Case One: Leighton Factor

Respiratory infection & ER Visit November 2019 Hip pain & limping Went to sports medicine physician & misdiagnosed with sports injury Physician suspected deep venous thrombosis Circumference of right thigh grew significantly larger than left thigh A few days later, pain extended from hip into entire leg Immediately went to imaging facility for ultrasound of leg, which confirmed DVT Went to ER, where medication was administered & prescription for anticoagulant was written before discharge Still in excruciating pain two days later, went to different hospital Established care with a PCP for continued treatment and monitoring Discharged from hospital with increased dose of anticoagulant Received CT scan at second hospital, showing a DVT that was more than 2 feet long + got admitted to the hospital Got a referral to a hematologist for definitive diagnosis Had to wait for diagnosis until finished 3-month anticoagulant course Three months later, got another CT to check clot & look for anatomical defects Post-operative follow-ups with hematologist & surgeon Had outpatient surgery about a month later with local anesthesia Had a consult with a cardiovascular surgeon to plan for surgery to place a stent in iliac vein Six months taking an oral anticoagulant Then switched to aspirin only January 2021 Diagnosis with Factor V Leiden mutation, antithrombin III deficiency, protein C deficiency January 2021 Finally could get labs for a definitive diagnosis had 16 vials of blood drawn

Leighton Factor is a 25 year-old, previously healthy first year medical student. A classmate noticed she was limping and she noticed some hip pain, but didn’t think much of it. A few days later, she called her school’s nursing hotline. She was directed to a sports medicine office, where she was diagnosed with a sports injury. The next day, she drove 3 hours to go home for Thanksgiving. The pain had progressed and now emcompassed her entire leg.

Her right thigh diameter was notably larger than the left. She had pain on passive stretch, and she was unable to walk. She made an appointment with her primary care physician (PCP), who was concerned about a deep vein thrombosis (DVT) but did not have an in-house ultrasound. Leighton was sent to an imaging center, where an ultrasound confirmed a DVT. Her parents took her to the ED, where she received an intravenous blood thinner (enoxaparin), a prescription for an oral blood thinner (rivaroxaban), and instructions to follow up with her PCP.

Two days later, her pain worsened, and her leg continued to enlarge. Her parents took her to another hospital, where she was admitted. She received pain medication, an increased dose of blood thinner, and was discharged the next day. At that point, the clot was 2 feet long, but the increased medications helped prevent it from growing.

After 3 months of blood thinners, she received follow up imaging to look for structural causes of the DVT and to check on the size of the clot.

A couple months later, more imaging confirmed the clot was stable. She met the cardiovascular surgeon who ultimately placed a stent in her iliac vein.

After the surgery, she had follow-up appointments with her surgeons, a blood specialist (hematologist), and her PCP, as well as numerous trips to the lab for monitoring.

She received bills from the two emergency rooms, the two sets of emergency physicians, the radiologist who read her imaging studies, the surgeon, the hematologist, and her PCP. She was surprised to see that all of the charges were broken up by the different provider types. She had to make a lot of phone calls to her insurance company to be sure that she received the correct benefits. Because she couldn’t afford to pay all the bills at once, she also had to set up payment plans with each provider.

More than a year after this all started, she is recovering well – and surviving medical school! However, she is still paying off and trying to make sense of her medical bills. The experience increased her understanding of what patients go through when they get billed for the services physicians provide.

Click on portions of her bill below to see what Leighton has learned about her medical bills.

The authors of this site would like to acknowledge Natalie Weston, who graciously shared her medical journey and associated hospital bills to be represented on this site. Her story has been adapted and portrayed as the case of Leighton Factor. We share these details with her permission.


Adapted from case written by Dr. Amit Pahwa and Dr. Danelle Cayea (John Hopkins University School of Medicine). Edited by Michelle Chen, Emma Williams, Nicole Xu, Kiersten Gabaldon, and Dr. Greg Seymann (UC San Diego School of Medicine).

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