By GRACE CORDOVANO PhD, BCPA
Being a patient or a carepartner can be a lonely, powerless
There’s no high powered legal or lobbying team to help support
you in your or your loved one’s health care journey. There’s no PR team at your
beck and call. There’s no advisory board, no executive committee, no
assistants, no chatbots or AI-powered technology coming to the rescue. There’s
no funding or a company sponsoring your efforts.
There’s no course in how to be a professional patient or
There’s no one there in the stillness and dark of the night, when
you are in the quiet of your thoughts, the privacy of your personal space,
where there are fleeting moments that you don’t have to be strong and
courageous. There is no one there to console you, support you as you lay there
willing to make a deal with the devil for the slightest glimmer of hope, the
slightest bit of clarity, or slightest bit of peace.
As a the carepartner to a loved one who is sick or disabled, many wouldn’t second guess charging head first through a thousand wielded swords if it meant a hope or a cure.
As an advocate, the majority of the work you do is self-created,
self-supported, and unpaid. A calling. An undeniable, magnetic force that pulls
you in because you cannot turn a blind eye no matter how hard you try. Because
you cannot bear witness to human suffering and not do anything. Because you’ve
been there and you can relate to another’s pain, grief, and sense of
hopelessness and it is unacceptable to not help ease the heaviness of another’s
By ANISH KOKA, MD
Mr. Smith has a problem.
He can’t see.
Even this cardiologist knows why. The not so subtle evidence lies in the cloudy
lens in front of his pupils. He is
afflicted with cataracts that obstruct his vision to the point he can’t really
do his job refurbishing antique furniture safely. His other problem is that he hates doctors.
He hasn’t had reason to see one for more than a decade. He’s 68, takes no medications, smokes a pack
of cigarettes a day, and is a master of one word answers. He’s in my office because
he needs a medical evaluation prior to his cataract procedure. Someone needs to
attest to medical safety. I’m it.
He just wants to get out of here.
His annoyance of being in the office is
justified. Cataract surgery is very low
risk. Unless he’s having an acute
medical problem, there is little to do.
The problem is that in an age of high volume, super specialized care,
the eye doctor can’t attest to this, and the anesthesiologists have little
interest in finding out the morning of his procedure that Mr. Smith has been
having more frequent episodes of chest pain over the last two weeks. Perhaps the chest pain is just acid reflux,
or maybe it’s because of a pulmonary embolism related to the tobacco induced
lung malignancy no one knows about. It’s possible, and highly likely, Mr. Smith
will survive his cataract surgery even if
he has a pulmonary embolism.
Cataract surgery really is pretty low risk.
But the doctor’s ethos has never been to
‘clear a patient for a cataract’, it is to commit to the health of the
patient. Mr. Smith deserves the
opportunity to receive good medical care that isn’t made threadbare just
because of the cataract surgery on the horizon.
By BRYAN CARMODY, MD
Surely every resident has had the experience of trying to explain to a patient or family what, exactly, a resident is. “Yes, I’m a real doctor… I just can’t do real doctor things by myself.”
In many ways, it’s a strange system we have. How come you can call yourself a doctor after medical school, but you can’t actually work as a physician until after residency? How – and why – did this system get started?
These are fundamental questions – and as we answer them, it will become apparent why some problems in the medical school-to-residency transition have been so difficult to fix.
In the beginning…
Go back to the 18th or 19th century, and medical training in the United States looked very different. Medical school graduates were not required to complete a residency – and in fact, most didn’t. The average doctor just picked up his diploma one day, and started his practice the next.
But that’s because the average doctor was a generalist. He made house calls and took care of patients in the community. In the parlance of the day, the average doctor was undistinguished. A physician who wanted to distinguish himself as being elite typically obtained some postdoctoral education abroad in Paris, Edinburgh, Vienna, or Germany.
By HANS DUVEFELT, MD
Many patients make this or similar requests, especially in January it seems.
This phenomenon has its roots in two things. The first is the common misconception that random blood test abnormalities are more likely early warning signs of disease than statistical or biochemical aberrances and false alarms. The other is the perverse policy of many insurance companies to cover physicals and screening tests with zero copay but to apply deductibles and copays for people who need tests or services because they are sick.
It is crazy to financially penalize a person with chest pain for going to the emergency room and having it end up being acid reflux and not a heart attack while at the same time providing free blood counts, chemistry profiles and lipid tests every year for people without health problems or previous laboratory abnormalities.
A lot of people don’t know or remember that what we call normal is the range that 95% of healthy people fall within, and that goes for thyroid or blood sugar values, white blood cell counts, height and weight – anything you can measure. If a number falls outside the “normal” range you need to see if other parameters hint at the same possible diagnosis, because 5% of perfectly healthy people will have an abnormal result for any given test we order. So on a 20 item blood panel, you can pretty much expect to have one abnormal result even if you are perfectly healthy.
By KIM BELLARD
The New York Times had an article that surprised me: Current Job: Award Winning Chef. Education: IHOP. The article, by food writer Priya Krishna, profiled how many high-end chefs credit their training in — gasp! — chain restaurants, such as IHOP, as being invaluable for their success.
I immediately thought of Atul Gawande’s 2012 article in The New Yorker: What Big Medicine Can Learn From the Cheesecake Factory.
Ms. Krishna mentions several well-known chefs “who prize the lessons
they learned — many as teenagers — in the scaled-up, streamlined world of chain
restaurants.” In addition to IHOP, chefs mentioned experiences at
chains such as Applebee’s, California Pizza Kitchen, Chipotle, Hillstone,
Houston’s, Howard Johnson’s, Olive Garden, Panda Express, Pappas, Red Lobster,
Waffle House, and Wendy’s.
Some of the lessons learned are
instructive. “It was pretty much that the customer is always
right,” one chef mentioned. Another said she learned “how to be
quick, have a good memory, and know the timing of everything.” A
third spoke to the focus that was drilled into all employees: “Hot food
hot. Cold food cold. Money to the bank. Clean restrooms,”
By HANS DUVEFELT, MD
A new decade and a new EMR are making me think about what the best use of my time and medical knowledge really is. The thing that stands out more and more for me is the tension between what my patients are asking me for and what the medical bureaucracy is mandating me to do. This is, to be blunt, an untenable, crazy-making situation to be in.
Many of my patients with chronic diseases don’t, deep down, want better blood sugars, BMIs or blood pressures – nor do they want better diets or exercise habits. People often hope they can feel better without fundamentally changing their comfortable, familiar and ingrained habits – that’s just human nature.
I went to medical school to learn how to heal, treat and guide patients through illness, away from un-health and toward health. I didn’t go to school to become a babysitter or code enforcement officer.
By HANS DUVEFELT, MD
I have noticed several articles describing how antibiotic development has bankrupted some pharmaceutical companies because there isn’t enough potential profit in a ten day course to treat multi-resistant superbug infections.
Chronic disease treatments, on the other hand, appear to be extremely profitable. A single month’s treatment with the newer diabetes drugs, COPD inhalers or blood thinners costs over $500, which means well over $50,000 over an effective ten year patent for each one of an ever increasing number of chronically ill patients.
Imagine if the same bureaucratic processes insurance companies have created for chronic disease drug coverage existed (I don’t know if they do) for acute prescriptions of superbug antibiotics: It’s Friday afternoon and a septic patient’s culture comes back indicating that the only drug that would work is an expensive one that requires a Prior Authorization. Patients would die and the insurance companies would be better off if time ran out in such bureaucratic battles for survival.
By DOUGLAS BRUCE, PhD
On January 1, 2020, recreational cannabis use became legal in Illinois. More than 80,000 people in Illinois are registered in the state’s medical cannabis program. Surprisingly, many of their doctors don’t know how to talk with them about their medical cannabis use.
As a health sciences researcher, I have a recommendation that is both practical and profound: Physicians can learn first-hand from their own patients how and why they use medical cannabis, and the legalization of recreational cannabis may make them more comfortable discussing its usage overall.
Nationwide, physicians too rarely discuss cannabis use with their patients living with chronic conditions, such as chronic pain, cancer, multiple sclerosis, epilepsy, fibromyalgia, and Crohn’s disease—all conditions with symptoms that evidence shows cannabis may effectively treat. Why don’t physicians talk with their patients about cannabis use? Research from states with longer histories of legalized medical cannabis shows that many physicians do not communicate with patients regarding their medical cannabis use for a variety of reasons.
First, physicians aren’t well trained in cannabis’ medical applications. Unlike the endocrine or cardiovascular systems, the endocannabinoid system—comprised of receptors which bond with the compounds THC and CBD found in cannabis—is not taught in medical school.
By MICHELLE COLLINS, PhD, CNM, FACNM, FAAN
The World Health Organization has named 2020 the Year of the Nurse and Midwife. However, most Americans have never experienced a midwife’s care. In my over 30 years working in maternal-child health, I’ve heard plenty of reasons why. Families are understandably nervous about that with which they are unfamiliar, and nervous about pregnancy and birth in general, with good reason. The cesarean birth rate in the US has more than quadrupled since the early 1970’s, yet we aren’t seeing healthier mothers and babies as a result. In fact, compared to the prior generation, women in this country are 50% more likely to die in childbirth, and for women of color (particularly black women) that risk is three to four times higher than white women, regardless of the woman’s education level or socioeconomic status. For those expecting a baby in the new year, let me set the record straight about midwifery care.
Today’s certified nurse-midwives (CNM) and certified midwives (CM) have earned a minimum of a Master’s degree, as well as have passed a rigorous certification exam. A third category, certified professional midwives, are not required to have an academic degree, but they must also must pass a certification exam “based on demonstrated competency in specified areas of knowledge and skills.” Midwives are intensely educated both in normal, as well as in complications of, pregnancy and childbirth, and are well-prepared to address emergencies as they arise.
Midwives generally care for women with low-risk pregnancies; however, most pregnancies are low-risk. And in those instances when a patient’s pregnancy or birth becomes high-risk, the midwife collaborates with physician colleagues to provide comprehensive team care to result in the best outcome for mother and baby.
By HANS DUVEFELT, MD
I looked at a free book chapter from Harvard Businesses Review today and saw a striking graph illustrating what we’re up against in primary care today and I remembered a post I wrote eight years ago about burnout skills.
Some things we do, some challenges we overcome, energize us or even feed our souls because of how they resonate with our true selves. Think of mastering something like a challenging hobby. We feel how each success or step forward gives us more energy.
Other things we do are more like rescuing a situation that was starting to fall apart and making a heroic effort to set things right. That might feed our ego, but not really our soul, and it can exhaust us if we do this more than once in a very great while.
In medicine these days, we seem to do more rescuing difficult situations than mastering an art that inspires and rewards us: The very skills that make us good at our jobs can be the ones that make us burn out.
Doctors are so good at solving problems and handling emergencies that we often fall into a trap of doing more and more of that just because we are able to, even though it’s not always the right thing to do – even though it costs us energy and consumes a little bit of life force every time we do it. And it’s not always the case that we are asked to do this. We are pretty good at putting ourselves in such situations because of what we call our work ethic.