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INTRODUCTION

He winced in a way that made me feel his discomfort. It wasn’t overly dramatic. It was the response of a man trying to put on a brave face and hide his pain, but—as I gently laid my hands on his belly—failing against his best efforts. This man had real abdominal pain, the kind that is impossible to not immediately empathize with. I got concerned.

“How long has this been going on?” I asked, while my mind began to immediately tick through a differential diagnosis.

“Well it probably started a year ago, but got really bad about four months ago,” this otherwise healthy-appearing, 30-something-year-old man said.

We were in a small curtained-off area in the hectic Emergency Department at San Francisco General Hospital. I was an internal medicine resident in my last year of training. I started to wonder what in the world would possibly cause somebody to wait many months with severe abdominal pain and rectal bleeding before coming to see a doctor.

I asked a few more questions, verifying that he was indeed having bright red blood with his bowel movements, had lost at least 10 pounds over the last few months, and has dealt with nausea and debilitating abdominal pain ever since the end of last year.

So, I pulled out one of my most tried-and-true questions that I had picked up during residency:

“What made you come to the hospital today as opposed to yesterday or last week?”

The answer should have surprised me.

“Well, I didn’t want to see a doctor because I couldn’t pay for it. I had to wait until my benefits kicked in so that I had insurance.”

The Emergency Department had already put him through the CT scanner prior to calling me to admit him to the hospital, to ensure that he “didn’t have something really bad going on,” which I have to admit that if you had put your hands on his abdomen you would probably think was a reasonable (if not very eloquently phrased) concern.

The CT scan showed inflammation of his colon in a pattern that the radiologist said was very likely Crohn’s disease.

His lab tests returned with severe anemia (hemoglobin of less than seven) and an undetectable iron level, revealing that the bleeding had been going on for a long time. I told him that I thought he needed a blood transfusion and a colonoscopy procedure in the morning by one of our gastroenterologists.

Then he asked me one of my most feared questions:

“But how much will that all cost and will my insurance pay for it?”

“I wish that I could answer that for you, but I really don’t know.”

Now, the thing is that I had actually spent more than the ...

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