The first dying patient I saw as a medical student was a man newly diagnosed with lung cancer, a chronic smoker with now oxygen-dependent COPD. In rounds, our medical team stopped outside his room, and the learned men and women pontificated about what to do next with the man. Chemo? Radiation? Both? I pretended to listen and rubbed my chin with feigned discernment, trying to understand the conversation like any good third-year medical student. The dying man made awkward eye contact with me, and I pretended not to see him, but when I looked again, he pointed his nicotine-stained finger at me and motioned with it to come in. In the room, he motioned with his head to the white plastic bag in the corner with the hospital logo that held his belongings, and with labored and suffocating breathing, he said: “Bring me … my bag.” I happily complied like any eager-to-please student, and the man rifled through the bag, procured a pack of unfiltered Marlboro Reds, and lit a cigarette. He breathed deeply and exhaled like he was born again and a new man. “Come here,” he whispered. I leaned my face close and could smell the freshly lit cigarette and the plastic smell of oxygen, not knowing the odd-smelling and impudent concoctions could blow our faces off at any moment. “You wanna know what the cure for lung cancer is?” I waited with bated breath, thinking the man had stumbled across some new treatment our team was unaware of. “… more cigs …” And he cackled loudly, and the sound of the laughter startled the rest of the medical team. My senior grabbed me by my ill-fitting white coat that fit my tall frame like a crop jacket and pulled me away. The patient lamented to the group that he could not afford chemo or radiation and that he was still in medical debt from his hip surgery. In this post-pandemic world, it is obvious our medical system is now end-stage. And like any end-stage or hospice patient, we must ask ourselves as physicians, is any treatment of benefit? Our insurance-based makeshift and MacGyvered system, held together by patchwork, chewed bubble gum, and duct tape, must be let go. Just like a dying patient, some therapies towards the end of the disease process don’t prolong life but prolong death and suffering. I used to be a firm believer in free-market principles, it works great for getting the cheapest gallon of milk or a competitively priced car. It does not work in health care, though. It does not work for chemotherapy, surgery, or other medical interventions. There is no free market in death and sickness, patients have no choice. Well, maybe they do, death or debt. That sounds catchy, maybe it should be America’s next nation health care slogan. Insurance is good for things that are rare and catastrophic. But every doctor knows getting sick and dying is neither: They are an unfortunate and uncomfortable inevitability of life. Insurance, and by proxy the pseudo health care we have now, make no sense financially (for the patient) or ethically for that matter. It’s time to let this horrible monster we have now die. Put it in hospice, it was good in the beginning, but now it is something else and only serves a select few. If we continue with this current dying system, it will take us down. We can do better and get rid of the entire idea of “insurance.” We can make something new and novel that takes the best from both sides of the aisle, not the worst. As a physician and as an American, I am embarrassed about the monstrosity that our health care has evolved into. Every doctor, nurse, EMT, and LPN knows our system is on the verge of collapse daily. But I feel the current system will continue. There is simply too much money for private health insurance companies to make off the sick and dying, the true American way. Months later, as I was sitting at a stop light. I saw the end-stage man at the corner of an intersection, smoking and drinking from a crumpled brown paper bag. I made eye contact with him again, and I smiled, expecting some reciprocation from our near face-blowing-off experience. He glared at me, squinted his eyes with suspicion, and then gave me the middle finger. After all these years, I never understood why, but after working through a pandemic and watching the system crumble around me, I now do. Source
