Last August, Rich Smith was at the peak of his career. He was being groomed as the next chief executive officer of Intermountain Healthcare's urban central region. He and his wife, Kristy, had just returned from Peru, where they'd floated down the Amazon and picked up son Christopher from an LDS mission.
Then tests showed an aggressive brain cancer was sending tendrils throughout his skull. It would be, doctors said, unstoppable.
Two decades ago, when Smith was a midlevel administrator overseeing heart care, he had turned down a patient whose one hope was a transplant. The man didn't meet all the requirements — clinical factors, family support, ability to follow through. The man also had no source of the anti-rejection drugs he'd need forever.
The money, Smith decided regretfully, would do more good helping a broader base of patients, like kids who needed immunizations or women who needed prenatal care or mammograms.
"But Mr. Smith," a reporter protested, "you're condemning that man to die."
Looking into the TV camera, Smith spoke the philosophy that guided his decisions: "I think I have to think of the higher good."
Dying hasn't changed his mind about that. He is now that individual patient, his time measured in minutes and days and, possibly, weeks. He is a man with one foot in the mechanics of the health-care system and the other in the realm of treatments and bills and predictions.
Coming to terms
When he was diagnosed, surgeons removed the 30 percent of the tumor they safely could, to buy him time with Kristy and their three children and grandchildren. It wouldn't be long, the doctors said.
He was battling back from the surgery when he had a massive stroke on Thanksgiving night, and intensive rehab couldn't restore what he had lost. "The stroke was what it was. The cancer is what it is," Smith says — a bad combination.
So the man who'd climbed the rungs from respiratory technologist to hospital administrator at Utah Valley and McKay-Dee to CEO of Logan Regional Hospital and finally chief operating officer of IHC's entire urban central region retired — "the hardest decision of my life," he said.
Still, his family spent Christmas in Sacramento, Calif., as always, with his wife's twin, Jody Price, and her husband Ben, who also has a terminal cancer. They played hard, and in spare moments, he wrote articles for Intermountain's internal newsletter, exploring the parallels between providing good health care and keeping the storm drain in front of the Prices' home clear to avoid flooding. When, inevitably, he got weaker, he and his family came home.
Unable to walk, he spends most of his days in bed in a bright room, surrounded by mementos of the life he has relished.
On the dresser, there's a model of a shiny red Life Flight helicopter, "which I really had a hand in," he says happily. "It's been fun to watch the program grow." Next to it is an award, presented recently by the American College of Health Care Executives. A small wood-framed sign above the room's door says "Journey."
He was no stranger to his diagnosis, but he was stunned to get it. His father, a rural family doctor in Monticello, had died three years ago of the same cancer, glioblastoma multiforme in its most aggressive stage. However, Smith was told the cancer's origins are likely environmental, not genetic. He wonders sometimes if it came from uranium tailings near where he grew up in southeastern Utah. But trying to place blame, he says, is not productive.
He pictures his tumor as Pac-man, eating up his brain, although he's not sure how fast it's moving now or how much it has chomped, and he has no interest in finding out. That takes energy he'd rather expend on other things.
His priorities are shifting.
He had loved doing family history, but "that's changing." He was a reader but lacks concentration. The tumor now affects his judgment. "He thinks differently and is sometimes confused," his wife Kristy says.
He focuses on blessings. "I've had a tremendous outpouring of love. The thing about being in multiple communities is I've gotten to know a lot of people, and you can't put a price on that."
He loves the company he spent 30 years with, and his view from the hospital bed has only enhanced that. "Even people who didn't know me have been kind. And most didn't know me."
Those who did might not recognize him. His thick red hair is gone, and his face is swollen from steroids that fight swelling in his brain.
He listens thoughtfully when Jody Price says, "We are nothing in the health-care world in Sacramento, and we wait five weeks to get a scan. No one's thinking we're important, and we are always fighting tooth and nail."
Smith frowns briefly. He hopes the difference is the diagnosis. In his case, there was no time to wait for a scan with glioblastoma multiforme.
The things that worry him are temporal, not eternal. He believes in an afterlife and is confident he will see his family again. But he struggles with his loss of independence. His pain has been managed with Tylenol, although his wife says he now needs morphine at night, and fluid is starting to build uncomfortably in his lungs. At least, he says, he can speak. His father had lost that ability.
"Reconfiguring my life" is what Smith calls letting go of mobility and church activities and work that consumed and invigorated him. "Worrying" is what he does about Kristy's future.
In two years, he would have been 55, and she could have tapped his retirement. Right now, they're using sick leave. If he lives until March, they'll qualify for disability. He's thankful he bought inexpensive disability insurance early in his career. "We learned a lot about insurance, including aspects we didn't know," he says.
"I've had to reconfigure the pie," adds Kristy Smith, "but I'll be OK. You never realize the cost of care until you start getting the bills."
A different perspective
He will die soon from bleeding or a stroke or pneumonia. His diabetes may hasten it. But today, he's feeling well enough to play "king of the health-care system" when a reporter asks him what he'd change, given his newfound experience.
Smith and his sister-in-law have talked about that. The Prices own a funeral home. They're self-employed and constantly shopping for the best health insurance. It's a lot different when you don't work for the same large organization for decades and when you have to pay the entire cost, she says.
Now that Smith is no longer an administrator, he has been given the chance to see how concepts and policies from that life actually work where the rule meets the patient. Long talks about "integrated care" for him mean surgeries and protocols and treatments that come together in a coordinated way. "I've been pleased to see that happen."
He can't believe how fast medicine moves and how much his treatment differs from his dad's just a few years ago.
Smith says if he had it all to do over again, he would spend more effort on teaching people about health care — not just the costs but on how to stay healthy. And he'd more adamantly pursue good policies.
"We need to be a little more practical about some of that," he says. "Alcohol, drug abuse, helmet laws, cigarettes — all craziness. You have to look at the cost to the community."
He'd be tougher on those things. He also would fight for programs that maintain access to health care, especially in rural communities.
"Everybody has to be engaged in this," he says. "It's not just one system that can do this. Salt Lake Regional has had a great education component for many years. I was a beneficiary of the educational resources at the old Dee Hospital (in Ogden), where my dad trained."
Utah is lucky to have competing health systems, Smith says. "It takes all of us — Intermountain, the University (of Utah) and Iasis, etc. Our relationship with the U. is important. Two things that make a difference in health care here are the teaching and research."
But Smith is stunned that "the richest country in the world" can't find a way to provide basic care to everyone. "Maybe not Cadillac care but prenatal for sure. Vaccinations. Prevention. We need to make sure everyone gets the preventive things that save money, the most critical things. If I were king for a day, that's what I'd do."