December 20, 2010
It Was Benign, but Almost Killed Him
By JENNIFER S. CHANG, M.D.

William Siewert almost died from an enlarged prostate.

Not prostate cancer, just a “benign” enlarged prostate. He is yet another example of the people who fall victim to our currently broken health care system. He agreed to share his story in the hope that someday cases like his would be rare exceptions.

Mr. Siewert, a 61-year-old native of San Francisco, had been living in Idaho for the past 10 years to care for his disabled girlfriend. He had to give up his job as a truck driver — and along with it, his medical insurance — but he did so willingly so his girlfriend could remain in her home as long as possible.

He had started noticing urination problems five years after he moved to Idaho. His urine stream had gotten weaker, and he had to get up frequently at night. Finally he went to see a urologist, who told him that he had benign prostatic hyperplasia and that his prostate would need to be “cut out.”

Unable to come up with $10,000 for surgery, he was given a rubber tube and instructed to insert it into his penis twice a day to empty his bladder.

He left the urology clinic dejected and never returned. Instead, he found a small free clinic two hours away. There he was given a drug to try to shrink his prostate.

The medicine seemed to help, but because of the long drive he had trouble returning for follow-up visits. He continued to empty his bladder with the rubber tube. He was constantly nauseated, so much so that he lost 50 pounds.

Finally, Mr. Siewert’s girlfriend persuaded him to return home and seek care through Healthy San Francisco, a program established in 2007 to make health services accessible to uninsured San Francisco residents. His sons helped bring him back, and he came to our county hospital’s urgent-care clinic for his first comprehensive evaluation in many years.

The evening after his visit, the laboratory found that Mr. Siewert’s potassium levels were dangerously high. A series of increasingly frantic calls to his home went unanswered, and finally the police were sent over. Mr. Siewert had simply been sleeping and agreed to come in for further evaluation.

His kidneys had failed. They had probably been failing over the course of months, if not years. After multiple blood tests, urine tests, imaging studies of his kidneys, and discussions with nephrologists and urologists, we concluded that the kidney failure was a direct result of the prostate enlargement. The gland had simply been too big for too long — he was unable to empty his bladder sufficiently, even with the rubber tube, and the whole system backed up until his kidneys became swollen and did not function.

For those who worry about the cost of the new federal health law — an estimated $938 billion over 10 years — it may be instructive to compare the costs of Mr. Siewert’s treatment options.

If the medications to shrink the prostate had been successful, they would have cost just $200 a year. If not, surgery to trim away extra prostate tissue would have cost $10,000.

That sounds substantial until you contrast it with the actual cost of the medical care he received: $44,500 for his four days in the hospital, $72,000 for one year of dialysis, and $106,000 for a possible kidney transplant with lots of medicines to prevent rejection. That adds up to more than $200,000 — at least 20 times the cost of early evaluation and prevention.

Furthermore, there is the cost of spending five hours in dialysis three times a week, the cost of a decreased life span with kidney failure, the cost of increased health risks with a lifetime of a suppressed immune system.

The price of Mr. Siewert’s quality of life? Impossible to estimate.

Dr. Jennifer S. Chang is a resident in internal medicine at the University of California, San Francisco. This essay was written as part of the university’s Partnership for Physician Advocacy Skills program.

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