By HANS DUVEFELT, MD
I’ve had several telephone calls in the last two weeks from a 40-year-old woman with abdominal pain and changed bowel habits. She obviously needs a colonoscopy, which is what I told her when I saw her.
If she needed an MRI to rule out a brain tumor I think she would accept that there would be co-pays or deductibles, because the seriousness of our concern for her symptoms would make her want the testing.
But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.
So, because there’s so much talk about free screening colonoscopies, patients who have symptoms and need a diagnostic colonoscopy are often frustrated, confused and downright angry that they have to pay out-of-pocket to get what other people get for free when they don’t even represent a high risk for life-threatening disease.
But, a free screening colonoscopy turns into an expensive diagnostic one if it shows you have a polyp and the doctor does a biopsy – that’s how the law was written. If that polyp turns out to be benign, or hyperplastic, there is no increased cancer risk associated with it, but you still have to pay your part of a diagnostic colonoscopy bill because they found something.
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 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 CHADI NABHAN, MD, MBA, FACP
thought about your own mortality?
given the frequency of seeing death and grief depicted in the media or through
real life encounters with friends, relatives, neighbors, or patients? These
incidents trigger uncomfortable and sometimes uneasy thoughts of how we might
personally deal with potential illness and disease. The same thoughts are soon
displaced by the busyness of living.
dealing with the death of his mother from a brain tumor, we learn David
Fajgenbaum was healthy, living life to its fullest, and a future doctor in the
making. He may have thought about his own mortality as he grieved the death of
his mother, but likely never imagined anything dire would happen to him.
Fajgenbaum was pushing forward on several fronts, including leading a
non-for-profit organization for grieving college students, symbolically named
“Actively Moving Forward” or “AMF” after his mother’s initials, all while first
playing college football and then attending medical school. By all accounts,
this was a vigorous young man, meticulous about his diet and physicality. When he became ill, it was a blunt reminder
that life is unpredictable.
In his book “Chasing my Cure”, Dr. Fajgenbaum takes us back to the time when he first got ill. He vividly describes his physical symptoms and various scans which detected his enlarged nodes. Interestingly, we learn how long he was in denial of these symptoms, thereby delaying medical attention in favor of studying. This neglect of self-care highlights part of his personality, but also represents the pressure and expectations placed upon a majority of medical students.
By ANISH KOKA, MD
It took some doing, but I had finally
made it to Bobby’s home.
It was a rowhome tucked into one of those
little side streets in the city that non-city folks wouldn’t dream of driving
down. As I step in, I’m met by the usual set up – wooden steps that hug the
right side of the wall leading up to the second floor. Bobby certainly hasn’t made it up to the
second floor in some time. At the moment she is sitting in her hospital bed in
the living room. The bed is the focal point to a room stuffed to the gills with
all manners of stuff. At least three quarters of the stuff seems to be food.
Cinnamon buns, Doritos, donut holes, chocolate frosted Donuts, crackers,
Twinkies. The junk food aisle at Wawa would be embarrassed by the riches on
Bobby weighs in at four hundred pounds, 5
foot 5 inches. She has a tracheostomy from multiple prior episodes of
respiratory failure that have required ventilatory support. I’m here at the
request of a devoted primary care physician that still makes home calls. I’ve
looked through the last number of hospital stays. The last few discharge
summaries are carbon copies of each other. Hypoxemic respiratory failure
related to pulmonary edema complicated further by morbid obesity. Time on the
vent. Antibiotics. Diuretics. Home. Return to the hospital 2 weeks later. The
last echocardiogram done was 3 admissions ago. A poor study. Not much could be
seen due to ‘body habitus’.
I sit on the side of the bed trying to acquire my own images of her heart. I talk to her as I struggle. Bobby is 58, the youngest of three sisters, and the only surviving member of the family. Her elder sisters died of respiratory complications as well. They both died with tracheostomies. The conversation is circular. The problem according to Bobby is the tracheostomy. Everything was fine before that. I explain that a prolonged period of time on the ventilator on a prior admission prompted the tracheostomy, and that the multiple recent admissions to the hospital that required a ventilator seemed to validate that decision. She doesn’t waver. Both her sisters died shortly after they got tracheostomies. Bobby thinks the physicians taking care of her sisters had a hand in their demise. “They didn’t care.” “We told them they were sick.”
By YOLONDA Y. WILSON, PhD
Last week a nurse posted a video of
herself on Twitter mocking patients with the caption “We know when y’all are
faking” followed by laughing emojis. Twitter responded with the hashtag #patientsarenotfaking,
created by Imani Barbarin, and
a slew of testimonials of negligent medical care. While the nurse’s video was
not explicitly racialized, plenty in the black community felt a particular
sting: there is clear evidence that this attitude contributes to the problem of
black patients receiving substandard care, and that negative behavioral traits like faking or exaggerating symptoms are more likely
to be attributed to black patients. The problem is so bad that it turns
out racial bias is built right into an algorithm widely used by
hospitals to determine patient need.
Since we can’t rely on the system or
algorithms, many health organizations and the popular media encourage patients to
themselves and their loved ones by, for example, asking questions, asking for second (or more) opinions, “trusting [their] guts,”
and not being afraid to speak up for themselves or their loved ones. But this
ubiquitous advice to “be your own advocate” doesn’t take into account that not
all “advocacy” is interpreted in the same way—especially when the advocacy
comes from a black person. Sometimes a patient’s self-advocacy is dismissed as
“faking;” sometimes it is regarded as anger or hostility.
Black male faces showing neutral expressions are more likely than white faces to be interpreted as angry, violent, or hostile, while black women are often perceived as ill-tempered and angry. These stereotypes can have a chilling effect on a person’s decision to advocate for themselves, or it can prompt violent reaction.
By ANISH KOKA, MD
No one likes getting bills. But there is something that stinks particularly spectacularly about bills for healthcare that arrive despite carrying health insurance. Patients pay frequently expensive monthly premiums with the expectation that their insurance company will be there for them when illness befalls them.
But the problem being experienced by an
increasing number of patients is going to a covered (in-network) facility for
medical care, and being seen by an out-of-network physician. This happens because
not all physicians working in hospitals serve the same master, and thus may not
all have agreed to the in-network rate offered by an insurance company.
This is a common occurrence in medicine. At any given time, your local tax-exempt non-profit hospital is out of network of some low paying Medicaid plan or the other.
In this complex dance involving patients, insurers and doctors, Patients want their medical bills paid through premiums that they hope to be as low as possible, Insurers seek to pay out as little of the premium dollars collected as possible, and Doctors want to be paid a wage they feel is commensurate to their training and accumulated debt.
Insurers act as proxies for patients when
negotiating with the people that actually deliver healthcare – doctors.
Largely, the system works to funnel patients to ‘covered’ doctors and
hospitals. Patients that walk into an uncovered facility are quickly
redirected. But breakdowns happen during emergencies.
There are no choices to make for patients arriving unconscious or in distress to an emergency room. It suddenly becomes very possible to be seen by an out of network physician, and depending on the fine print of the insurance plans selected, some or none of these charges may be covered.
By HANS DUVEFELT, MD
It is well known by now that a physician’s demeanor influences the clinical response patients have to any prescribed treatment. We also know that even when nothing is prescribed, a physician’s careful listening, examination and reassurance about the normalcy of common symptoms and experiences can decrease patients’ suffering in the broadest sense of the word.
This has been the bread and butter of counselors for years. People will faithfully attend and pay for weeks, months and even years of therapy visits just to have an attentive and active listener and to feel like they have an ally.
We also have data that shows that adherence to treatment plans is dependent on how patients feel about their provider. One problem solved can build an ally for life
Primary care medicine is a relationship based business. I don’t know how often that basic fact is overlooked or denied. Whether you are trying to get another person to alter their lifestyle, take expensive medicines according to inconvenient schedules or even just trust and accept your diagnosis, you have to “earn” the right to do those things. Our titles and medical accoutrements give us a foot in the door, but they don’t usually get us all the way into peoples inner circles of trusted advisers.
In this age of corporate medicine, there is a belief that patients attach themselves to institutions and networks because of their trust in the organizations, and that therefore the connection with their individual providers is secondary.
By HANS DUVEFELT, MD
I scribbled my signature on a pharmaceutical rep’s iPad today for some samples of Jardiance, a diabetes drug that now has expanded indications according to the Food and Drug Administration. This drug lowers blood sugar (reduces HbA1c by less than 1 point) but also reduces diabetes related kidney damage, heart attacks, strokes and now also admission rates for heart failure (from 4.1% to 2.7% if I remember correctly – a significant relative risk reduction but not a big absolute one; the Number Needed to Treat is about 70, so 69 out of 70 patients would take it in vain for the heart failure indication. The NNT for cardiovascular death is around 38 over a three year period – over a hundred patient years for one patient saved). There are already other diabetes drugs that can reduce cardiovascular risk and I see cardiologists prescribing them for non-diabetics.
It’s a bit of a head scratcher and it makes me think of the recently re-emerged interest in the notion of a “Polypill” with several ingredients that together reduce heat attack risk. The tested Polypill formulations are all very inexpensive, which is a big part of their attraction. Jardiance, on the other hand, costs about $400 per month.
The “rep” asked whether this medication would be something I’d be likely to discuss with my diabetic patients.
“Well, you know I’ve only got fifteen minutes…” dampened his expectations. But I told him about the Polypill studies. I think patients are still not ready to make the distinction between on the one hand medications that treat a more or less quantifiable problem like blood sugar levels, blood pressure or the much less straightforward lipid levels and on the other hand ones that only change statistical outcomes. Most of my patients have trouble wrapping their head around taking a $400 a month pill that doesn’t make them feel better or score a whole lot better on their lab test but only changes the odds of something most people think will never happen to them anyway.