Tuesday, February 17, 2015

The eager Salesman and the stubborn Doctor.

     I really don't enjoy going into a store with a planned purchase only to get hassled and cajoled into purchasing something different. The fact is, with so much information at our fingertips, I decide ahead of time what I want and the price I'm willing to pay.

     Recently, I dropped my smart phone in the toilet bowl.

(Take 1 minute to laugh at me.)

     This event forced me to run to my wireless store and purchase a new smart phone. Despite having done my research, my anticipated 10 minute purchase turned into a 45 minute battle of wills between an eager salesman and my practical sensibilities.

     He couldn't have been a nicer guy. In his mid twenties, he had energy and enthusiasm for his job that likely made him very successful. His great attitude won me over and I let him do his sales pitch despite fully knowing I only came in for 1 specific purpose that I wouldn't veer from. He used numbers, diagrams, compliments, (even mild insults!), jokes, clever colloquial lines all to convince me I was making a huge mistake not heeding his advice. In the end, he relented, went to the back of the store and came back with my phone.

     As he was ringing up my purchase on his tablet,  he made one last ditch effort to win me over. In the process, he asked me what I do for a living. I told him I was a physician and suddenly, the entire tone of our conversation changed.

He paused, gave me a forced smile as I watched the wheels spin in his eyes. For the 1st time I sensed the smallest hesitation in his sales pitch and instead of talking about his product, he came back with this:

"How do you treat vertigo?" 

     I felt bad that I made him expend a lot of energy  knowing he'd fail. I humored him and we switched roles. Standing in a quiet corner of the store, I began asking him all the questions I normally would. After a few minutes of trouble shooting, we changed the symptom description to "disequilibrium" instead of vertigo and I reassured him while encouraging further evaluation with his primary care doctor. He seemed grateful but I couldn't help notice a morose coming over him.

     He explained to me he always worries about something terrible happening to him just like his sister. I delved further to find out several years prior, his 16 year old sister died of a pulmonary embolism. His voice lost clarity as he fumbled around his tablet muttering how all the bad doctors ( pediatricians, ER etc)  missed the diagnosis. He chuckled recalling how an x-ray went missing but was subsequently found and clearly had abnormal findings. Although I didn't ask, I presumed the x-ray was later found as part of some litigation process.

     I couldn't imagine how it must have felt to lose a sister when you are a child yourself. I could understand the frustration and anger under his breath that probably took years to soothe. An unexpected death of a loved one is always a tragedy especially when it seems the answers are so obvious and in the hands of the physicians entrusted to figure it out. I felt terrible for him, as he pulled out his own smart phone to show me an old picture of her,

     As objective physicians we always contemplate alternatives. I didn't know the physicians that treated his sister, but I empathized with them a little bit We are taught very early on in our education that pulmonary embolism is one of the trickiest diagnosis and easy to miss. We are taught about pre-test probabilities and chest pain in a teenager is statistically much less likely to be a life threatening condition. I imagined that could have easily been me, a well meaning physician doing their due diligence and something terrible like this still happening. As a physician, we never get comfortable dealing with the death of a patient. It's even more difficult when there's an unexpected death and you're left wondering what else you could have done. These very personal emotions are occasionally twisted, tossed and turned through malpractice litigation ; a process after which physicians are left confused, numb and questioning their purpose. This is a burden many physicians carry to their own grave, quietly without any expectation of assistance or pity.

     As he finalized my purchase, I completed my thoughts coming to the conclusion that no matter what the circumstances were, he went through a tragic experience and nothing can change that. I was happy to see he survived  and had become a very good salesman with a good attitude and great smile. But on this day he didn't get the sale he wanted. I regained my connection to the digital world with a new smart phone. I'm hoping he regained the tiniest bit of faith that doctors despite being fallible, listen and care.

Sunday, February 15, 2015

Health Insurance ; A prerequisite to the American Dream

The American dream is alive and well. We still live in the land opportunity where hard work is the ticket to endless opportunities. On the contrary, bad health poses a major impediment towards fulfilling that dream. Besides the physical toll of an illness, the financial cost of an illness can make the American dream impossible to achieve. Millions of people without health insurance everyday face the spectre of their dream becoming a health care nightmare. Recently I got some great news about a family member who immigrated to the U.S a few years ago. A middle aged man with a wife and 2 kids, he came ready to do whatever it takes to secure a future for his family. An educated man, he struggled to find employment. He latched on to several different jobs that helped continue to build his skills but was given no health care benefits. He didn't qualify for Medicaid and couldn't afford private health insurance. Just like many Americans in this situation, his health took a backseat. But recently, he was finally able to secure a job that offered benefits including health insurance. He now had the security that seemed like a natural prerequisite towards pursuing his own American Dream. He took this opportunity to finally seek out world class healthcare. From a distance, I began to get caught up with what was happening with his health. Fortunately, he didn't have too many medical problems besides benign prostatic hyperplasia (BPH). It was significant enough that he was referred to a urologist. He felt lucky to find a local well renowned urologist with many positive reviews (both online and word of mouth) that also took his excellent new health insurance. After 1 visit, it seemed like he was appropriately placed on some medications to try to alleviate his symptoms. What was surprising is that he was also placed on brand name testosterone replacement. Immediately, skepticism towards testosterone replacement therapy began to engulf my thoughts. I began to wonder if my family member was another victim of the "Low T" marketing campaign. Furthermore, I was shocked to find out that within weeks of seeing this doctor, he was being offered greenlight laser prostatectomy. Granted I am looking at this case as an outsider. But without trying various types of medical therapy at optimal doses and for significant periods of time, the recommendation for surgery seemed very premature. Since then, my family member has been directed to a second opinion.
Health insurance is an extremely high priority issue for most Americans. It is the sensible thing to attain, whether it is to ensure wellness or treat illness that might otherwise derail a lifetime of hard work. But my family member's reward for obtaining health insurance wasn't good health but rather a glut of potentially wasteful and dangerous medical care. As we continue to expand health insurance in an attempt to cover all Americans and provide them access to care, we have to continue efforts towards curtailing health care that is not evidence based, wasteful and only serves to fulfill the American dream of providers and drug companies while taking advantage of hard working naive citizens. 

Monday, February 9, 2015

Don't hate the Anti-Vaxxer

     It's easy and convenient nowadays to take a few minutes to rally against the "Anti-Vaxxer" movement. With the recent measles outbreaks, there's no shortage of articles, memes, jokes and cartoons to share on blogs, Facebook, Twitter etc. But I'm going to throw a very small teeny tiny microscopic bone to the Anti-Vaxxer camp. I will do so with the disclaimer that as a primary care physician I think vaccines are an extremely important part of good health. Anyone that doesn't see their value, is misguided and perhaps misinformed.
    Having said that, there's no denying that the Anti-Vaxxer  movement  is real and unfortunately seems to be growing. They have quietly become a significant part of the general population. The reason for their growth is multifactorial, but the easiest targets are probably defrauded scientists, celebrities and politicians with dubious opinions. But the target that's probably hardest to identify is the one looking right back at us in the mirror.  When a problem afflicts society, the easiest thing to do is blame others. The introspective route asks us to look within to identify causes and offer solutions.
     How did we let this happen? The Anti-vaxxer movement is just another example of the growing mistrust and lack of faith in our doctors and healthcare system. There are many reasons for this. When it comes to vaccines, why aren't we, the trusted physicians able to educate and change their minds? Perhaps we are not living up to the true latin meaning of the word "Doctor" which is "to teach." Perhaps the modern doctor,  gathered and taught in traditional (antiquated?) methods are struggling with modern informed patients who challenge and question rather than accept paternalistic physician decision making. Perhaps we simply just don't have time to have a decent conversation with our patients about the importance of vaccines.
    Whatever the reasons, we need to figure out better ways to connect with this subset of our patients whose beliefs about vaccines post significant individual and community health risks. What we don't need to do is further alienate this population by kicking the proverbial horse while it's down. The amount of  seemingly joyous vitriol pouring from the medical community against anti-vaxxers is disappointing and at times bordering on classless. Social media is teeming with derogatory descriptions of this population.  I think this only furthers many people's views of rampant intellectual elitism in our doctors. The most disappointing stance on this issue is when doctors proclaim they will refuse to see patients who don't believe in vaccines. Hey genius, if you don't see that patient, then they definitely don't stand a chance of getting a vaccine!
   The anti-vaxxer type of population is something that has always existed in most medical practices. They represent a group of people who don't believe in the gospel you are preaching. I have patients who don't believe in cancer screenings, statins and a whole host of other great evidence based ideas. They can be frustrating and time consuming.  But they are still my patients and I will continue to respect them and care for them with the confidence to know I will eventually change some of their minds.

Thursday, December 4, 2014

Endings and Beginnings

It's been a while since my last post. I've been busy and life has been changing.

For one, we had our third baby! She's beautiful and certainly takes up a significant amount of our time (disproportionately at night!)

I'm also moving. After a lifetime of calling myself a New Yorker, we're packing up and moving to Dallas, Texas.
I will always be a New Yorker and the emotions regarding this change are far too complex to discuss on this post.

But with this move ends a tremendous chapter of my medical life. Much of my posts on this blog were based on stories and experiences from these past 5 years.

We go into medicine because of the patients. The patients and their stories will always be the crux of my existence in medicine. I will always find inspiration to write and keep practicing medicine because of them.

But these past 5 years have been about more than just patients. I got to take care of a different group of people. I got to be a caretaker of some pretty incredible internal medicine and med-peds residents.

They inspired me, taught me, challenged me, tested  me, made me laugh but most importantly made me feel proud to be a medical educator.

As doctors we love making patients better. As medical educators we love making patients better and making doctors better. It's an incredibly fun and gratifying career path.

So with that, a sincere thank you and good bye to my trainees past and present. I hope your interactions with me were as meaningful to you as it was for me. I can't wait for our paths to cross again as professional colleagues.

To my new patients, I can' t wait to meet you all and take care of you!

To my new trainees, I can't wait to meet you all!. Let's get to work to make healthcare better and change medicine forever!

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.


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.