agasfer (agasfer) wrote,


Довольно мрачное письмо врача из Оклахомы в номере ДжАМА от 14 марта, в котором он сравнивает свою судьбу с судьбой женщины, которая отказалась от хемотерапии, чтобы не обременять семью долгами: "У меня была хорошая страховка, [поэтому] я получил оптимальное лечение, и 5 1/2 лет спустя я не только выжил, но живу относительно нормально, хотя и вынужден продолжать лечение. У моей пациентки не было страховки, ее диагноз и лечение задержались, и она умерла менее чем за 2 года после диагноза излечимой болезни." В общем, "я жив, потому что я достаточно богат, а она умерла, т к была бедной."

Привожу полностью под катом.

What Makes a Difference

as I entered his office for my postcolonoscopy conference.
With that, I knew immediately that I had colon cancer. I
remember little else of what he said except that he had set up
an appointment for me to see a surgeon at 1 o’clock that same
Wednesday afternoon. I didn’t have time to go home so I ate
a light lunch and met the surgeon at the appointed time. “You
have a tumor about the size of a golf ball in your colon, close
to the appendix, and we’ve got to get it out of there. I think I
can work you into the schedule on Friday.”
I had the surgery that Friday. The tumor was removed,
along with a section of the ascending colon, the appendix,
and the omentum. Of the 16 lymph nodes removed, four
were positive for cancer and two spots of tumor were visible
on the omentum. That’s why it was removed.
About three days after my surgery, the oncologist came
to see me. “Since your cancer has spread beyond the colon
we would have to call it stage 4, and if we want to be more
optimistic we could call it stage 3½. In any case, with this
staging, you are eligible for a new chemotherapeutic agent
along with the usual two that are given.”
I had recovered from the surgery very nicely. And so nearly
five weeks later a port was placed just below my left collarbone
and I started chemotherapy. I was able to tolerate chemotherapy
well enough to go back to work.
I received the most efficient care possible. I was 61 years
old and had good group health insurance through my workplace.
I was a physician in a community health center.
Several months after returning to work, I saw a patient
who was my age, with abdominal pain, weight loss, and
blood in her stool. She stated that several months earlier
she had been admitted to a community hospital through
the emergency department because of abdominal pain and
weakness. In the hospital she was found to be anemic, and
her upper gastrointestinal tract was examined for ulcers.
None were found so she had been placed on iron and
encouraged to see a gastroenterologist for a colonoscopy as
an outpatient.
She supported herself by taking care of her grandchildren
so her children could work. She had several children
who lived nearby so this arrangement worked very well for
her. She delayed making an appointment with a gastroenterologist
because she had no insurance and felt she could
not afford the test anyway.
A relative who happened to be a patient of mine referred
the woman to the health center where I worked because we
could accept her as a patient and her payment would be based
on her income and the number of dependents in her household.
On examination, I found that she was anemic with significant
weight loss, blood in her stool, and a mass in her
left lower abdomen. I told her that I was concerned about
the possibility of colon cancer and that she needed a colonoscopy
as soon as possible.
The earliest appointment that could be arranged was three
months later. Prior to this appointment, I saw her once more,
and because her symptoms had worsened I was able to arrange
an earlier colonoscopy. The biopsy revealed cancer of
the colon and surgery was scheduled two weeks later. At surgery
the tumor was found to have spread into the surrounding
tissue and the liver. It was not possible to remove the tumor.
It was definitely stage 4 colon cancer. She was offered
chemotherapy but declined it. She said that she could not afford
chemotherapy, it would inconvenience her family to take
her for therapy, and she did not want to leave her family with
a large bill. She was a woman with a strong faith in God, and
this sustained her until she died about one year later.
The difference in the outcome of these two similar situations
is obvious. I had good health insurance, received optimal
care, and 5½ years later I not only have survived, but
lead a fairly normal life even though I still have cancer and
have to have regular treatment. My patient had no health
insurance, delayed her evaluation and treatment, and died
less that two years following diagnosis of a preventable and
treatable disease.

Perry A. Klaassen, MD
Oklahoma City, Oklahoma

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