Josiah Yoder often came to our Ohio emergency department straight from the fields, still wearing boots caked with mud and manure. He wore sturdy black pants and suspenders over his blue shirt, which always showed signs of sweat and heavy wear. His face was mostly obscured, hidden as it was behind a thick, full beard and a wide-brimmed black hat. He was so quiet that we often overlooked him in the waiting room. But everyone knew him, and as soon as they saw him waiting he was escorted back to one of the cardiac rooms.
Mr. Yoder was an Amish farmer who suffered from periodic flare-ups of his PSVT. He knew all the tricks for breaking it on his own. But some times he just couldn’t do it. When that happened he would check the cash jar that he kept in the kitchen, then call one of his non-Amish neighbors who owned a pickup truck. He always offered to pay his neighbor for his trouble, but I suspect that very little money ever exchanged hands between these long-time friends. His neighbor would then bring Josiah to the ED where he would sit patiently in the waiting room until it was his turn to be seen. Whatever distress he was in at the moment his demeanor never changed.
The first time I met Mr. Yoder I was just a few years out of training. Our group of young EM trained specialists had taken over the ED contract of a group of generalists who had been at the hospital for years. So when Mr. Yoder saw me, he questioned me in his thick Dutch accent about my education and experience. After satisfying himself that I was qualified, he explained that he was paying in cash and didn’t want anything more than was absolutely necessary to take care of his problem. He gave me his history in some detail. What I couldn’t get from him, I gleaned from the fat chart that came up from medical records. Yep, he had PSVT, just like he told me. And he required synchronized cardioversion about once every year or two. He had been offered ablative surgery many times. But he considered how often he required cardioversion and decided that the cost of surgery wasn’t worth it.
Despite the fact that he had an active lifestyle and no cardiac risk factors, I explained to him I couldn’t guarantee that he hadn’t had a small heart attack without a full set of cardiac enzymes. I emphasized the fact that the stress of his prolonged rapid rate could put him at risk. He was used to reading between the lines and got my CYA message loud and clear. “Don’t worry, doctor,” he said in deep tones as he patted my arm with his worn hand. “I won’t sue you if something happens to me. Just shock me with the paddles and I’ll be on my way.”
“OK,” I said reluctantly. Turning to the charge nurse I ordered my usual preparation for conscious sedation.
“Oh, that won’t be necessary,” he said. “It only hurts for a second or two. It feels like a horse has kicked ye. But then it’s over real quick. I don’t need any of yer IVs or medicine.”
Surprised, I looked around to see that the charge nurse hadn’t even started with the IV prep. Instead, she gave me a knowing look and said, “He never uses any sedation.”
“Really? You just shock him and send him on his way?” She just gave me a contorted tight-lipped smile and shook her head as if to say ‘That’s right’.
As I took a moment to reassess the situation I noticed that there was a little crowd of Amish farmers starting to gather in the waiting room. “What’s going on out there?” I asked the charge nurse. She seemed to be the only one in the room to have been in this situation before.
“Oh, they’ve come to say a prayer for Josiah...and to pay the bill.”
“He wasn’t kidding was he. He really expects to pay the bill before he leaves.”
“He will pay for what he can. And if he can’t cover it all they will pay the rest.”
“Really?” I was incredulous. As a part of the administrative team I had gone over the financials of our groups contract with the hospital. On the whole we only collected about fifty per cent of what we billed. But this man was going to pay the full price of what I billed for my services. And he was going to pay it in cash...that day.
And as a final note, at the end of the day, Mr. Yoder’s bill was a fraction of what would normally have been charged for that diagnosis.
At the time I thought of Josiah Yoder as merely an interesting anachronism, a good story to tell at dinner. But now, as I grow older and internalize the broader scope of health care in America, I see that this man embodied much of what is missing in the health care debate.
Mr. Yoder embodied the essence of preventative health. His religion led him to a vigorous lifestyle absent some of the biggest blights of our society, namely drugs, alcohol, and tobacco. While society isn’t going to embrace the Amish religion in large numbers, we can learn that public social pressure is the best and cheapest way to change lifestyle habits.
Second, despite his humble surroundings, Josiah was not ignorant of his true health needs. He didn’t come in for a hang nail. But he didn’t die in the field either, having neglected to seek appropriate medical care. He had become appropriately educated as to important warning signs and symptoms. Mass media could be used for this purpose, but because media is driven by money, the majority of education is about erectile dysfunction, overactive bladders, and insomnia. I’m so tired of hearing commercials tell the viewer to “Talk to your doctor,” I could scream. “I don’t want to talk to you about your overactive bladder. And if you can’t sleep, TURN OFF THE TV!”
Third, Josiah embodied the sense of responsibility that comes with communal spending. He felt an obligation to his neighbors not to overspend on his health care. His money from the mason jar was for birthday gifts. And his neighbors, though generous, had needs of their own. So he wasn’t about to spend his money, or theirs, on over priced or unneeded care. With insurance, patients have the idea that they are spending the money of some faceless company. Or worse, with public insurance, some feel that their health care is a right, paid for not from their own taxes, but by ‘all those rich people.’
Doctors aren’t above feeding from the public trough either. But in Mr. Yoder’s case, I felt a sense of responsibility to him and his neighbors. I felt obligated to inform him of his real needs, but not to exaggerate the risk. And I wasn’t about to charge him for something he didn’t need.
And finally, Mr. Yoder represents the bond of trust that can exist between patient and physician when oppressive fear of litigation is taken off the table. I knew I could inform him of his risk, treat him as I would a family member, and not fear the result of some unforeseen bad outcome.
As we look at health care reform in the coming months, I ask readers to take a lesson from a simple Amish farmer and look long and hard at the elements that make up patient driven, cost-effective, quality care. We must be a society that is not afraid to put social pressure on its members to observe healthy lifestyles. We must appropriately educate our patients as to their real and perceived health needs, but bring them into responsibility for their own care decisions. Further, we must find ways to encourage personal responsibility in health care spending from the first dollar of care. And we must protect society from the indirect costs of overtesting and overtreatment due to the fear of litigation.
We can deliver quality care for less cost. The key concepts are so simple. An Amish farmer figured them out twenty years ago.