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3 Patient Lessons: What Cancer Patients Teach Me

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By YASMIN ASVAT

An estimated 1.8 million people in this country may face a cancer diagnosis this year, in what has already been a bleak year of isolation and loss.  

While news of the COVID-19 vaccine rolling out across the U.S. offers hope in a year of 311,000 deaths,  11 million  people face the financial pressure of unemployment, and, approximately 43 percent of the nation reports some symptoms of anxiety or depression.  

It is understandable that a cancer diagnosis now may be too much to bear. And yet, somehow, many patients cope with the diagnosis and the associated uncertainty, fragility, and the threat of mortality with remarkable resilience.  

As a clinical psychologist in the Supportive Oncology program at a major Midwestern cancer center, I witness these quiet heroics every day. 

Since the beginning of the pandemic earlier this year, I have been striving to listen, empathize, support, and help cancer patients cope as their lives have been disrupted by both a cancer diagnosis and COVID-19. These are lessons these patients have taught me. 

Courage is being faced with doing something that utterly terrifies you, and you do it anyway. One of my patients described that leading up to the day of chemotherapy treatment, she is highly anxious, has racing thoughts and worries, and has trouble concentrating and sleeping. The morning of treatment, she vents to her partner about how she doesn’t want to go to the clinic. During the drive, she braces herself repeating, “I don’t want to do this” over and over again. 

Once in the clinic, she tells some of her nurses that she doesn’t want to be there because she worries about COVID-19 exposure, despite all the precautions the clinics have in place. She tells another set of nurses that she is scared of the side-effects of treatment – the disabling fatigue, the nausea, the suppressed immune system. 

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A Christmas Message to All Physicians From a Swedish-American Country Doctor in Maine

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By HANS DUVEFELT, MD

Growing up in Sweden without a Thanksgiving holiday, Christmas has been a time for me to reflect on where I am and where I have been and New Year’s is when I look forward.

I have written different kinds of Christmas reflections before: sometimes in jest, asking Santa for a better EMR; sometimes filled with compassion for physicians or patients who struggle during the holidays. I have also borrowed original sentences from Osler’s writings to imagine how he would address physicians in the present time.

This year, with the pandemic changing both medicine and so many aspects of life in general, and with a gut wrenching political battle that threatens to erupt in anarchy or civil war within the next few weeks or months, my thoughts run deep toward the soul of medicine, the purpose of being a good doctor, even being a good human being.

We live in ideological silos, protected from dissenting opinions. News is not news if it is unpopular. Fake news and fake science are concepts that seemed marginal before but have now entered the mainstream.

As a physician, I serve whoever comes to see me to the best of my ability. But this year I have had to pay extra attention to the fact that so many people have already made up their minds about the nature and severity of the pandemic we are living with. If they don’t believe the country’s top experts, they are not likely to believe in me. Still, I try to gently state that we are still trying to figure this thing out and until we do, it’s better to be cautious.

I am starting to read about what some are now calling the Fourth Wave of the pandemic, the mental health crisis this winter may see in the wake of the physical illness we are surrounded by.

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Two Surgeons—a Veteran and a Newcomer—Talk Fighting COVID Burnout

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By MICHAEL E. LIPKIN and RUSSELL S. TERRY, JR.

Burnout has always been a concern in medicine, and that concern has been amplified by the added stress of COVID-19. Many months into an unpredictable and distressing situation, we have both hung on to our mental health and professional passion by seeking out strategies that work for us. We offer them in two perspectives: veteran and relative newcomer.  

Dr. Lipkin: A Veteran’s Perspective

When lockdown began in March, we slowed down my practice for about 6 to 8 weeks, and then returned to full pre-COVID levels. It feels like the uncertainty has affected me most, since it has not been clear if and when things will get substantially better. Everyone is both experiencing and projecting persistent anxiety, stress and uncertainty. Isolation is a problem as well. I no longer have the time or ability to sit down with colleagues and vent over a beer, which was an outlet I counted on to mitigate burnout. At the same time, on a more concrete level, the pandemic has made everything we do incrementally more difficult, which is grindingly stressful. These tips are helping me cope and avoid burnout.

There are so many changes—just accept them. As COVID affects so many areas of practice, there’s a kind of low-grade stress that fluctuates with events. It seems like everything is a little bit harder. We have to shift some patient visits to telehealth and make sure they get COVID tests before surgery. We’re all looking over our shoulders, wondering who’s going to get us sick. There’s always the specter of more shutdowns and how they might affect our livelihoods. Budgets have been cut back, so hiring is frozen and there’s virtually no incremental spending. Everything will stay this way for now, so the best thing to do is accept that we’re going through a tough period and focus on the big picture, rather than the list of irritations.

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CRAZY AMERICA: Health Insurance Covers Testing When You Are Well But Not When You Are Sick

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By HANS DUVEFELT

Insurance is the wrong word for what we have here. Our private health insurance system’s prioritization of sometimes frivolous screenings but non-coverage for common illnesses and emergencies is a travesty and an insult to typical American middle class families.

State Medicaid insurance for the underemployed has minimal copays of just a few dollars for doctor visits and medications. From my vantage point as a physician, it is the best insurance a patient can have. They cover almost everything and it is clear to me how to apply for exceptions or follow their step care requirements. I cannot say that about most other insurers.

Most employed people have the kind of commercial health “insurance” that covers an annual physical and certain screening tests at no cost, but requires people to pay the first several thousand dollars of actual sick care expenses out of pocket. This is, in my opinion, insane. It causes delays and omissions in diagnosis and treatment.

A shining example of this bizarre arrangement is the screening colonoscopy. It is free as long as it is normal. If a patient has a polyp removed, which if unchecked could turn cancerous, future health care costs for treating colon cancer are eliminated. But the patient gets billed for the early cure.

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The Art of Listening: Beyond the Chief Complaint

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By HANS DUVEFELT

A doctor’s schedule as typical EMR templates see it only has “Visit Types”: New Patient, 15 minute, 30 minute. But as clinicians we like to know more than that.

One patient may have a brand new worrisome problem we must start evaluating from scratch, while another is just coming in for a quick recheck. Those are diametrically opposite tasks that require very different types of effort.

Some visits require that test results or consultant reports are available, or the whole visit would be a waste of time. How could you possibly plan your day or prioritize appointment requests without knowing more specifically why the patient needs to be seen?

So, as doctors, we usually want our daily schedules to have “Chief Complaints” in each appointment slot, like “3 month diabetes followup”, “knee pain” or “possible dementia”. That helps everybody in the office plan their day.

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Health Professionals Are Tomorrow’s Health Journalists. Here is a Code of Ethics to Guide Us and Trump’s White House Doctor.

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By MIKE MAGEE

The patient/health-professional relationship is fundamentally grounded in science and trust, and involves the exchange of compassion, understanding and partnership. The Covid-19 pandemic has challenged this relationship by acutely increasing the nation’s burden of disease, creating new barriers to face-to-face contact, and injecting high levels of fear and misinformation.

Dr. Sean Conley, Trump’s White House physician, in his dodgy and evasive management of legitimate questions from the White House press corps regarding the President’s health, has made matters worse.

As this week’s report on an analysis of 38 million articles on the pandemic revealed, much of the misinformation our citizens have experienced can be traced to a single individual who lacks any health credentials – our own President Trump. Sarah Evanega, the director of the Cornell Alliance for Science and lead author of the report stated, “The biggest surprise was that the president of the United States was the single largest driver of misinformation around Covid. That’s concerning in that there are real-world dire health implications.”

The solution to that specific problem is only one month away – vote him out. But if Trump can be successfully sent packing, how prepared are our health professionals, in the face of these new and complex challenges? A President Biden health reform package will likely include expansion of health care teams, exponential growth of telemedicine, and increasing dependence on reliable information to advance personal health planning.

Today’s modern health professionals are tomorrow’s health journalists. What principles should guide them in their new and expanded role. As a guide, I offer the following:

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Physicians’ Communication Skills are Overlooked and Undervalued

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By HANS DUVEFELT

Interviewing celebrities can make you a celebrity yourself, and it can make you very rich. So there’s got to be something to it or it would be a commodity. The world of media certainly recognizes the special skill it takes to get people to reveal their true selves. 

At the other end of the spectrum of human communication lies our ability to explain and also our ability to influence. These three aspects of what we do—elicit, explain and influence—are far from trivial, and in my opinion quite fundamental aspects of practicing medicine. 

Eliciting an accurate patient history or administering standardized depression, anxiety, domestic abuse, smoking and alcohol screenings are commoditized activities in today’s healthcare. There is little time allotted and these tasks are usually delegated to non-clinicians. 

A complicated patient’s clinical history seldom lends itself to straightforward, structured EHR formats. It can be more like a novel, where seemingly unrelated subplots converge and suddenly make complete sense in a surprising last chapter. 

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Talking Politics in the Exam Room: A Physician’s Obligation to Discuss the Political Ramifications of Science with Patients

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By HAYWARD ZWERLING

I walked into my exam room to see a patient I first met two decades ago. On presentation, his co-morbidities included poorly controlled DM-1, hypertension, hyperlipidemia, and a substance abuse disorder. Over the years our healthcare system has served him well as he has remained free of diabetic complications and now leads a productive life. Watching this transformation has been both professionally rewarding, personally enjoyable, and I look forward to our periodic interactions.

At this visit, he was sporting a MAGA hat. I was confused. How can my patient, who has so clearly benefited from America’s healthcare system, support a politician who has tried to abolish the Affordable Care Act, used the bully pulpit to undermine America’s public health experts, refused to implement healthcare policies which would mitigate COVID-19’s morbidity and mortality, and who minimizes the severity of the coronavirus pandemic every day. Why does he support a politician whose healthcare policies are an immediate threat to his health and longevity?

My brain says, “You are the physician this patient trusts to take care of his medical problems. You must teach him that COVID-19 is a serious risk to his health and explain how the President’s public health policies threatens his health. You must engage in a political conversation.”

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Measuring the Effectiveness of Cost-of-Care Conversations

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By NELLY GANESAN, JOSH SEIDMAN, MORENIKE AYOVAUGHAN, and RINA BARDIN

With support from the Robert Wood Johnson Foundation, Avalere assesses opportunities to normalize cost-of-care conversations through measurement.

Cost continues to pose a barrier to accessing healthcare for millions of Americans. Research has shown that conversations addressing costs among patients, caregivers, and the clinical team can help build a more trusted relationship between patients and clinicians.

Avalere has partnered with Robert Wood Johnson Foundation (RWJF) since 2015 to work toward normalizing cost-of-care (CoC) conversations in clinical settings, including identifying barriers and facilitators to engaging in conversations about cost. CoC conversations can be defined as discussions that address any costs patients and families might face, from out-of-pocket (OOP) to non-medical costs (e.g., transportation, childcare, lost wages). To that end, Avalere collaborated with the National Patient Advocate Foundation to explore the feasibility of patient-centered measure concepts to support quality improvement, increase satisfaction, and improve outcomes. This issue brief highlights the challenges associated with measurement in this space alongside alternative solutions to encourage CoC conversations in practice.

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Doctors Urge Caution in Interpretation of Research in Times of COVID-19

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September 9, 2020

To:      

American College of Cardiology

American College of Chest Physicians

American College of Physicians

American College of Radiology

American Heart Association

American Society of Echocardiography

American Thoracic Society

European Association of Cardiovascular Imaging

European Society of Cardiology

European Society of Radiology

Heart Rhythm Society

Infectious Disease Society of America

North American Society of Cardiovascular Imaging

Radiologic Society of North America

Society of Cardiovascular Magnetic Resonance

Society of Critical Care Medicine

Society of General Internal Medicine

Society of Hospital Medicine

Dear Society Leadership:

We are a group of clinicians, researchers and imaging specialists writing in response to recent publications and media coverage about myocarditis after COVID-19. We work in different areas such as public health, internal medicine, cardiology, and radiology, across the globe, but are similarly concerned about the presentation, interpretation and media coverage of the role of cardiac magnetic resonance imaging in the management of asymptomatic patients recovered from COVID-19.

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