Drying Up Of The Vine

Drying Up Of The Vine

I recently saw an elderly patient of mine. He was in his late eighties, but he stood tall and was sprightly. He was in excellent health for his age. The only evidence of his advancing years was a hearing aid in one ear.

We took care of his routine health needs. On one visit, he talked about how things change over time. I asked him how? He then told me his story.

In his younger years, he had moved to a very small town in Georgia. This town was established in 1820 and was one of the oldest towns in that area. In 1887, the railroad came through and the town boomed. People moved there and businesses were established.

In the 1920’s, this area became a favorite visiting place for the future President Franklin Delano Roosevelt. FDR loved the wide open areas and the multiple springs beneath the land. He kept visiting until his death in 1945.

This area continued to do well, with cotton mills and some manufacturing plants. Almost forty years ago, my patient opened a hardware store there. He ran it with his wife and worked every day except Sunday. Both husband and wife knew most of their customers by name and business was steady.

Unfortunately, a few years ago the main industrial plant in town shut down. This was a food processing plant, and with it came the loss of several hundred jobs. Many people moved out and businesses started shutting down.

His hardware store also started to decline. This was hastened by the opening of a large chain department store in a nearby town. My patient was getting older and the store, in his words, was bleeding money. He decided to try to sell it.

There were no offers on the store. He finally closed the store and auctioned the inventory. The town agreed to buy his building, and they used the building as a medical office. My patient was now officially retired.

He finally decided to move away from his small town and move closer to where his children and grandchildren were living. While he is much older, he remains in good health. He spoke with a little sadness of the decline of his store and his small town. His description of it struck me. He said it was like the “Drying up of the Vine”.

This was a beautiful way of expressing his thoughts. I later found out that this expression comes from the Bible; “The vine is dried up and the fig tree is withered; the pomegranate, the palm and the apple tree, all the trees of the field are dried up. Surely the people's joy is withered away”. (Joel 1:12).

After our visit, I looked up his old town. It had declined to a population of less than a thousand. However in recent times there had been a renaissance. Tourism had remained popular as many people would come to see President Roosevelt’s cabin. This fairly modest cabin was known as the ‘Southern White House’.  This term has been used for many presidential retreats, but this is probably the most modest.

Some of the old stores were renovated and antique shops were opened in them. More recently a Korean auto parts manufacturer has opened a plant in that area and the population is slowly increasing.

My patient is also doing well. He is a little bored in retirement but is content. His phrase ‘Drying up of the Vine” has stuck with me.

However it now appears that the vine is growing again!

                                    President Roosevelt's Southern White House in Georgia

The Denial

The Denial 

Health care coverage has changed these days. In the old days, if you had medical insurance, you went to the doctor, and perhaps had to pay a small co-payment. If you had a deductible, it was fairly small. Over the last few years, this has changed. Now most insurance companies have large deductibles. A deductible means that you have to pay the first several thousand dollars of your medical bills, before the insurance company will pay anything. There are also ever increasing lists of reasons for denial of payment for specific services.

This improves the insurance company’s bottom line, but the effects on the patient can be devastating. I have seen many people forego appointments and tests, simply because they found the deductible too expensive or coverage was denied. Here is one such story that I found particularly heart wrenching.

Several months ago, I was seeing a new patient in my office. He was in his fifties and came in with his wife. He had developed abdominal pain several months ago, and had difficulty keeping anything down. He had lost considerable weight of about sixty pounds and felt very unwell.

He had been to two other doctors. They had done lab work on him, but this did not show anything. A CAT scan had been recommended, but not done, as he had been concerned about both his deductible and the insurance company coverage.

When I examined him, the weight loss was very concerning to me. I told him that I too would like to get a CAT scan of his abdomen. He was concerned about the costs. I however reassured him and was fairly confident that insurance coverage would not be a problem.

My patient however was very despondent. He felt something was seriously wrong with him, but he was concerned about his high deductible and he knew that he would be unable to pay for the scan if insurance would not cover it. He was so resigned that he told me that he would prefer to die rather than go into debt that potentially his wife and four teenaged children may have to pay.

I obtained a prior approval from his insurance company and he went for his CAT scan. I still remember that day, because I got a call from the Radiology department. His insurance company had suddenly denied coverage of the scan for no clear reasons. My patient had been sent away. I was just being given a courtesy call.

I was incensed. I called the insurance company and told them right there that I was ordering the scan for possible cancer of the colon, and if the insurance did not cover this, they would be responsible for anything that happened to my patient. This was of course a possible cause of his symptoms.

The effect of this was instantaneous. The CAT scan was approved and my patient was immediately called back in to get it. Two hours later, the radiologist called me. He did have cancer. He had a large mass in his colon. Now, I was totally taken aback. This was the last thing I had wanted to find.

I immediately called my patient and gave him the news. He was more relieved at finding the diagnosis, rather than being upset. He wanted to know what would be the next step to take.
I called our surgeon that afternoon and he agreed to see him the next day. He was scheduled for surgery within a day or two and the mass was removed from his abdomen. Pathology of the mass confirmed cancer, but it was localized and had not yet spread.

My patient made rapid progress thereafter and regained his appetite and weight. He went back to work. He came to see me several months later. There was no sign of the cancer and he was doing extremely well.

I thought this was a happy ending, but it was not to be. My patient kept regular appointments with the Gastroenterologists and Oncologists and there was no signs of the cancer. About a year and a half after his initial diagnosis, he came to me with complaints of abdominal pain. I immediately repeated his CAT scan. The report showed multiple areas of cancer in his liver. He had just had a colonoscopy which was negative, so the cancer in his liver probably started at his first diagnosis but was too small to be detected at that time.

His cancer doctors could only offer him palliative care and he declined. He went into hospice care and died five months later. I will forever wonder if the delay in his initial treatment contributed to the seeding of the cancer in the liver.

There are many others that also do not end well. They have delayed diagnosis or treatment because of their high deductibles or insurance denials, and this is for people with insurance. I hope and pray that this state of affairs changes in the future.

CAT scanner