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Reconsidering patients who go AMA

January 2010

The call comes in from the floor: “Mrs. Jones is leaving AMA. Can you come sign the paperwork?” As hospitalists, we encounter this scenario almost every week. Most of us respond the same way, trying in earnest to convince the patient to stay.

We spend our whole careers as physicians delivering advice, from “take two aspirin and call me in the morning” to “eat an apple a day and you might keep me at bay.” However, rarely in medicine are we forced to be so pedagogical, if not downright self-righteous, as when we tell patients that they must reconsider their decision to leave.

We start with a reasoned discussion and varying degrees of patience and vigor, but eventually all recalcitrant patients are read the standard AMA Miranda Rights. “You have the right to leave AMA. If you do, your decision cannot and will not be held against me.” Usually, AMA Miranda Rights are preceded by, “Where are you, who are you, how old are you and who is the president?” We wrap up with, “Do you understand that you could die or suffer a serious medical injury if you ignore my advice?”

And then it is, “Adios.” Our internal emotional response, depending on the patient and daily circumstance, varies from frustration to outright anger. “I have done all I can do, you have refused my advice, I have 15 other willing patients to see, I say good day sir!”

Recently, though, I have had cause to rethink my relationship to the AMA patient. It turns out that the number of patients leaving AMA between 1997 and 2007 jumped 39%, while the total number of admissions during this period rose only 13%.

And this was before the recession. Given the current downturn, the median household income fell to it lowest level since, you guessed it, 1997. In a direct correlation, poverty jumped to an 11-year high.

Even more data: The uninsured and Medicaid populations accounted for nearly half of all AMA discharges, but less than 20% of all other stays. And AMA discharges were 2.7 times more likely to occur in patients living in the poorest communities than in the wealthiest. If that was the case as of 2007, I can’t imagine how bad it will be when more current data emerge.

I certainly don’t need data to tell me that I have been seeing a 100% increase in the number of patients saying, “How am I a going to afford this, doc?” Recently, I had this unfortunate first: After a surgeon asked me for a medical consult, the patient asked that I not evaluate her, for fear of my professional fee.

And for many hospitalized patients, the ever-perplexing observation status causes tremendous angst as well. For some, this designation leads only to larger copays to their insurer. Another recent case in which a patient presented for chest pain found him contemplating leaving AMA for fear of the observation bill. When he “ruled in” and qualified for inpatient status, there was palpable relief. Seriously, what does it say about our health care system when patients are relieved to know that their troponins are positive?

What to do? The AMA patient is clearly emblematic of larger health care problems. Hospitalists’ options are limited when trying to help those who are driven from the hospital due to being more afraid of financial consequences than of medical complications. Perhaps all we can do at present is be thankful that no insurance or copay is needed to ensure that patients receive our compassion and empathy.