Tuesday, August 12, 2014

Tribute to Robin Williams and Patch Adams

In honor of one of our favorite "Doctor" movies, we turned our brunch into a Patch Adams/Robin Williams tribute!

U treat a disease, u win, u lose. U treat a person, I guarantee u, you'll win, no matter what the outcome." -


Monday, August 11, 2014

Picking up the pieces

At home I'm usually surrounded by a mess of toys. With 2 toddlers running around, the floor is littered with knick knacks and my evenings are spent picking it all up. It's challenging, sometimes frustrating but I know with time and education, they will learn and it will change.

I'm often doing the same thing at work. Patients come with their internal home littered with problems that my residents are constantly trying to correct and pick up after. In this era of chronic illness, this is a challenging and sometimes frustrating endeavor. But with medical expertise and a partnership with the patient, many of these problems can be fixed.

But there are some things in medicine that are extremely difficult to "pick up" after. The most difficult one is the chronic pain, opiate dependent patient. This group of patients has become an albatross for too many primary care physicians. There are many unfortunate reasons for this.

Like most problems in our healthcare system, it begins with the system itself. Simply put, when you don't have insurance and access to healthcare, it's very difficult to get well. With chronic illnesses like diabetes, high blood pressure and obesity, they can be managed (albeit sub-optimally) without insurance. We can see these patients every few months and work around the limitations of insurance. We can easily switch medicines to more cost effective ones. Patients are usually pretty adaptable to medication changes with these conditions.

When a chronic pain opiate dependent patient doesn't have insurance, it's a real quagmire. First, they need to come monthly for assessments and refills. With such potent potentially addictive medicines, monthly visits are appropriate and the standard of care I advocate in our resident training clinic. Without insurance, monthly appointments become expensive and patients get frustrated. Secondly, changing or even stopping the medicines is extremely challenging. This drug class creates a level of dependency similar to how Frodo Baggins felt towards the one ring of power in Lord of the Rings. It is impossibly hard to change or let go.Thirdly, without insurance its very difficult to do urine drug screens  (expensive!) which is rapidly becoming the standard of care in managing this group of patients.

The insurance problem also highlights an issue with accountability with chronic pain opiate dependent patients. I'm constantly seeing patients who've recently lost their insurance or their doctors stopped taking whatever insurance they have. This is not unusual these days. If they were on a brand name drug for cholesterol, I can easily switch to a generic. If they were on a medication that I thought was unnecessary, I can easily stop it. But when a doctor creates an opiate dependent patient then essentially dumps them because of their insurance, I have serious issues with this. It's just wrong. The ethics and morality issues in this scenario are honestly better explained by Mary Shelley's Frankenstein than my little blog.

Besides the insurance angle to this problem, I won't even get into misguided guidelines created in the 1990's by specialists and drug companies that touted the safety of opiate medications for non-cancer pain.

When you combine such realities together, you get patients with many chronic illnesses without proper access to care, hopelessly dependent on dubious medications, nowhere to go except the overwhelmed safety net that is primary care.

A litany of toys in my living room is just not acceptable. I pick it up, optimistic that eventually it won't be a mess anymore. And with that same smile and vigor, I (we) pick up the pieces of our patients, working and waiting for the system and our patients to get healthier.


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Friday, July 25, 2014

A lesson in Math

I was never very good at math. I barely survived my pre-med requirement for basic calculus. Although I don't use any calculus in my day to day clinical life, I get by with my basic arithmetic skills and trusty smartphone calculator.

Infectious diseases is a great field in medicine. There's often a clear association between causative agents and diseases. For example Helicobacter Pylori (H Pylori) is a common infection found in the stomach that's associated with a lot of bad stuff if not treated properly. Fortunately, there are treatment regimens involving some common antibiotics that make this condition very treatable.

Recently, I saw a case of H. Pylori that made me question those basic math skills that helped me survive 4 years of medical school, 3 years of residency and 6 years of attending life.

My general understanding of the concept of "addition" was as follows.
1+1 = 2.

This case of H Pylori that I'm about to reference totally rebuked my basic understanding of this equation.
The case taught me 1+1 doesn't always equal 2. It's often quite more than that.
Perhaps there are advanced theories in math in which 1 +1 doesn't equal 2. Such advanced concepts are beyond my pedestrian physician mind!

Ms. Anita Smith (name changed) was a 40 year old woman with no medical insurance and numerous chronic illnesses. She came to our resident clinic already diagnosed with H-Pylori. It was recommended she complete one of the several 3 drug regimens needed to eradicate this bacteria. Unfortunately, she hadn't started the treatment because she couldn't afford it. This was surprising because I recalled that the medications (bismuth, metronidazole and tetracycline) were old generic medications.

When the resident and I looked into the price for these medications, each individually appeared to cost about $15-25 dollars. Based on our basic math skills, we didn't expect this to cost more than $75.
We were shocked to find out Ms. Smith was charged $700! She politely refused this treatment.

We investigated this further and found out she was prescribed a tablet that combines all three medications.
A combination tablet has many advantages. For a hearty organism like H Pylori, a combination pill improves adherence to the regimen and eradication rates. That's great except for the ridonkulous price!

Is it justified to charge $700 for 3 medicines that individually cost a total of $75?
Granted if she had insurance, she would only have a co-pay. In that case the insurance company is likely getting charged an exorbitant fee to carry the drug on its formulary.

It's understandable when a new drug is developed from scratch and after a long FDA approval process, a company attempts to recoup those costs and also profit from it. But taking old drugs and mashing them together, marketing it as something new and marking up the price amounts to highway robbery.
This deceitful gimmick is unfortunately an all too common tactic that further drives up the cost of our healthcare system.

And that is how I came to learn that generally speaking, 1+1 =2.
In the healthcare and pharmaceutical world, 1+1 does not equal 2, but often much more than that.







Tuesday, June 24, 2014

Disparity in Doctors. Reflection on Washington Post Blog " The Outrageous cost of working in Medicine."

"The journey to and through medical school was challenging and expensive. " - Me

I grew up in a middle class family in New York City. My father was a civil engineer for the NYC department of transportation. He worked hard and gave us a humble and honorable upbringing. We had everything we needed in life. Everyone in my family made certain sacrifices to sustain our middle class life.
     Despite a New York City public school system that often gets criticism, I managed to get into a competitive exam based science high school. I never had extra tutoring or took a review course and therefore feel lucky to have gotten accepted. Today these high schools are extremely competitive and many students are paying significant amounts of money for tutoring and review courses to augment their opportunities.
     I also never had a job in high school and had time to focus on my studies. Fortunately I got into an excellent, albeit expensive university. In addition to loans, my parents luckily had the ability to stretch their budget to pay for my tuition. I also participated in the work-study program for 2 years until the mounting pressures of the pre-med life forced me to quit. I was able to focus on my MCAT's and had the financial means to pay for an expensive review course. The review course definitely helped a lot.
     I didn't get into a medical school right away and applied for 3 years. It was a process that cost me close to $10,000. Once again, my family was there to support this expense while I had a low paying research position. I persevered, got into medical school and finally was able to bear the entire brunt of my educational expenses in the form of loans in excess of $250,000. I'm recounting my educational journey through the financial lens to highlight that even starting in high school the journey has been an expensive one. This is a journey many students cannot afford to make.
    The Washington Post article highlights several critical issues facing healthcare today. The cost of medical school is immense and has been looked at as a key reason why medical students are opting for higher paying specialties instead of primary care.  I think this makes absolute sense. But interestingly, the article also highlights a very important separate issue. The fact is that only 3% of medical students come from families in the lowest 20% incomes and 60% of students come from the top 20% incomes. This reality directly correlates with the paucity of minorities (especially African American and Latinos) entering medical school and our physician workforce.
     The article argues that the cost of medical school is a reason why minorities veer away from medicine. I agree there is some truth to this. But it's a lot more than that. Getting into medicine is a series of hurdles scattered over many years. Broken public school systems, social and financial pressures make these hurdles significantly greater for students in lower socioeconomic groups. To optimize academic opportunities there are many added costs that only students and families with financial security can better handle. This includes tutoring, review courses, books and a myriad of extracurricular activities. This makes the gauntlet to medical school  immensely challenging for students in the lower socioeconomic strata. Even for middle class families, this process is a huge struggle. This is a key reason why 60% of the medical students come from families in the top 20% of incomes.
    This also brings us back to the question about why students are choosing higher paying specialties instead of primary care. There's no doubt the enormous cost of medical school is a big reason. But logically, you'd think if 60% of the students are coming from the top 20% of earners, they might have less medical school debt and therefore be more apt to choose lower paying specialties. But the reality is, one of the great motivators in human behavior is the fear of loss. In this case, if you're coming from a higher socioeconomic group, why would you pursue career paths that threatens that?
     I'm not criticizing successful successful parents who give their children every opportunity to succeed in life. Nor am I criticizing students for choosing career tracks that best suits them. But the current construct of our educational systems are not set up to solve some of the critical problems in healthcare.We have struggling primary and secondary education systems followed by woefully expensive undergraduate, graduate and medical schools. We don't have enough medical schools or enough residency spots.The people that do take those few spots are not doing primary care (the foundation of a successful healthcare system). We live in a diverse multi-ethnic country yet several key minorities are underrepresented in our healthcare system.
       This highlights just another one of the several systematic problems in our healthcare system that is self perpetuating with no end in sight.

Here's a link to the Washington Post piece.
The outrageous cost of working in medicine


   
   

Tuesday, June 10, 2014

The Calm before the storm. Tips for New Interns

It's June kids.
Time to ditch the short white coat, grab the long one and start being a doctor.

There's lots of helpful tips written by residents out there.
Here's a quick list of tips from the perspective of an Attending in Internal Medicine who primarily does outpatient work.

1: Focus on the "WHAT" and the "HOW?" 
For the short term, focus less on the "WHY."
    As a new intern, your job essentially is to get things done. So constantly ask your resident/attending/nurses "What do I need to do?". Keep an organized list.
   Since you're  in a new hospital, also ask "How do I do this?". If you don't know how to get it done, don't wait to figure it out. Ask right away and get it done.
   As you get more comfortable and efficient, then you'll be able to ask the WHY questions.



2: Be humble.
    Yes, you're extremely smart, you're an MD/DO now and you've crammed your heads with tons of esoteric medical stuff which most people (even residents and attendings) have forgotten. But realize, you may know a lot of medicine, but taking care of patients is completely different. Humility will leave your mind and days open to learning and endless possibilities.



3: Try and have fun!
Don't get me wrong. This isn't going to be easy and there will be moments and days where your patience will be tested. There will be moments where that polaroid smile while seem like an insurmountable task.Nevertheless, try to see the glass half full and find the joy and humor in the craziness that is Internship.  Have fun for your own sanity, the sanity of your team and most importantly for your patients. If you enjoy what you do, patients will sense it and believe in you!



4: You are an incredibly important person in the team.
    Sometimes it may seem like your presence isn't that important and you're simply a cog in the machine. But to that very ill patient (in hospital or in clinic) you are critically important. You are the physician that's going to spend the most time with the patient. You are the first contact when things go bad. You are the eyes and ears for the senior resident and attending.



5: Residency is a PIT STOP in your life
Life is like a Nascar (or Formula 1) car race. It's a long race, hundreds of miles, it's relentless and it goes fast.  Residency is just a small fraction of your life. It's like a pit stop in automotive racing. The race may last a few hours but cars spend only a few minutes in a pit stop.

But if you know anything about car racing, teams work tirelessly to make those pit stops perfect. In fact, races are often won and lost in the pit stop.
You should approach residency the same way. Realize it's just a small part of your life, but strive to make it perfect, and work tirelessly at it to win the bigger race.



6:You are being evaluated by everyone
    This is the era of 360 evaluations which means everyone has a say on how you are doing. I can't tell you how many times I've seen excellent interns and residents rotation get derailed (Despite being an excellent doctor) by negative evaluations by medical students, nurses, residents, sub-specialists etc. Be a professional towards everyone!

               


That's all I've got for now. Hope this helps.

Good luck to all the new interns! You've made a great career choice and it's only going to get better!

Monday, June 2, 2014

Fast Food Medicine

"Would you like fries with that?” 
"Would you like to upgrade to a large soda instead of a medium?"
“Would you also like an additional blood test for Lyme disease?”

Sure why not? I love fries!
And a larger drink? Heck yeah, if it's only a few cents more.
I'll also take that Lyme disease test, just to be on the safe side!

The above sounds like a great fulfilling experience.
You get delicious inexpensive food, served by very pleasant and efficient people that were also willing to cater to whatever you want. You also get a doctor who seems to really care and thorough by ordering a battery of tests. It's the kind of experience and place that anyone would want to keep coming back to, again and again.

This is not the typical experience many patients (consumers?!?) have when they interface with our general healthcare system. Healthcare is not inexpensive, not convenient at all and the quality of the product is variable. And in many cases the experience is very unpleasant.

"Necessity is the mother of all invention."

What started out as filling a void for overcrowded emergency rooms and unavailable primary care physicians, urgent centers have been flourishing. It's simple supply and demand. Supply of primary care doctors are dwindling and the demand for more convenient patient care is increasing. Now in any of your neighborhoods, you can get coffee, fast food and some "healthcare" rather quickly and merrily. 

I've gotten used to counseling my patients on the dangers of obesity and its association to fast food. Lately, I've had to start counseling my patients on the dangers of fast food medicine. Although I recognize their need and why they appeal to patients (consumers!?!), I have serious concerns about the impact Urgent Care centers have on healthcare at large. Just in the past few years, these are the types of issues I've noticed from care provided by such places.

Over prescription of antibiotics
Unnecessary use of broad antibiotics
Shot gun blood work with spurious findings
Recommendations to pursue unnecessary advanced imaging
Unnecessary recommendations to see specialists
Patient expectations for over treatment and extensive work ups

These are just broad generalizations but after a years, my patient sample size is growing.

I'm not a business man, but in the "for-profit" world" you do things that get you paid (x-rays, blood work?) and you give the consumer what they want to ensure return business. These are dangerous business concepts when applied to healthcare and urgent care centers are rapidly becoming the prime example of this. 

As the cost of our healthcare approaches 20% of our GDP and medical educators at all levels preach value and cost, urgent care centers, retail clinics and their profit incentives threaten to undermine this entire movement.

I'm not the only one that is worried about this.

The link below comes from a blog post on Kevinmd.com echoing similar sentiments. 


Reflection from Spring APDIM 2014

    A little late, but this is a small piece of my Spring APDIM experience that I forgot to publish.

      For the second time, I had the privilege of attending an APDIM conference.  For spring 2014 it was held in Nashville, Tennessee. And just like Fall APDIM 2013 in New Orleans, the streets were filled merriment, music and food while the conference halls were filled with bright minds, ideas and tokens of inspiration for medical educators like me. 
     This was essential my first trip to a "southern city" (Florida doesn't count). True to southern tradition, hospitality was abundant. Though diverse in its population, the southern twang was prominent and enjoyable for a Yankee New Yorker like me. Downtown was lined with bars and restaurants all staged with talented musicians raucously playing traditional country, rock and honky tonk into the late hours as locals and tourists danced with each other in small smoke filled venues. Add to this, jubilant fans of the UCONN huskies women's basketball team emptied Bridgestone arena into downtown one night. "Nash-Vegas" as my taxi driver called it, was kicking. 
     It was this same taxi driver who on my first night in Nashville brought me back to my physician roots and reminded me why I was there in the first place. As a primary care physician, I love stories. It is the story of each life, whether it is drama, tragedy or comedy and its successful completion under our watch that makes this a gratifying career choice. It was his successful story that makes our field an important part of the fabric of American society.
     As we drove to downtown Nashville, he told me he was from Acapulco Mexico. He immigrated to the USA in hopes for a better life 25 years ago. He started in Texas and left despite the large Mexican community. He took a chance on Nashville. He worked nights driving a taxi so that he could purchase a home for his family. Eventually he turned his 1st house over for a profit and built a dream home.  He was quick to tell me his home would cost millions in New York. Along the way, he fell in love with a nurse, raised two kids who currently attend top rated colleges. His story doesn't end there. He continues to work nights to save up to start his own business. He wants to create a Latino southern themed department store to cater to immigrant populations that are homesick and struggling to find their own American dream. I never asked what medical problems he had or what role his doctor played in fulfilling this life. But I know every day when I see patients in my office, whether it's through prevention or managing chronic illness, my mission is to ensure illness doesn't derail a story like his. And if illness does catch a gentleman like him, we as primary care physicians treat and guide them so that his story has a happy ending. 


Friday, May 30, 2014

Uganda Medical Mission

I wanted to use this post to highlight  the blog on one of our  Med-Peds chief residents here at Stony Brook University School of Medicine.

Dr. Robert Abdullah (@docbobert) is a terrific person and physician who recently participated in a medical mission to Uganda. His blog has several posts from that experience and an incredible array of pictures.

I really enjoyed following his experiences and I think you will too!

It's also his birthday today!

Scribe for Life- Dr. Robert Abdullah

Enjoy!

Wednesday, May 28, 2014

Climb YOUR mountain

     There's a lot to be done in our healthcare system today. Wherever you look, there's a problem that needs to be solved. Sometimes it seems like we have less and less people with the right training and attitude to take on these challenges and re-engineer our healthcare system.
     Most people start their career with the intention of not just practicing medicine but also working towards making healthcare better. But once you start your career it all gets overwhelming very quickly. As patients come in droves, many of us are simply trying to stay afloat with providing good patient care. After a few years of getting comfortable with this, I finally was able to take a breath, take a step back and start looking at doing something else with my life in addition to seeing patients. I once again started asking myself, how can I make the world around me (our healthcare system) better? As I began to figure this out (and this takes time, introspection, education) and develop my own interests, I got wrapped up in other things. I got caught up in the moment and the immediacy of the problems around me. I did a lot of good things but before I knew it several years passed and veered further away from what initially got me excited.
      The amount of time, energy that's required to happily succeed in medicine is immense. The only way to sustain energy and momentum, is to be passionate and have a greater purpose that you sincerely believe in. Hard work and a desire to do the right thing can overcome a lack of passion. But if you have a greater purpose in medicine, you have to stick to your guns, get back to things that get you excited and fulfill that sense of purpose.
      We all have the proverbial mountains to climb in our career. Just make sure it's a mountain of your choosing. You don't want to spend your life climbing, and in the end, not enjoying the journey or the view from the top.
 
   

Thursday, February 27, 2014

A Wasteful Week

     I'm a bit of a backseat driver these days. As a result of the economy and the number of people who have lost insurance (and gained Medicaid) we're seeing a lot of new patients who previously had commercial insurance plans and were being seen by community providers that do not accept Medicaid. Some of them reluctantly come to our resident clinic, but the majority are very grateful for the opportunity to receive excellent comprehensive care from our well intentioned trainees during a difficult transition in their lives.
I've never really worked as a private practitioner in the community, but this influx of patients switching to our clinic has given me some (albeit very limited) perspective on the care they receive in the community with commercial insurances. For the most part, everyone receives excellent care and they often express disappointment that they have to leave their long standing doctor. But on several instances, when we investigate their past medical histories, we've been seeing several instances of what appears to be wasteful unnecessary care.

In 1 week, here is a sampling of a few of these cases.

1: Middle aged gentlemen in good health, well controlled high blood pressure and some family history of heart disease was getting yearly stress tests because " My doctor  was thorough and wanted to be sure."

2: Gentleman who got his first colonoscopy at age 47 because according to his wife "We had really good insurance."
 
3: Twenty something  year old female, with mild occasional anxiety was getting yearly EKG's as part of her "Annual Exam."
  
I know I'm looking at these cases as a backseat driver. Perhaps I was getting an incomplete history and there were good reasons why these tests were ordered. But my instincts, medical knowledge and perspective on our current healthcare system suggests it falls under the category of wasteful care.
Reuter's Report on Healthcare system waste 2009

We are all guilty of practicing wasteful care and it's a multi-factorial problem. It start's by changing our mindset towards healthcare by looking at things in terms of value. We also need to make a concerted effort towards following the evidence, and when the evidence is overwhelming, use validated clinical decision support tools.

Case 1: See number 2. Choosing Wisely (American College of Cardiology)
Case 2: USPTF Colon Cancer screening guidelines
Case 3: Rethinking the value of the annual exam

We also have to hold each other accountable for these problems, and sometimes that means being an annoying backseat driver with a computer and a blog :-)