This is why I am angry:

I evaluated a man in the emergency room. His wife, tired and stressed out, had brought him to the hospital for care.

They were both young twenty-somethings. They met in high school and started dating shortly thereafter. Following graduation, he conferred with her father and obtained his permission to ask for the young lady’s hand in marriage. She immediately squeaked yes! and less than a year later, they wed in holy matrimony. He worked in construction; she worked as a secretary. They were trying to save money to start a family. Neither one had health insurance.

The nurses told me that the man was unwell: “He’s really got problems.”

He was sitting on the gurney, his left hand over his left ear. A tired blue tee-shirt covered his stocky torso. He wore faded blue jeans that were a bit too long for his legs. Around his right wrist was a small, grey watch with a plastic band. He was probably four weeks overdue for a haircut. When he rubbed his right hand over his chin, the soft sound of his facial hair bristling against his skin crept out from underneath his stubby fingers.

After introducing myself and orienting them both to the interview, I asked, “What brings you to the emergency room?”

He looked up towards the ceiling, his lips muttering silent words. Both his wife and I watched him, waiting for his response.

His eyes eventually darted to my face and he simply replied, “I need to get this lump surgically removed from my chin.” He looked up again, muttered some more, and added, “God says it shouldn’t be there.”

I felt my heart sink.

“You have a lump on your chin?”

He looked up and silently mumbled something.

“Yes.”

“How long has it been there?”

More muttering. His gaze moved from the ceiling to my face.

“About nine weeks.”

He flattened his left palm against his ear and added, “It’s about the size of a cantaloupe now.”

I looked at his chin. Nothing about it resembled a cantaloupe.

The interview quietly unfolded. Things started to change about nine weeks ago. He learned that he was the Emperor of Microsoft. Satellites in space were tracking his movements through his cell phone and communicating with a worldwide network of Microsoft computers. The lump on his chin was alternatively a mark of royalty and a potential manifestation of infection. God had directed him to start building an ark and to take two types of all types of electronics on board.

He looked up again.

“I notice that you keep your left hand over your left ear. Why is that?” I asked.

“Satan is on my left,” he answered matter-of-factly—after conferring with the ceiling. “I can ignore him better if I cover my ear.”

His wife quietly picked at her fingernails.

When the interview with him drew to a close, he spontaneously commented, “I know I’m not acting the same way I did nine weeks ago.” He paused, looked up. “I can’t tell the difference between reality and fiction.” He paused again. “God tells me that this is the case.”

I nodded. He knew.

His wife then spoke in a hushed voice about his slow unravelling over the past few months. First were the references to God, then the consultations. His constant efforts to recruit other workers to help him build an ark resulted in his termination from construction. He started to barricade himself in the bathroom to test the water resistance of various materials. He turned on all the faucets in the apartment to flood the floors to model the ark that he had yet to build. Sometimes he declined to eat, as God would provide all the sustenance his body required.

“The mental health professionals have seen him three times,” she commented, referring to the sole agents in the state of Washington who have the power to involuntarily hospitalize people for psychiatric reasons. “They told me all three times that he’s unwell, but he’s not unwell enough. They said he hasn’t been a danger to himself or to anyone else, even with all the flooding and terrible things he’s said to his co-workers when they refused to help him build the ark.”

She sighed.

“He’s refused to see a doctor up until today. I don’t know what happened today—he was out walking along the waterfront—and when I asked him if he wanted to get help today, he said yes. This is why we’re here now.”

“God tells me that I’m not the same person I was. I think God is right. God likes doctors and wants you to help me today.”

I looked at him, completely uncertain what to say. However, we were all in agreement—a voluntary hospitalization seemed appropriate.

For patients who lack health insurance, one must obtain authorization from the county to voluntarily admit a patient to the hospital for psychiatric reasons. (This may also occur on other services, but I can guarantee you that no other resident or attending from those services is required to make these types of phone calls.) The screener gives authorization for the county to pass the bill from the hospitalization onto Medicaid to pay for services.

The screener asks a multitude of questions to the person who evaluated the patient to assess if the patient warrants hospitalization. Generally, patients are admitted if the clinical history supports that the patient is in imminent danger of hurting himself or someone else (where “imminence” is highly subjective and has little inter-rater reliability). Furthermore, if there is evidence that the patient has not adhered to treatment recommendations on “less restrictive” terms (e.g. outpatient care, follow-up appointments, etc.), this bolsters the case for inpatient treatment.

“I don’t see enough support to hospitalize this patient,” the screener told me. I’ve spoken to this particular screener before in the past and knew that he was sympathetic to my plea. “You haven’t told me anything that suggests that he is about to hurt himself or anyone else. However, I am going to consult with the supervising psychiatrist and get back to you.”

I waited. I was not optimistic. Yes, it was true: The patient wasn’t endorsing any suicide or homicide risks. The patient, however, was also remarkably disorganized: His (mis)perceptions of reality were directly affecting his behavior and, if no interventions occurred, his condition would only worsen.

This man and his wife were amenable to receiving help now to improve his function.

I didn’t pick up the phone on the first ring. I wasn’t hopeful.

“I cannot authorize this hospitalization,” the screener informed me. “Less restrictive options must be explored.”

When I shared this news with the patient and his wife, they both stared at me. She was shocked. His facial expression was completely blank—as is consistent with people who are psychotic.

“What?” the wife exclaimed. “Are you serious?”

Yes, I thought. Even though he’s psychotic, he’s not psychotic enough for hospitalization. Even though he’s flooded your apartment where electricity runs alive and free, he’s not unwell enough for acute intervention. Even though he’s barricaded himself in the bathroom and declined to eat due to dictums from the divine, he hasn’t harmed himself enough to warrant mental health care.

Yes—even though both the patient and his wife are requesting for help now, they cannot receive it because no one can pay for it.

Yes, only when he’s injured himself—only when there is documented proof that he has (inadvertently?) electrocuted himself or his wife—can he receive services. Only after he’s become so psychotic that he antagonizes other people to the point that they physically assault him is when he finally deserves care. Only after he’s stopped eating and drinking for a week and falls into delirium is he worthy enough to have money spent on him.

Never mind preventing morbidity or mortality as soon as possible. Let’s punish the people who are actively seeking care by withholding it from them because someone who has not evaluated the patient directly deems that they are not sick enough. Let’s only extend services to those people who may have nearly killed themselves or someone else.

Yes, I get it—everything has a price. We can’t just give free care to everyone. People argue about the costs of healthcare all the time. I get it.

What price are you putting on a human life? Are psychotic people worth less than people who are not? Does it really save any money to offer acute care to someone who is voluntarily asking for it in contrast to acute care that occurs after a potential fatality? Just what message are we communicating to people who have mental health conditions? That they’re not worth preventative care? That they’re just not worth it, period?

Is the investment of a voluntary psychiatric hospitalization—which also includes (1) establishment of health care benefits, (2) education and support resources, and (3) connection with outpatient mental health services to help prevent future hospitalizations—really unreasonable? What costs more: a voluntary psychiatric hospitalization or a medical hospitalization following a significant medical or surgical injury? (Think ICU, all the various nurses, physicians, ancillary staff, the supplies used for medical interventions….)

How can we withhold appropriate care from people who are appropriately requesting for help? Why are the opinions of evaluating physicians deemed inferior to those working for the financial establishment?

How can we as physicians ever expect our patients to trust us to provide appropriate care for them when we are essentially limited in our abilities to offer appropriate interventions?

How is this okay?

This story has a happy ending. I conferred with an attending who, in his wisdom, helped me to reframe the above arguments. I contacted the screener’s supervising psychiatrist and appealed the decision. I was able to obtain authorization for the hospitalization. We were all relieved.

“Thank you,” the wife gushed, the relief apparent in her face and body. She extended her hand, eagerly grasped mine, and shook it vigorously.

After looking up and recupping his hand over his ear, the patient said, “Thank you. God thinks this is the right decision.”