. Both seek care at our hospital for chest pain. I am the medical student who sees them both. Chest pain is one of my favorite differentials, so I see both patients, one after the other. Both are men in their 70s, with a history of a prior heart attack status post–coronary artery bypass grafts, high blood pressure, and high cholesterol. Both dread they are having another heart attack. And both describe eerily similar symptoms: retrosternal chest pain that radiates up their esophagus and is worsened by both lying flat and eating. Their workups mirror each other. EKGs show no evidence of ischemia or a STEMI. Serial troponins come back within normal limits for both. I spit out my differential to the attending: serious causes include acute coronary syndrome, which I am reassured against by the negative EKG and serial troponins. Probable and treatable causes include GERD. My differential and assessment for each patient are identical: treat both patients for acid reflux and send home with strict return precautions given normal cardiac workup. But one patient gets admitted for observation. The other is discharged home. For all their similarities, these patients couldn't be more dissimilar. One is fluent in English, the other only speaks Spanish. One is, I am told, a VIP, or “very important patient,” and the other, by implication, is not. One is a donor, endowing the hospital with a large enough gift to not only warrant being named in the hospital's donor wall, but also a direct number to contact the head of cardiothoracic surgery during this admission. The other is a receiver, eligible for means tested programs, such as food stamps, but too traumatized by the public charge, even though it is no longer in effect, to seek help from these services. I take a deep breath and ask my team, what did I miss? Why were these two nearly identical patients managed so differently? But I know the answer. I simply wish it wasn't true. Because the idea that status is a contributing factor for my patients' diverging dispositions does not sit well with me. It seems to be the antithesis to what I envisioned medicine to be as a naive third-year medical student early in my clinical training. One intern assures me they treat everyone the same. And I don't doubt they believe that to be true. Another chimes in to add that every patient should be cared for as a VIP. My chief resident directly addresses the disparities between my two patients. “It's a necessary evil when donor dollars save lives.” Donor dollars save lives. But they also harm the lives of their donors. Research suggests that "very important patients" can influence health care providers to veer from standard of care, sometimes to their detriment.1 In a profession that prides itself on evidence-based practice, this specialized treatment seems counterintuitive. I wonder what my patients would have thought if the curtain concealing all the truths behind their medical decisions was pulled back. Would my discharged patient be relieved at avoiding an unnecessary stay? Upset at not being admitted? Unsurprised in the slightest by this sleight of hand? Would my admitted patient be equally unsurprised? Was this seemingly "above" standard of care the expectation? How would they feel knowing it could be substandard instead? I didn't have to wait long to have some of these questions answered. I had been virtually following both patients, devouring the admit and progress notes for confirmation that I was right, and dreading seeing a note for the patient we discharged that would suggest something more insidious than acid reflux. Both turned out to be GERD. The patient we discharged returned to the emergency department and was admitted for another medical concern. The patient we admitted was discharged after two days, the second at the family's insistence. They did not return during the remainder of my rotation. But another VIP came to our service. One who asked not to be treated differently, one who requested to share a room at our old hospital rather than its newer, billion-dollar sister. That patient left me with these haunting words: "I want the best care."