Categories
Clinical General Healthcare Cost Healthcare Costs Healthcare Disparities Innovation Patient-Centered Care Primary Care Quality Improvement

Let Me Be Brief: Medicaid Expansion

A series of briefs by the Texas Medical Students

By: Ammie Rupani and Alwyn Mathew

In 2019, 18% of Texans had no form of health insurance.1 650,000 Texans have lost their health insurance due to unemployment during the pandemic. The rate of uninsured Texans is staggering and has only been worsened by the pandemic. During this critical time, we must talk about Medicaid Expansion and the potential solutions for millions of people with no health insurance. As a medical student, I have seen patients defer life-saving medications such as insulin in order to afford rent or groceries. Consequently, these choices have brought such people to the Emergency Room in diabetic ketoacidosis, which could have been easily avoided with regular insulin treatments. Stories like this are far too common in Texas, and it is important to recognize such outcomes are easily preventable with improved access to health insurance coverage. How can we as students learn to treat people, when the system we are bound to  practice in is perpetuating their very diseases?

Retrieved from Texas Comptroller

Medicaid is a health insurance program managed through the Federal Centers for Medicare and Medicaid Services (CMS). Medicaid is currently jointly funded by the Federal and State governments with the Federal government matching each dollar the State spends. Texas Medicaid is primarily a fee-for-service model that has poor reimbursement rates and high administrative burden that discourages physicians from accepting Medicaid in their practice. Currently, Texas Medicaid coverage is only offered to children, pregnant women, seniors, and people with severe disabilities, who also fall below a certain income threshold. For example, a single mother making minimum wage at her  full-time job is not eligible for Medicaid because she earns too much. However, she does not qualify for Federal subsidies covering some of the insurance cost because she does not earn enough. The Patient Protection and Affordable Care Act of 2010 would help address this woman’s dilemma since Medicaid Expansion would cover all individuals with incomes up to 138 percent of the Federal Poverty Level, amounting to $16,643 for individuals and $33,948 for a family of four. Medicaid Expansion would provide a health insurance option to an estimated 2.2 million uninsured low-wage Texas adults.2

Although the original arguments against Medicaid Expansion in Texas focused on States’ rights and limiting Federal dependence on funding, the primary opposition to this program was the Federal mandate. In 2012, the US Supreme Court ruled that the Federal government could not mandate the Expansion of Medicaid in any State, leading to Texas and several States opting out of the program. Realizing the benefits and improvement in health outcomes, several States have since adopted the Expansion program offered through CMS, including Arkansas (2014) and Louisiana (2016). Currently, Texas spends nearly $40 billion (State and Federal funds) for the Medicaid program, with a 60-40% distribution between the Federal and State Government respectively.3 Expansion would be fiscally sound for Texas as it will reduce the strain on our State budget and draw in more Federal resources. Looking past the dollar amount, it is crucial that medical students and other healthcare professionals recognize the benefits of improved access and early medical intervention that can be achieved through Medicaid Expansion.3


TMA’s Legislative Recommendations4
  • Develop a meaningful, statewide health care coverage initiative using federal dollars to:
    • Extend meaningful coverage to low-income uninsured working-age adults, and
    • Establish a state-administered reinsurance program to reduce premiums for people enrolled in marketplace
  • Provide 12-months’ comprehensive coverage for women who lose Medicaid 60 days
  • Establish 12-months’ continuous coverage for children enrolled in Medicaid, the same benefit given to children enrolled in the Children’s Health Insurance Program.

  1. Accounts TCof P. Uninsured Texans. Retrieved from- https://comptroller.texas.gov/economy/fiscal-notes/2020/oct/uninsured.php
  2. How Many Uninsured Adults Could Be Reached If All States Expanded Medicaid? – Tables. KFF. https://kff.org/report-section/how-many-uninsured-adults-could-be-reached-if-all-states-expanded-medic aid-tables/. Published June 25, 2020.
  3. Federal and State share of Medicaid Spending, 2019, Kaiser Family Foundation- retrieved from – https://kff.org/medicaid/state-indicator/federalstate-share-of-spending/?dataView=1&currentTimeframe=0 &sortModel=%7B%22colId%22:%22State%22,%22sort%22:%22desc%22%7D
  4. Provide Meaningful Health Care Coverage for Uninsured Texans. Texmed. https://texmed.org/Template.aspx?id=55300.
  5. Status of state medicaid expansion decisions: Interactive Map, 2021. Retrieved from- https://kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
Categories
Community Service Emotion Empathy Global Health Healthcare Disparities Innovation Medical Humanities Patient-Centered Care Public Health Reflection

Beyond Medicine: The Peer Med Podcast, Serving Humanity !

Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.” – Voltaire

The covid-19 pandemic has claimed millions of lives, shut down economies, restricted movement and stretched our healthcare systems to the edge; but despite this time of destruction, Peer Med, a podcast dedicated to serving humanity was born! Established as a platform for creation, innovation and above all a platform for unity.

A student-led initiative of the Peer Medical Foundation, the Peer Med podcast intertwines medicine, an ever changing science of diagnosis and treatment, with conversations about issues in healthcare where lives are on the line. Due to the fashionable focus of medical education on biology, pathology and disease there has been a reduced emphasis on the social determinants of health. As such physicians lack an empathetic character understanding the human aspect of medicine and in this, fail to communicate effectively rendering patients dissatisfied with care.

Seeing the need for more fruitful discussions, the Peer Med Podcast provides listeners with a more nuanced interpretation encouraging health professionals to look beyond medicine and into the experiences, values and beliefs of patients to assure a successful therapeutic relationship. It serves as a reminder of the importance of self-determination, beneficence, non-maleficence and justice as medicine naturally exposes health professionals to the darker side of human existence. The podcast explores these themes by delving into the underbelly of life where homelessness, drug addiction, abuse, trauma, and death are brought to the surface of conversations. It takes the already prevalent cases of strokes, pneumonia, heart attacks, fractures, and miscarriages from the everyday scenarios in emergency rooms plaguing our species and encourages a more humane outlook amidst all conflict and chaos.

“Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.”

– Voltaire

Founded on March 24th at the start of the COVID-19 pandemic, Peer Med is dedicated to humanity and the millions of people worldwide without access to education, health and water, sanitation and hygiene (WASH) services. The podcast aims to inspire, engage and promote action to solve challenges in global health, human rights and medicine. Acknowledging that the delivery of healthcare requires a team effort, the podcast invites everyone from clinicians, advocates, economists and even comedians to delve into the subjects of medicine. While peer-reviewed information is important, not all valuable work belongs in an academic journal. In order to strengthen health systems a multidisciplinary set of perspectives is required to teach and inspire people. Therefore, Peer Med encourages dialogue so that all listeners may raise their voices advocating for humanity.

Ensuring Peer Med is truly a global podcast is the goal but despite the best intentions to ensure inclusivity, barriers in terms of gender, language, and access prevent this from happening. To tackle the problem, Peer Med aspires to invite speakers from all corners of the world, not only to assure equitable representation but to also gain advice on how to empower those in low-and-middle-income-countries (LMIC) so that their voices may be heard. In serving humanity, Peer Med is completely free and available on a variety of platforms aiming to leave listeners refreshed, empowered and motivated to effect change. These can be heard from a mobile phone, shared via social media, or played for a friend. The conversations will leave listeners burning with a flame in their hearts to do their utmost on life’s quest to serve humanity.

It serves as a reminder of the importance of self-determination, beneficence, non-maleficence and justice as medicine naturally exposes health professionals to the darker side of human existence. The podcast explores these themes by delving into the underbelly of life where homelessness, drug addiction, abuse, trauma, and death are brought to the surface of conversations. It takes the already prevalent cases of strokes, pneumonia, heart attacks, fractures, and miscarriages from the everyday scenarios in emergency rooms plaguing our species and encourages a more humane outlook amidst all conflict and chaos.

Leah Sarah Peer

The support for the podcast has been humbling as love has poured in from around the globe. So many are keen on sharing their stories and this speaks volumes to the passion of the podcasts’ guests, their enthusiasm and commitment to mankind. Some have included a world renowned speaker and human rights champion, a Brooklyn-based singer, songwriter, teacher and PhD candidate in Comparative Literature, a range of student initiatives – Meet the Need Montreal, Helping Hands, to Non-profit Organizations such as Med Supply Drive and so many more.

World-Renowned Humanitarian & Neuroscientist, Abhijit Naskar

If there is something the COVID-19 pandemic has taught us, it’s the power of community and compassionate care’s strength in uniting us across the world. Peer Med hopes to serve as a medium for inspiration, for reflection, and invites people from across the healthcare spectrum to come together committed and dedicated to serve humanity.

To listen to Peer Med, visit Spotify, Apple Podcasts. To read about the individual episodes visit the website for more.

Categories
Clinical General Opinion Patient-Centered Care Quality Improvement

Notes from a waiting room: What are doctors doing while I’m waiting?

Hello Clinical Laboratory, my old friend,

I’ve come to take my blood test with you again. Because my specialist wants the latest update, so I visit you every 3 months. My appointment was 48 minutes ago, and there are 16 people who arrived earlier than me, still waiting. As the clock ticks, I can hear everything but the sound of silence. Of course you are not alone, Clinical Lab; my other doctors made me wait for them as well. On average, Americans wait 19 minutes and 16 seconds to see a physician, according to Vitals’ Wait Time Report [1]. But the report forgot to add the wait time for check-in at registration and in the examination room. The funny thing about waiting in a clinical laboratory is that a majority of the patients have been fasting before a blood test. So now your patients are not just becoming impatient, but also hungry (or as young people like to call it, “hangry”) as we enter lunchtime.

You offered some reading material to help us pass the time. Many clinics present entertainments like magazines and television to improve the waiting experience [2]. I once visited a fancy clinic that provided an espresso machine for parents and a touchscreen-wall video game for their children. But I have to tell you: I have watched this Judge Judy episode four times in other clinics’ waiting rooms, and I have no desire to touch this well-thumbed Cosmopolitan magazine. Thank you, but, no thanks.

You might wonder why I care about waiting so much. Let me be honest with you: like most of your patients, I compare the waiting time with the time actually spent with the doctor [3]. As patients, if we spend 45 minutes waiting but only get 5 minutes of the doctor’s time, we won’t feel all that waiting was worth it. Certainly, I understand that a vast amount of effort was made behind the scenes. Like the story of Picasso and the bold woman, most people don’t understand that a seemingly effortless one-stroke drawing actually took a lifetime of practice to achieve [4]. I imagine that Dan Ariely and Jeff Kreisler would happily back me up in their book Dollars and Sense: “Assessing the level of effort that went into anything is a common shortcut we use to assess the fairness of the price we’re asked to pay” (in our case, we pay with time).  To solve the problem of customers being reluctant to pay for “invisible effort,” Dan offered the solution of providing transparency [5]. For example, shipping tracking shows all the transactions in each location, and an open-kitchen restaurant shows its staff busy fulfilling food orders. Needless to say, due to medical confidentiality, you can’t have an “open clinic” that shows the staff taking blood pressures or running tests to everyone in the waiting room. But perhaps you could still give us some indication of the “behind the scenes work.” Tell me that you were reading my medical history, that you were double-checking my results, or that you were researching the latest cure. It would make me feel much better to know that you were doing all the “ground work” while I was waiting for you. And I will pretend that I didn’t see you eating bonbons and doing crossword puzzles as I walked past the doctors’ lounge.

And now, I would like to end this letter with a quote from Oscar Wilde’s “The Importance of Being Earnest”:

If you are not too long, I will wait here for you all my life.

Yours truly,

Yi-Lin

 

References:

  1. Vitals wait time report. (2018). Retrieved from https://www.vitals.com/about/wait-time
  2. Ahmad, B., Khairatul, K., & Farnaza, A. (2017). An assessment of patient waiting and consultation time in a primary healthcare clinic. Malaysian Family Physician : The Official Journal of the Academy of Family Physicians of Malaysia, 12(1), 14–21.
  3. Huang, X. (1994). Patient attitude towards waiting in an outpatient clinic and it’s applications. Health service management research. Retrieved from http://journals.sagepub.com/doi/pdf/10.1177/095148489400700101
  4. Airey, D. (2017, September 25). Picasso and pricing your design work. Retrieved from https://www.davidairey.com/picasso-and-pricing-your-work/
  5. Ariely, D., & Kreisler, J. (2017). Dollars And Sense: How We Misthink Money And How To Spend Smarter. Harper

———

Author: Yi-Lin Cheng (website)

Editor: Mary Abramczuk

Image credit: Abraham Solomon, “Waiting for the Verdict” (England. 1859), The J. Paul Getty Museum, via Getty.edu

Categories
Clinical General Healthcare Costs Opinion Patient-Centered Care Reflection

Excellent, good, or fair? How accurately can patient satisfaction surveys measure quality of care?

Last week I had my semiannual dentist appointment. Right after I stepped out the door, I received an email: Dental Office – Patient Satisfaction Survey. Hi, thank you for visiting the dental office. Please take a minute to complete the survey…. Was it a déjà vu? Didn’t I just fill this out recently? Oh wait no. That was for the hygienist? Or was it for that new periodontist? Maybe it was my other specialists?

So besides rating my favorite restaurants and shops on Yelp and Google, now my clinics and insurance companies also want to know how I would rate my doctors– how splendid!

To my surprise, when I clicked the link, the questions were trickier than I expected. According to the email title, it seemed like the survey was about my dentist, but 75% of the questions were about the clinic itself: Waiting time in reception area, appointment phone call answering friendliness, waiting room neatness, office decoration….(Wait…my dentist is responsible for decoration? Great, let’s talk about changing the interior lighting and repainting the wall at the next appointment). As I was filling out the questionnaires, my head started to spin with my own questions: It was a normal checkup appointment, will “fair” be good enough? But I remembered I had given the hygienist an “excellent,” and honestly I couldn’t tell which one was better…oh boy! How are they going to use my answers? Who will be reading my survey responses? Who will be affected by my answers?

To me, it’s difficult to judge the doctors’ performance fairly. I can measure a finance manager by his portfolio performance, a designer by how many designs have been ordered, and a lawyer by how many lawsuits she has won. But judging a doctor is more like judging a piece of artwork: there’s a lot of subjectivity. How do I know Dr. ABC is better than Dr. XYZ? By my test result? Or by the number of medications they prescribe? Like with my dental visit, I couldn’t really tell the difference between that cleaning from the previous ones. Interestingly, some physician groups use patient satisfaction surveys to allocate bonuses [1]. That would make the weight of responsibility seem heavier; I would hate to find out that my dentist lost his Christmas bonus because of my thoughtless answers.

Needless to say, it’s difficult for management to evaluate every department and employee in a large organization. I truly hope that upper management does not blindly rely on this “big data” to determine a doctor’s career path. I would very much like my doctor to focus on my health, instead of for him or her to be driven by monetary incentives and to act as a salesperson. If the survey data is used for allocating the budget, perhaps the survey needs to be transparent about how the clinic is going to use the result: “This survey is for quality training purposes only” or “this survey is for determining the best doctor of the month and who gets the nearest parking spot.” I suspect that knowing the purpose of the survey helps the respondent think twice before jotting down comments or complaints. It might motivate patients to actually finish the survey (I would very much like to meet the saintly soul who is able to finish 30 ambiguous questions without losing their temper). Also, I would like to suggest that since we are giving patients such power, perhaps we can give some power to the physicians too and allow them to rate their patients (like how Airbnb and Uber lets hosts/drivers grade their guests/riders).

Surveys and ratings can be important sources of information. If I need to find a new doctor or specialist, the first thing I do is go on Yelp and sort the list by how many stars they have. Some industries routinely rely on survey systems to improve their customers’ experiences [2].

I understand that the idea behind patient satisfaction surveys is to encourage more communication. But at the end of the day, I believe that the doctor and the patient should have a strong mutual trust that enables them to communicate and give feedback freely and respectfully, without needing to rely on 30 ambiguous survey questions.

 

Reference:

  1. White, B. (1999, January 01). Measuring Patient Satisfaction: How to Do It and Why to Bother. Retrieved April 17, 2018, from https://www.aafp.org/fpm/1999/0100/p40.html
  2. Columbus, L. (2018, April 22). “The State of Digital Business Transformation, 2018.” Retrieved April 25, 2018, from https://www.forbes.com/sites/louiscolumbus/2018/04/22/the-state-of-digital-business-transformation-2018/#761f84535883


Edited by Shaun Webb

Photo credit: Steve Harris

Special thanks to Blog Associate Editor, Janie Cao, for some last-minute content revisions

To learn more about the author, please visit her website here

Categories
Emotion Empathy General Humanistic Psychology Literature Opinion Patient-Centered Care Psychiatry Psychology Public Health Reflection

Book Review: Loose Girl by Kerry Cohen

Hi MSPress Blog Readers!
……
We didn’t have a blog post scheduled for this week, so here’s a book review instead 🙂 I read this book last week for my Adolescent Sexual Health MPH course and enjoyed it.There’s a lot of interesting tidbits on sexual health issues. I mention two.
Even if you don’t agree with everything the author says, I think memoirs can be helpful in showing you unique life perspectives based on true experiences that you may never have experienced yourself. Furthermore, reading memoirs can get you acquainted with potential resources to help others. Ever heard of bibliotherapy, anyone? 🙂
……
Your Blog Associate Editor,
Janie Cao

Categories
Clinical General Healthcare Costs Law Opinion Patient-Centered Care Primary Care Public Health Reflection

Discontinuity in Care

My resident tries fairly hard to take care of his patients. When he is with them, I catch him paying attention to all sorts of details that he could have easily let slip past. So it made it all the more difficult when I saw him enraged. When he opened up his list of clinic appointments one morning, on the list was a patient he did not want to see. It was not just that she was a new patient to him. It was not just that her problem list went on like a run-on sentence. It was that both were true, and my resident was still expected to see her in only 15 minutes.

While chart reviewing, he learned that the only consistency in this patient’s medical care at our clinic had been a history of inconsistent providers—and based on their notes, none of them had the complete story. “Why am I even seeing her?!” my resident asked rhetorically, as he frantically searched for answers he knew he did not have the time to find. I wondered, too. This visit seemed to benefit no one except the Billing Department, and even that would depend on whether the Medicare reimbursements actually made it through.

That patient’s experience was hardly unique, though. While rotating through various specialties as a medical student, I have met several patients who were passed from one provider to another. Maybe the provider had to switch services. Maybe they left the institution for better opportunities elsewhere. The reasons were myriad. Stories like those suggest that continuity of care may still only be a priority in primary care literature.

I think one reason for this reality is a lack of incentives to keep doctors and patients together. In any field, including medicine, we see money driving people’s attention and vice versa. Since our country has historically kept primary care on the back burner, there is little evidence to believe that practical incentives for continuity of care will spontaneously appear in the near future.

So, for the primary care fans out there, it might be worth it to start speaking up.

 

Photo credit: Norbert von der Groeben/Stanford School of Medicine, posted by National Center for Advancing Translational Sciences

Categories
Clinical Patient-Centered Care Reflection

“Listen to understand” not “listen to reply”

A two-month stint at the oncology department in a Singapore government hospital has provided me with vivid examples of the importance of doctor-patient relationships and communication. Cancer, in many societies, is still widely regarded as medical taboo – a condition people closely associate with death. While I got to witness very sensitive and depressing conversations in relation to end-of-life care, the most impactful conversation I experienced had nothing to do with end-of-life care. Rather, it was a complaint from a patient about his team of allegedly negligent doctors.

It took place in a private ward room with just Mr. C and his wife. When I first entered the room, Mr. C gave me a hostile look and asked me who I was. Feeling awkward given the cold welcome, I persisted to introduce myself as a medical student who wanted to take his history. Although reluctant, he agreed to talk to me. What started as a cold introduction turned out to be an hour-long avenue for Mr. C to vent his anger and frustrations. It became etched in my mind for the important lesson that came with it.

I understood from Mr. C that it was not the diagnosis that brought about his unhappiness, but how the diagnosis came about.  Mr. C presented with a 6-month history of progressive dull epigastric pain and loss of weight with no co-morbidities. He had no associated fevers, nausea or vomiting. The conversation went well until I asked him the question, “Did you bring this to your doctor’s attention?”

Immediately, there was a change in his facial expression. I divined from his grim expression that the news was not good. He started shaking his head, somewhat in disappointment. His wife started tearing. I had inadvertently asked a sensitive question and was caught helplessly in that moment of grief and sorrow.

Mr. C then explained that he actually went to the Emergency Department (ED) thrice as his abdominal pain worsened. Unfortunately, on the first two occasions, they sent him home after establishing that his vitals were stable with no abnormalities in his test results. He was sent home with a stack of medications but without a diagnosis.

Interestingly, Mr. C actually suspected himself that he had gastric cancer given his strong family history; he expected that he would suffer from it one day. The doctors shook it off despite his persuasion. On the third visit, however, the doctors finally admitted him and performed an endoscopy. It was later confirmed to be Stage 3 gastric cancer. It was at this point in the conversation when emotions started running wild.

The atmosphere heated up. I was shot with questions and complaints by both Mr. C and his wife.

“I would not have been denied earlier detection and treatment if doctors listened to my history,” Mr. C said.

“That period of 6 months could have made a huge difference to his disease stage and prognosis!” Mr. C’s wife added.

“Do you think the doctors have done the right thing for me?” he asked.

“Doctors never bother to hear patients out!” he shouted.

It felt as if the blame was on me, and I felt angry for a moment. I was on the edge of questioning his accusations, and refuting his comments. I was conflicted inside. On the one hand, the manner in which he was treated at the ED seemed unjustified. But at the same time it did not seem fair for me to blame the doctors without understanding what their line of thought was.

I further understood that Mr. C had explained his case to a senior consultant, who was also the surgeon who performed his gastrectomy. The surgeon brushed Mr. C off, and told him rudely to switch to another hospital if he did not like it here. It was at this point that I stood in favor of Mr. C. I actually could not believe such an insolent comment would come from the mouth of a senior doctor, whom I thought was supposed to possess the maturity and authority to handle such a complex matter.

Mr. C and his wife were evidently distraught with how the diagnosis came about, compounded by the fact that he was still relatively young to suffer from stage 3 gastric cancer. He explained that gastric cancer is one of the most aggressive and treatment-resistant cancers with the highest mortality rate, as evident from the young deaths of his family members who succumbed to the illness. My heart immediately sank after coming to terms with his bleak prognosis.  I recalled what was taught in my clinical skills classes, and took on an empathetic coat to try and calm them down. I felt an ephemeral sense of shame for the apparent lack of professionalism Mr. C’s doctors had displayed. Furthermore, I was sunk in guilt for initially doubting his comments.

I continued with the rest of the history and thanked Mr. C and his wife for their time. I walked out of the room and told them, “Thank you for sharing with me. Both of you have taught me about the kind of doctor whom I do not want to emulate in the future”.

It was an eventful hospital experience for Mr. C, and a rather eventful conversation for me with him and his wife. Despite the awkwardness and negative emotions, it taught me a great deal about the nature of difficult situations, the qualities a doctor should possess, and the importance of communication.

It was no doubt a challenging conversation. It was unlike all the other conversations I have had with patients, that were full of praise for their doctors, which always reassured me of my choice to become one.  My limited exposure to issues that arise from the lack of proper doctor-patient communication caught me off guard during this particular conversation.

When I mentioned to Mr. C that I was a medical student, his facial expression and body language conveyed his bitterness and dissatisfaction. It was almost as if he had something against me. I was filled with self-doubt and hesitancy. I was unsure if I should persist with the conversation given his hostile appearance but I knew that he had a story that he was dying to tell. Mr. C’s experience at the ED has probably altered his perception of doctors, and it was worth it to hear him out.

In hindsight, I am consoled by the fact that I had that conversation with Mr. C because he gradually opened up to me, treated me as an avenue to vent his frustrations, and perhaps subconsciously, taught me a lesson or two about being a doctor. I have learned that patients are always keen for a listening ear, be it to share their joy, or to pour their sorrows. It is hence important for medical students like me to not be doubtful when approaching patients for the fear of intruding in their privacy or taking up their needful rest time. Never be afraid that you are just an unqualified medical student.

Communication is the crux of medicine. As Sir William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” History-taking is not just about the whims and fancies of signs, symptoms, investigations, and differentials. It is in fact a conversation, an opportunity to build rapport and trust with the patient. We are not community health surveyors ticking off boxes in our questionnaire; we are there to hear our patients out by expressing their problems and concerns. There is no better opportunity than in medical school, where you are not confined by the “rush hour” situation in hospitals, to hone these human skills.

Fortunately, patients tend to given you their trust, and willingly share their most personal information with you. This has shown me the power imbalance of the doctor-patient relationship, which arguably has been exploited in Mr. C’s case – i.e. doctors sometimes do not give patients enough attention.

Another issue that I struggled with was handling the complaints that were hurled my way. My lack of maturity was evident from my agitation, and the urge I had to refute Mr. C. Deep down, I was conflicted and defensive. Mr. C’s story contradicted my own impression that all doctors do their best for patients. It felt as if I was taking the blame on behalf of all doctors. However, I decided to stay quiet about it. I learnt that doctors aren’t  “super-humans” who will never make mistakes. It was only when I started consolidating my thoughts and weighing out the situation that I was eventually convinced that Mr. C’s care was indeed compromised by the negligence of his various doctors.

Admittedly, I handled the situation rather poorly. I reckon it was largely due to lack of exposure to such situations, especially given the sheltered, cozy environment we enjoy in medical school. Clinical interactions are based around simulated patients who, more often than not, have simple presentations that are short enough for us to take a history and perform a physical examination. Everything is staged for us to learn in a protected environment. Even in hospitals, the patients we see are recommended by interns as “cooperative enough” for us to take a history.

Medical students should be taught how to deal with complicated cases through the use of simulated patients. When I say complicated, I mean in a psychosocial sense rather than in a medical sense. The skills needed to deal with these situations are those that cannot be taught through textbooks, but through practice. These are human skills; skills that define the art of medicine. These non-scientific skills may not be as interesting as pathology, physiology or anatomy, but are equally, if not more important than the scientific aspects that students are often keener about.

Students are often enthusiastic to ask senior doctors about the scientific aspects of a patient’s presentation. Similarly, they should not be shy to ask them about approaches they should adopt when such situations arise. I am inclined to believe that most students underestimate the importance of communication, which often takes a backseat in their learning priorities.

Medical schools can no longer assume that their students are equipped with the necessary communication and social skills from just clinical skills examinations, which are often not representative of an actual hospital setting. Rather, explicit emphasis on the mastery of such complicated yet common social presentations, should be made an integral part of the curriculum.

I have learned the importance of giving patients the space to talk. For example, in my encounter, I was close to interrupting Mr. C when he was complaining about his experience. Having done so, however, would have prevented me from comprehending the entire situation in context. As medical students, we need to appreciate the difference between “listening to reply” and “listening to understand”. Practice the latter, not the former. Never be too quick to cut off your patients halfway through, and jump to conclusions. Let them tell their whole story, and you will be surprised to find that it contains most of the answers you need.

Photo Credit: Ky

Categories
disability Emotion Lifestyle Patient-Centered Care Psychology

Nodding Along

My grandmother was a strong and compassionate Egyptian woman, a mother of three, and a pathologist. On a glass slide, exactly like the ones she used daily, cells from her colon biopsy were identified as undifferentiated, and within days she was diagnosed with Stage IV Colon Cancer.

Although I am learning how to care for people in sickness and health, someday, the chest compressions will be applied to my chest. Disease knows no discrimination, and death unites us all. Thousands of cancer diagnoses and precise and growing knowledge of cancer cell types did nothing to protect my grandmother from that which she knew so much about.

In Egypt, cancer is called ’the bad disease’, and bad it is. Over the next couple months, we watched as the bad disease took our beloved grandmother away from us. During that time, my family members, and my grandmother, had to make a series of challenging decisions that they were very obviously not prepared to make.

Medical advancements, although the main reason we are living longer lives, have caused the complexity and variety of end-of-life decisions to be ever increasing. Uneasy about the series of decisions that my family had to make and handicapped by my ignorance, I found myself reading Being Mortal by Atul Gawande. Atul Gawande led me through a vulnerable and imperfect but inspiring conversation about death and dying, exposing our medical system’s inability to understand health beyond the one-dimensional, and presumptuously noble, endeavor to prolong life at any cost.

While reading Being Mortal, I found myself enthusiastically nodding along, agreeing with the theme of the book: we need to change everything about our simple but destructive approach to aging and our increasing elderly population. Our singular approach to prolonging life simplifies complex social and medical decisions. It seems the attitude now is that longer life is all that matters. Ensuring nutrition and shelter is our only standard for a viable living environment for the elderly. We are failing our parents and grandparents.

Atul Gawande’s presentation of ideas changed how I perceive aging and our healthcare decisions at the end of life. I became a strong advocate of having conversations about the inevitability of our death and the choices we want to be made during our end-of-life care. I was convinced that society and healthcare should ensure that the elderly remain the authors of their own stories for as long as they are willing, and actively empower them to do so. Nutrition, shelter, and minimizing fall risk are minimums of care, not acceptable standards.

The Literature in Medicine Student Interest Group at my school decided to read Atul Gawande’s Being Mortal, and I could not be more excited. In the middle of our meeting discussing the book, as I was passionately sharing my ideas, it occurred to me that although I was full of strong opinions, I had done absolutely nothing to be a part of the solution. My grandfather had come to live with us after his wife of 55 years, my grandmother, passed away from colon cancer, and my only roles/concerns in his care have been to ensure food, sleep, and meds. My strong opinions had not inspired my actions.

Nodding along to Atul Gawande’s criticisms of our medical system is easy, but having an honest conversation with my grandfather about his priorities and end-of-life care preferences as he reaches 90 years of age is not so easy. How might I empower my grandfather to continue to be the author of his story? Believing that healthcare is a right and not a privilege is easy, but carrying out the responsibility that this belief invokes is not so easy. How might I work to help provide all my neighbors with equal access to high-quality care? Practicing the invaluable intervention of presence is not easy, and working day after day to hone my abilities at the art of empathy is not easy. How might I overcome my doubts, fears, and insecurities, and avoid being frozen into lack of compassion?

Too often my strong opinions do not inform my actions. Too often my hate for dysfunctional and unjust systems overshadows my love for the people in the systems. I call myself to love my neighbors more than hate the systems, for love is actionable and hate is stifling and tiresome. Let love fuel the tank, for compassion-based activism is the only kind that goes the distance.

Photo Credit: Dan Strange

Categories
Clinical Patient-Centered Care Psychiatry Public Health

If you don’t ask, you’ll never know

On the first day of my first rotation as a medical student, my preceptor shared this bit of wisdom: if you don’t ask, you’ll never know.  In the nearly 18 months that have followed, I think about those words on a daily basis. To my mind, asking questions does more than just help us gather data. Asking questions establishes the type of relationship we are going to have with our patients. There are so many questions I wish I would never have to ask, whose affirmative answers are often indicative of the cruelty of this world. But when I ask about things like whether a patient has been the victim of abuse, I hope it sends the message that the relationship we are about to embark upon is one that can withstand such unpleasantness.

Not only can it be excruciatingly frustrating when other practitioners don’t share this point of view, it potentially has grave consequences. Unfortunately, patients with mental illness often seem to be the victims of physician “brush-off.” As someone who plans to devote her life to working with the mentally ill, I can only hypothesize as to why the same patients I find so much joy in working with are often given sub-par medical care as compared to their non-mentally ill peers. Perhaps physicians feel uncomfortable providing care for patients who come across as different than the norm, or perhaps their medical problems are too frequently attributed to psychiatric causes.

I recently cared for a patient who was two weeks post-partum from the birth of her first child. Though she was being seen for psychiatric admission, multiple aspects of her health were addressed during our initial evaluation.  When asked about her post-partum health, she denied having been scheduled for a post-partum visit with her obstetrician. Casually, she mentioned that she was having some malodorous green discharge since giving birth. It doesn’t take a medical degree to know that green, foul-smelling discharge is not a good sign, let alone when it occurs in the immediate post-partum time period. We were able to secure a next-day appointment with our hospital’s obstetrical practice, and with the patient’s permission, called ahead to the clinic to alert them of her complaints.

The next day, the care team gathered around to read the note from the obstetrician who had seen our patient. The note comprised all of five lines.  There were no pending labs. There was no mention of a physical exam.

There was no mention of the discharge at all.

The American Congress of Obstetricians and Gynecologists (ACOG) states, “It is recommended that all women undergo a comprehensive postpartum visit within the first 6 weeks after birth. This visit should include a full assessment of physical, social, and psychological well-being.”[1] The issue here, though, isn’t really about post-partum care. The issue here is about how we as health care providers need to provide equal care for unequal bodies and minds, and how we need to protect and advocate for our patients.

Patients with mental illness undeniably have poorer overall health. The average lifespan for an American adult with mental illness is a striking 30% shorter than for a non-mentally ill individual.[2]  While it is known that mental illness itself creates difficulty in accessing the healthcare system, for mentally-ill patients who do access healthcare, their quality of care is demonstrably lower than it is for those without mental illness. Literature consistently demonstrates that patients with psychiatric diagnoses receive fewer preventative health measures and have overall poorer quality healthcare than patients without psychiatric diagnoses.[3],[4] No matter what field of medicine you are in, you will see patients with mental illness. For these patients who sometimes cannot speak for themselves, the role of the physician in patient advocacy becomes even more crucial.

I will never know exactly what transpired during that appointment between my patient and the obstetrician, but I do know that obstetrician did not ask the questions that needed to be asked, and therefore did not ascertain the information necessary to appropriately care for the patient. At our request, a different practitioner saw the patient again. This time, the appropriate questions were asked, the appropriate testing was completed, and ultimately the patient was diagnosed with a sexually transmitted infection. Left untreated by the first obstetrician, this infection could have caused my patient systemic symptoms and permanent infertility.

As future physicians, it’s important for us to keep asking questions. So often, I have been surprised by the information I find when I ask a question about which I almost kept silent. Equally as important as asking the questions, however, is doing something with the information that you receive. The good doctor isn’t necessarily the one that stops the green discharge; they’re the one the identifies the problem in the first place and advocates on behalf of the patient to get the best people for the job.

[1] https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care

[2] http://europepmc.org/abstract/med/19570498

[3] http://journals.lww.com/lww-medicalcare/Abstract/2002/02000/Quality_of_Preventive_Medical_Care_for_Patients.7.aspx

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951586/

Photo credit: airpix

Categories
Clinical Lifestyle Patient-Centered Care

Running Low and No Longer Running

I recently completed a rotation in endocrinology, and I learned valuable lessons about diabetes management in both the inpatient and outpatient setting. Today, I wanted to share a clinical pearl generally not discussed in lectures: Diabetic patients often gain weight because of the fear of hypoglycemia.

That’s right. The fear of hypoglycemia drives patients to eat a little more at meals. Let’s backtrack. Patients who have persistently elevated sugars are often started on insulin in addition to oral agents. Depending on their insulin regimen, patients may not eat enough after an insulin dose to prevent a drop in blood sugar. Patients who experience a hypoglycemic event try their best to prevent it from occurring again. This is understandable—fainting is scary and should not be taken lightly (pun intended).

The problem is that patients counteract this fear of hypoglycemia by either eating more after an insulin injection, or by exercising less. This impedes diabetes management. In addition to advising our diabetic patients to monitor their carbohydrate intake, we urge them to start some form of physical activity. Physical activity enhances the body’s insulin sensitivity—it gets to the core of the problem (insulin resistance) and improves overall cardiovascular health as well. But how can we encourage these lifestyle modifications if our patients are getting lightheaded after injections?

The answer: carbohydrate counting and education.

Not the answer: increasing insulin.

My attending explained that “increasing insulin” is actually what happens in some cases. For example, let’s say a patient named Sara comes in for her follow-up appointment and unknown to us, has “fear of hypoglycemia.” Sara brings her glucose meter, and the sugars are poorly controlled. Part of the reason for this poor control is secondary to a) eating more after an injection to prevent fainting and b) decreased physical activity to prevent fainting. Now, if we just treat her numbers, we would increase her insulin.

The lesson here is that one can’t just treat the number in medicine. Talking to the patient, even for a few minutes, will provide the story. Increasing the insulin perpetuates a viscous cycle, and breaking the cycle comes from better regimen management. Validating patient concerns about hypoglycemia and educating them on injecting based on carbohydrate intake is invaluable.

Photo Credit: Melissa Johnson