When Common Sense Takes a Sick Day

The Palliative Lens

By Andrew Esch

My 18 year old son recently applied for a secured credit card from his bank.

For those unfamiliar with the concept, a secured credit card is essentially training wheels for credit. You deposit your own money with the bank, and that deposit becomes your credit limit. In my son’s case, he wanted to deposit $500. His credit limit would be $500. If he failed to pay his bill, the bank already had the money.

This arrangement seemed about as risky for the bank as lending someone their own lawn mower.

The application was declined.

I reread the letter several times because I assumed I was missing something. Perhaps there had been a clerical error. Maybe they thought he was applying for a traditional unsecured credit card. Maybe someone accidentally checked the wrong box.

Nope.

The bank had reviewed the application and determined that extending him credit, secured entirely by his own money…..was too great a risk.

As a physician who has spent 99% of his career in palliative medicine, I immediately recognized the feeling. It wasn’t frustration. It was familiarity.

The secured credit card rejection felt like healthcare.

In palliative medicine, we encounter versions of this absurdity every day.

A patient becomes sicker, weaker, and more medically complex, yet every step of obtaining care somehow becomes more complicated.

• More forms.

• More denials.

• More portals.

• More prior authorizations.

• More people involved.

• Clinicians spend precious hours proving they delivered care instead of delivering it.

The one thing that never seems to increase is simplicity.

The logic behind each individual rule often makes sense in isolation. Someone created it for a reason. Perhaps there was fraud. Perhaps there was waste. Perhaps there was a genuine need for accountability.

But over time, systems accumulate layers of protection against increasingly unlikely risks while becoming blind to the realities directly in front of them.

• My son has $500.

• He wants to give the bank $500.

• The bank would hold the $500.

• If he fails to pay, the bank keeps the $500.

  
  

Yet somehow this transaction was deemed too dangerous.

Healthcare does this too. We create processes to protect against rare exceptions and end up burdening the overwhelming majority of people who are simply trying to receive care.

We become so focused on preventing the possibility of misuse that we make appropriate use nearly impossible.

In palliative care, I often ask a deceptively simple question:

“What problem are we actually trying to solve?”

It is remarkable how often that question cuts through complexity.

• What problem was being solved by declining a secured credit card application backed entirely by the applicant’s own funds?

  
  

• What problem is solved when a dying patient waits days for approval of a medication?

  
  

• What problem is solved when clinicians spend more time documenting care than providing it?

  
  

Sometimes organizations become so committed to following a process that they lose sight of the purpose of the process.

But healthcare’s absurdities do not end with bureaucracy. There is another layer we are often reluctant to discuss.

Money.

Not healthcare economics. Not responsible stewardship of resources. I mean the uncomfortable reality that some of the irrationalities we tolerate persist because they are profitable.

The credit card denial was likely an example of bureaucracy gone wild. A system became so focused on managing risk that it lost sight of common sense.

Healthcare is different.

Some of our absurdities are not accidental. They generate revenue.

• When a patient receives a surprise bill, someone benefits.

• When a medication that costs pennies to manufacture is sold for hundreds or thousands of dollars, someone benefits.

• When patients and families spend weeks navigating denials, appeals, authorizations, and administrative barriers, there are organizations whose business models depend on those barriers existing.

  
  

The uncomfortable truth is that many inefficiencies in healthcare survive not despite their cost, but because they create value for someone within the system.

What troubles me most is not that greed exists. Human beings have always been motivated by money.

What troubles me is how effectively healthcare has normalized it.

We have become accustomed to seeing financial incentives masquerading as clinical decisions.

• We tolerate hospital systems competing for market share of the most profitable areas of medicine ( e.g. orthopedic surgery) while communities lack essential services.

  
  

• We tolerate insurers reporting record profits while patients ration medications and suffocate in paperwork and denials

  
  

• We tolerate pharmaceutical pricing strategies that would be considered outrageous in nearly any other sector.

And many of us, including clinicians, participate in the system every day. That is the part that deserves reflection.

Complicity rarely looks like villainy.

More often it looks like exhaustion.

We are busy. We have patients to see, charts to complete, inboxes to manage, metrics to satisfy, and families to support.

We learn to work around problems rather than confront them. We become experts at navigating dysfunction instead of questioning why it exists.

Palliative care places us in a unique position to see these contradictions because we spend our days focused on what matters most.

At the bedside, the gap between what matters to people and what matters to institutions becomes impossible to ignore.

• Patients never tell me they wish their care involved more administrative complexity.

• Families never ask for additional prior authorizations.

• No patient or caregiver looks back fondly on the three days suffering in pain waiting for the pharmacy to get their pain medicine in stock.

People want comfort.

• They want relief from suffering.

• They want honesty, dignity, and time with the people they love.

Yet we have built systems that too often prioritize process over purpose, revenue over value, and metrics over meaning.

One of the greatest lessons palliative medicine has taught me is that common sense is not nearly as common as we would like to believe.

Systems frequently reward consistency over wisdom, procedure over judgment, and compliance over outcomes. The result is a world in which a bank can reject someone for borrowing against their own money and nobody involved finds that particularly strange.

Healthcare contains contradictions just as glaring. We have simply stared at them for so long that many of us no longer see them.

One of the responsibilities of palliative medicine is to ask difficult questions when everyone else has accepted the status quo.

• What are we doing?

• Who benefits?

• Who suffers?

• What problem are we actually trying to solve?

And perhaps most importantly, when did we become comfortable with systems that confuse complexity with value and profitability with purpose?

The answers may be uncomfortable.

But every absurdity begins when people stop asking questions.

And every meaningful improvement begins when someone finally does.