tag:blogger.com,1999:blog-8831981328545272024-03-12T17:35:00.934-07:00The MessyOne doctor muddles through the health care systemEijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comBlogger23125tag:blogger.com,1999:blog-883198132854527.post-12486866836996580922013-01-01T21:48:00.001-08:002016-03-11T13:10:50.627-08:00Healing Wounds<!--[if gte mso 9]><xml>
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<span style="font-family: "arial";">Maria was one of my
luckier patients, someone with a solid support system and safe home. She came
into the hospital for a relatively small surgery. Her concerned family drilled
me with questions.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "arial";">“How is her wound?”<o:p></o:p></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: "arial";">“It’s looking pink and
clean, just like it should.”<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: "arial";">“Is <i>abuelita</i> in
pain?”<o:p></o:p></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: "arial";">“I think the morphine is
helping. Her face is peaceful.”<o:p></o:p></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: "arial";">“Can she hear us?”<o:p></o:p></span></div>
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<span style="font-family: "arial";">“Maybe. Talk to her. Hold
her hand. Let her know you are here.”<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "arial";">Unfortunately, Maria
suffered a major operative complication. And, even though she woke up after a
second emergent surgery, she soon went into multi-organ failure.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "arial";">I was heartbroken,
struggling with how to explain what happened to the family and myself. Despite
my best efforts and the tools of modern medicine, Maria’s life was slipping
away. I stayed up nights replaying what happened before, during, and after the
surgeries. I went into work early to do thorough physical exams; I stayed late
to scrutinize lab results and imaging studies. I consulted subspecialty teams
to patch up every failing organ. I relentlessly called the nurses and residents
for updates, and bombarded my attendings with details about Maria’s
medications, oxygen supplementation, and fluids. Her family members weren’t the
only ones praying for a miracle.<o:p></o:p></span></div>
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<span style="font-family: "arial";">“She’ll be ok, right, doc?
Please do everything you can. She was bossing us around before she came in.
She’s a fighter.” The family said this every day, as if repeating it could make
it true.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "arial";">I nodded. “We’ve been
taking care of her a long time, and will keep doing so. She’s in critical
condition, but we will do everything we can. She won’t suffer.”<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "arial";">Partly out of guilt and
partly to prove my commitment, I took extra care to tend to Maria’s open wound
every day. While I removed the drenched dressings, gently scrubbed the edges
clean, and placed new gauze, I talked to her family members. I explained the
numbers on the vitals monitor and went through each intravenous drip. I
described for them what was happening to her heart, lungs, and kidneys.
Sometimes, she was better for awhile, and then declined, and then held steady. I
didn’t want to take away Maria’s family’s hope, but I also didn’t want them to
be surprised if she died sooner rather than later.<o:p></o:p></span></div>
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<span style="font-family: "arial";">“Her hands are so swollen
it looks like they’re going to pop. Last night, she started gurgling. What do
we do now?” For the first time since I met him, the grandnephew looked
defeated. He had organized a family schedule to make sure Maria was never
alone, and took the late shifts himself.<o:p></o:p></span></div>
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<span style="font-family: "arial";">“Can you get the family
together? I think we need to talk again.”<o:p></o:p></span></div>
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<span style="font-family: "arial";">“Ok doc. We’ll be here. An
hour? Will you still be here?”<o:p></o:p></span></div>
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<span style="font-family: "arial";">“Yes, of course.”<o:p></o:p></span><br />
<span style="font-family: "arial";"><br /></span></div>
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<span style="font-family: "arial";">Maria passed away a week
after her second surgery.<o:p></o:p></span></div>
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<span style="font-family: "arial";">Perioperative mortality is
a known occupational hazard for all gynecologic oncologists. No matter how
meticulous we try to be, we all know that patients may die from surgery.
Sometimes, we re-operate only to find that the problem is beyond repair.
Occasionally, we can identify the mistakes. Most often, we are grappling with
messy uncertainties, trying to make sense of the perpetually moving targets of
clinical data. Like patients and families, we too bounce between the extremes
of optimism and objectivity.<o:p></o:p></span></div>
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<span style="font-family: "arial";">When Maria was dying, it
might have been practical to step away. More experienced physicians advised
that I shouldn’t try to do everything. I had other patients to tend to, and I
needed to pace myself to avoid burn-out. They said it would be prudent to call
a palliative care consult and let “the professionals” take over the end-of-life
discussions. In a fragmented county system where the patients and families see
a different face every shift, the family would not have expected more from a
surgeon.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: "arial";">Yet, though I could no
longer fix Maria’s broken body, I felt responsible for her family’s experience
of grief. Staying to the end felt like the right thing to do under the
traumatic circumstances. As I physically tended to Maria’s open wound, I was
preparing her family for their impending loss. I wanted to communicate that my
team would be present in the most vulnerable and difficult moments. We would
see them through, even if there was little left to do <i>medically</i>.<o:p></o:p></span></div>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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</xml><![endif]-->
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<style>
/* Style Definitions */
table.MsoNormalTable
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mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-parent:"";
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<span style="font-family: "arial";">The night before Maria took
her last breath, I shook each family member’s hand and they thanked my team for
“having a heart, and not just doing our jobs.” We all had tears in our eyes.
Despite the deep sadness, there was an air of peace. The wound healing had
begun -- the one without a roadmap.</span></div>
</div>
</div>
<div class="separator" style="clear: both; text-align: center;">
</div>
</div>
<!--EndFragment-->Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-77250717134892583932012-11-18T22:40:00.001-08:002012-12-02T08:22:40.523-08:00A View from the Trenches<!--[if gte mso 9]><xml>
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</div>
<span class="Apple-style-span" style="font-family: Arial;">The line starts forming outside
the building around 6 AM. When I walk from the parking lot to the cafeteria to
get my morning coffee, I see my patients, crowded under the awning, ready for
the monthly ritual of coming to a county cancer clinic. Many of them have bags
packed with magazines and snacks. Some are catching up with other patients who
have become their friends. Some are holding sleeping grandchildren in their
arms. I marvel at how they have adapted their lives to a clunky bureaucracy
that doesn’t respect their time. The ones who are first in line may get in
before noon, and maybe even get their chemotherapy the same day. The ones in back
of the line could be there until 8 pm at night, and then have to return the
next day for their treatment. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">Inside the clinic hours
later, I am running back and forth between two rooms, seeing patients as fast as
I can. I sit down in one room and ask Maria how she is doing. Immediately, she
bursts into tears. She lost her apartment this week because she has been unable
to work. Her landlord wouldn’t even let her back in to get her clothes. Her
nephew was kind enough to take her in, but her chemotherapy schedule has made
it impossible for her to get a new job. We discuss how she has been through
multiple lines of chemotherapy already, and options are limited. There is no
cure and I can’t guarantee that what we are doing now will help. She nods
acceptingly. Maria asks only one question: do I have a cell phone charger for
her flip phone? The battery died, and her ride’s number is in there. We get
lucky in the waiting room and find another patient who has a compatible charger
with her. Maria is happy for the small victory.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">I see Gloria next. It’s an
easy visit. She has completed her treatment. When I enter the room, her husband
has his arm around her shoulders, and her sister is holding her hand. They look
at me with anxiety and anticipation. I cut to the chase. “I have good news. We
don’t see any cancer on the CT scan.” I am pulled into a group hug. “You saved
my life!” Gloria exclaims. Her sister cries, and the husband leans back in his
chair with relief. I give my spiel about close monitoring. They ask if she can go
to the Philippines for vacation. I joke, “Only if you take me with you!”
Everyone laughs, as months of blood tests, side effects, and fear momentarily
melt away. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">I close out my day with Lily
and her husband, quiet people who have been coming to the clinic for years; her
disease is stable. Her husband tells me that on my recommendation, they bought
a new bed. Not only has Lily’s back pain improved, he is also sleeping better.
Lily’s wig is askew, and she looks distracted. She shares that her daughter is
having a baby soon. I congratulate her and ask her when she is going to visit.
She points to her percutaneous nephrostomy, a drain that empties urine from her
kidney, and says she doesn’t think she can be around a newborn with that “dirty
tube.” I see from her recent imaging tests that the kidney has minimal function,
and I propose we remove the tube. Lily laments that it takes weeks to get an
appointment with the interventional radiologist. I step out of the room to call;
the radiologist confirms that it would take weeks for him to see her, and I ask
for instructions to remove the tube myself. When I cut the hidden sutures and
the tube smoothly slips out of Lily’s back, she stiffens for a moment, then
relaxes. “Ok, I want to see the baby pictures,” I tell the couple. Lily smiles
for the first time that day, “You are a good doctor.” Her husband beams at me.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">When I chose to
sub-specialize in gynecologic oncology, I thought my days would be filled with
operating, concocting chemotherapy regimens, and staying up to date on clinical
trials. What I found out very quickly was that being a gynecologic oncologist
often has more to do with managing the <i style="mso-bidi-font-style: normal;">fall-out</i>
of cancer, rather than the cancer itself. Patients come wanting you to make the
cancer go away, because they think you have the secret to making their lives
normal again. Over and over, my patients tell me they will do anything I say. They
bring in soaps, fabrics, recipes, and herbs for my approval before use. They
want my permission to take day trips. Betrayed by their bodies, they no longer
trust themselves to know what’s safe.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">The humbling reality is that
there is no cure for most cancers right now. We can do everything right and cause
harm to the patient; we can do everything wrong and the patient thrives. My job
focuses instead on empowering the patients to regain each precious moment of their
lives, despite the cancer. I try to convince them that cancer is an aspect, not
the totality of their existence. And in the final moments when there is no
earthly solution for the suffering, I try to help the families make peace with
what can’t be controlled. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">In this way, I am comforted
that my work serves some good, even though it is far from perfect. In the
trenches of the War on Cancer, the small daily battles matter just as much,
because so many unique lives hang in the balance.<o:p></o:p></span></div>
<!--EndFragment-->Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-87883995386807925882012-06-29T06:07:00.000-07:002012-06-29T09:13:01.608-07:00An Essential Connection<br />
<div class="MsoNormal">
<span style="font-family: Arial;">When I first met José, he
was already intubated in the ICU, breathing only with the help of a ventilator.
Suffering severe pneumonia, he had been found unconscious in his apartment by the
landlord. José wore a crucifix around his neck, and had a business card for the
local LGBT center and a bottle of HIV medications in his pocket. There were no
documents to confirm his identity.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">For weeks, my medical team
and I meticulously watched over José’s physical health. Twice, his lungs collapsed
and we put in several catheters to re-inflate them. Five times he went into
respiratory failure despite being on maximal mechanical support. We spent hours
manually pushing air through his breathing tube to keep him alive. A multitude
of continuous IV medications and blood products maintained a semblance of vital
signs. Drains in his bottom kept him clean and dry. We could not feed him because
he had persistent bloodstream infections. Every week, the quality assurance
team came by to ask: What are your care goals?<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">This is usually a question
my medical team and I would discuss with the patient or a patient’s family. But
José could not be woken up and no one ever came to see him. Fingerprinting
turned up no leads. No missing person’s report had been filed fitting his
description. We called the doctor who wrote José’s prescriptions. He gave us
the number for an emergency contact; however, that man said he had not seen or
heard from José for months and knew no personal information about him.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">José’s profound disconnectedness
troubled me. Every day, his nurse and I evaluated all his tubes, medications,
and machine settings with extra care, trying to compensate for his loneliness.
I would squeeze his hand for a moment before I left, though I wondered if he was still with us in this world. The immensity of his solitude weighed on me. He
could pass away without anyone who had ever mattered to him having a clue. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">How did José become so cut
off? Was it because he was gay or HIV positive or both or something else
altogether? Working in a safety net hospital, I have cared for many people like
José, who are hanging by mere threads in the margins of society. What kills them,
and often in heartbreaking ways, is not their medical illness. It’s their
social isolation. Stigma is the cultural stress that ultimately extinguishes
their lives.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">When academics talk about
“vulnerable” populations, they are usually referring to people who have no
money, no power, or need public assistance to thrive. Health care disparities
are defined along demographic factors like ethnicity, income, employment,
education, and marital status. Ultimately though, what makes certain groups
more vulnerable than others is not the category they identify, or are
identified, with; it’s how connected they are to other human beings. Poor
people can belong to strong communities that will take care of them in times of
need, and thus be resilient. The same goes for people who are unemployed,
disabled or uneducated. People only end up on the street when they don’t have
anyone at all.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Arial;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial;">It is in this light that I
have come to appreciate marriage equality as an important and relevant policy
issue for our society. Beyond civil rights and basic human dignity, marriage
creates a connectedness that is protective against life’s unknowns. When crisis
strikes, it is a buffer that prevents people from ending up like José, who
essentially became a ward of the state. What cause does the public have to deny
equal benefits to consenting adults who want to make a lifelong commitment to
each other? Why do we still quibble over gender when so much collective good is
at stake?<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="MsoNormal">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGpp3JwohktLy5z2WhRXfSXEwRh8DWY-0mKh5ofl2cQS8uBIelBBDObPX4Hi4vh1kbV7b74PsMcAe7w3iMtDNOxcCwMNqcNFOcG0-BCvIc3J5j19faTKN4VxnhEjEow8IzTCt9dD3RfQ/s1600/loved.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGpp3JwohktLy5z2WhRXfSXEwRh8DWY-0mKh5ofl2cQS8uBIelBBDObPX4Hi4vh1kbV7b74PsMcAe7w3iMtDNOxcCwMNqcNFOcG0-BCvIc3J5j19faTKN4VxnhEjEow8IzTCt9dD3RfQ/s200/loved.jpg" width="195" /></a></div>
<span style="font-family: Arial;">The same month I took care
of José, I met Oscar and his “cousin” Eddie. Like José, Oscar also came to the
hospital with severe pneumonia, but Eddie was with him, and brought him in in
less critical condition. I was able to counsel both of them about intubation
when breathing became too difficult. Oscar designated Eddie as his health care
proxy. As long as Eddie was there, Oscar did not require much sedation and pain
medication. We could see how quickly his heart rate and blood pressure improved
with Eddie by his side. One quiet night, I finally asked Eddie why he
introduced himself as Oscar’s “cousin,” when it was obvious that he was his
partner. Eyes to the ground, Eddie muttered that he was afraid we’d kick him
out if we didn’t think he was “<i style="mso-bidi-font-style: normal;">family</i>.”
I started to apologize if we had made him feel uncomfortable in any way, but he
interrupted and said, “It’s not you. It’s <a href="http://www.npr.org/blogs/thetwo-way/2012/06/05/154359513/californias-prop-8-same-sex-marriage-ban-looks-headed-to-supreme-court" rel="nofollow" target="_blank">Prop 8</a> that’s been hard on us,” as he
laid his head on Oscar’s chest. “When will you be able to take this tube out,
Doctor?”<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">As a whole, we have enough
intractable conflicts to contend with, without wasting valuable time and
resources to set up more stumbling blocks for ourselves. The ultimate goal of
government is to provide an infrastructure for diverse peoples to live
peacefully, happily, and freely together. Marriage equality on this level isn’t
about interpretations of religious text, historical precedent or legal
technicalities. Moreover, it is not about whether or not the private sex lives
of two people make us feel “icky” or not. As far as our elected officials are concerned,
marriage is a simple civil construct to bolster beneficial human connections
that spill over into all aspects of our lives - at work, in schools, in
hospitals, in neighborhoods and beyond. Pride can overcome individual shame,
but it takes all of us together to remove stigma. It’s time to end the
unnecessary suffering.<o:p></o:p></span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-12890598304726542082012-06-11T18:20:00.001-07:002012-06-11T19:50:57.011-07:00Achieving Physician Autonomy<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7MijbQFDoaGoQnogIo7hYqfg3pipPtbW1nAfRXPSJ5cnUzr8Xvtwm1ycUXJVsBuIkkgldkdhaxfY7HcZTiNURzIwOoZIbdkC9Vty5zUfYFYg4ElcxyGfLWJDSK6a7btwfp6X5MLDUdg/s1600/graphs.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: left;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7MijbQFDoaGoQnogIo7hYqfg3pipPtbW1nAfRXPSJ5cnUzr8Xvtwm1ycUXJVsBuIkkgldkdhaxfY7HcZTiNURzIwOoZIbdkC9Vty5zUfYFYg4ElcxyGfLWJDSK6a7btwfp6X5MLDUdg/s400/graphs.jpg" width="317" /></a></div>
<div class="MsoNormal" style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The American Medical
Association and the American Association of Medical Colleges reported recently that <a href="http://www.ama-assn.org/amednews/2012/04/23/prl20423.htm" rel="nofollow" target="_blank">increasing numbers of medical students are seeking dual degrees</a>. The most popular combination was the
MD/PhD for physician-scientists, followed by MD/MPH for physicians with public
health interests, MD/MBA for physician-entrepreneurs, and lastly MD/JD for
physician-lawyers. Despite the extra time and money, MD candidates believed
that additional training would lead to a more sustainable, and perhaps, more productive
career.</span></div>
<div class="MsoNormal" style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Interestingly, my dual
degree, the MD/MPP was not discussed in this article. <i style="mso-bidi-font-style: normal;">MPP</i> stands for Master’s in public policy, a hybrid between an MPH and
an MBA with a dash of public administration. My fellow MPP classmates included
healthcare providers, state officials, presidents of foreign countries, military
leaders, and directors of nonprofit organizations. I was drawn to the program
because it allowed me to learn from my classmates, as well as experts who
taught in the law, education, public health, and business schools of the
university. When a number of my teachers and classmates left abruptly to return
to government service after the 9/11 tragedy, I felt even more thankful for the
richness of knowledge and influence that was expanding my view of the world.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Many people over the years
have asked me why I chose to take this detour. Being a nontraditional candidate
doesn’t win you many points in what remains a conservative application process
for medical school. I was frequently asked during residency and fellowship interviews
why an aspiring doctor would waste time dabbling in public policy. I told the
truth: I wanted to learn how to protect my patients from the system. I never
wanted to feel helpless in the face of laws, regulations, and bureaucratic red
tape. My interviewers liked how I emphasized the primacy of physician autonomy.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Sit down with any group of
doctors and you will hear that we want people to stop getting in our way of taking
care of patients. Just last week, Dr. James Breeden, the president of the
American College of Obstetricians and Gynecologists, wrote an <a href="http://www.acog.org/About_ACOG/News_Room/News_Releases/2012/Letter_to_the_Editor_New_York_Times" rel="nofollow" target="_blank">impassioned letter to the editor of the New York Times</a>, demanding that politicians “get out
of our exam rooms.” The letter struck a deep chord within the
physician community. Throughout 7+ years of education, we were preparing to
combat disease and to hold the doctor-patient relationship as sacred. Then, we
graduate into the world of clinical practice, and realize that the U.S. health
care infrastructure was not created to support our mission. Doctors lose hours
on the phone trying to convince insurance agents to approve indicated
treatments. Scheduled surgeries are cancelled last minute due to nurse under-staffing.
Uninsurable patients with pre-existing conditions go to emergency rooms for
routine care. Hospital financial managers tell families that their unconscious loved
ones in the intensive care unit have to go elsewhere because they have the
wrong insurance.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">In pursuing a dual degree,
my colleagues and I wanted to guarantee our independence in an often-dysfunctional
system. Autonomy should naturally develop from greater self-sufficiency and
competence, and we would have more letters after our name to confirm it. Yet,
12 years into my pursuit for autonomy, I find myself going back to a lesson
learned early on during my public policy years -- team players get better
results than lone wolves. When faced with serious problems, professional collaboration
usually trumps single expert opinions in getting things done.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I especially remember the <i style="mso-bidi-font-style: normal;">Spring Exercise</i> in graduate school, a
class-wide activity in which 130 of us were expected to organize and produce a
detailed solution to the issue of HIV/AIDS in Africa, using real-time data. We
had one week to prepare the report and presentation for faculty members. I
still recall the stunned pause in the auditorium when my classmates and I
wondered how we could possibly complete this massive assignment, not knowing
each other’s names, much less worked together. Then, we rose to the occasion.
We formulated objectives and assigned them to committees based on our majors
and interests. We made contact lists and set up a strict schedule of meetings.
We had daily check-in times when every committee shared their progress with the
entire class. We debated, negotiated, walked away from the table, came back to
the table, and ultimately drew up an extensive policy brief with graphs and
figures, a budget, and a political strategy for execution. Who knew a ragtag
collection of people from all over the world with various backgrounds could
pull together and accomplish a common goal in 7 days? During our final
presentation, we found out that our work would be given to the Secretary of
State for review. It was exciting to hear echoes of our efforts in subsequent
government briefings. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I didn’t appreciate the true
power of the Spring Exercise until years later, after I have stayed up nights
wondering why our health care system is so inadequate. It was a success that
continues to remind me of what’s possible. Medical training encourages lone
wolf behavior, but health care reform needs team players. Doctors want to be
left alone to do our work, but sustainable autonomy won’t happen until we let
go of our siege mentality and look for solutions outside our comfort zone. I had
originally set out to equip myself for independence, but instead, I’ve learned
that our problems are too big and too complicated to tackle alone. I hope that
what our country is experiencing now is that pause in the auditorium before the
action gets underway. </span><span class="Apple-style-span" style="font-family: Arial;"><o:p></o:p></span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-29777821454034174682012-04-07T23:33:00.000-07:002012-06-29T09:57:20.416-07:00Choosing to Practice Good Medicine<div style="text-align: left;">
</div>
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“We need you to counsel a pregnant
patient about getting an MRI.”</span><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">In my public, inner-city emergency
room, when the medical student calls requesting an OB/GYN consult, I know it’s
been a bad night down there. Heading over, I could already envision the rows of
patients shivering in half-open gowns, waiting hours to get answers to the
emergent reasons that brought them to the hospital. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The medical student led me
to the patient, asleep and huddled under her coat. “Her temperature is normal,
but her pulse is on the high end and she has vomited 2 times. We think she has
appendicitis. The ultrasound shows an 11-week pregnancy, but couldn’t visualize
the appendix. Surgery team hasn’t seen her yet, but recommended an MRI.”</span><br />
<br />
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I flipped through the chart as the medical student spoke. The patient had been driven in by a co-worker, who found her vomiting in the bathroom at work. Since her arrival to the ER, she has been given intravenous fluids and a single dose of nausea medication. Her care had now passed on to the next shift. The new team wanted to do further testing.</span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“Why do you think she has
appendicitis?”<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“She came in with abdominal
pain, hasn’t wanted to eat and has a slightly elevated white count.”<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“That can be normal in early pregnancy.
Tell me about her chief complaint and initial exam.”<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The medical student sheepishly
admitted that he didn’t have the details. The patient spoke minimal English.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">A surgeon by training, I
tend to tread carefully when it comes to medical interventions. My mentor taught
me early on that I should think through every history question, physical exam
element, and diagnostic test, as judiciously as I would for major procedures. His
mantra was: <i style="mso-bidi-font-style: normal;">What is the indication?</i> Clinical
decisions should be focused on doing the appropriate thing for the specific
individual. “Every patient is your grandmother, mother, sister, or daughter,”
he liked to say. I took his words to heart.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I set up the translator phone,
and gently tapped the patient’s shoulder to wake her up.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“Can you please take out this
tube?” She winced and pleaded, pointing towards the catheter that led from her
bladder to a bulging bag of clear urine on the floor. Sympathizing, I took out
the catheter, figuring this would build rapport. She exhaled with relief and
gratitude.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“How are you feeling? How’s
the pain, the vomiting?”<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“Much better now.” She
elaborated that she always had terrible morning sickness with her pregnancies.
But because she didn’t want her new boss to know she was pregnant, she had
allowed herself to be taken to the hospital. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Finishing up my evaluation
with an abdominal exam, I concluded that the patient probably didn’t have
appendicitis. What she needed was not an MRI, but prenatal vitamins and a prenatal
appointment. I gave her the obstetric clinic’s business card and told her to
follow-up within 2 weeks, or call if her condition worsened. She nodded and said,
“I need to get home to my kids. What time is it?”<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My ER colleague was hesitant
about my plan. “The MRI is already ordered. We don’t want to miss anything.”<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I understood that my colleague
wanted to be thorough, though critics may call it <i style="mso-bidi-font-style: normal;">defensive medicine</i> – performing additional tests on the patient primarily
to protect the physician from potential malpractice claims. In my mind, appendicitis
was not likely enough of a diagnosis to warrant extra hours in the emergency
room and an uncomfortable, hi-tech imaging study. The MRI would contribute
little to our therapeutic decision-making, especially since the patient has
improved already. Moreover, we could find ourselves trying to explain
physiologic cysts, pelvic fluid, and other routine incidental findings, causing
undue distress for the patient. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">That, in a nutshell, is my
problem with defensive medicine. The weight falls disproportionately on the
patients. They and their families lose time, money, and sleep for no health
benefit. Over time, this phenomenon erodes the essential trust between doctors
and patients. It gets harder and harder for patients, already in a vulnerable
state, to differentiate when their doctors are advocating for them, versus when
their doctors are fearfully responding to a mix of real and imagined pressures on
their reputations and bottom lines. This only adds fuel to the fire.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Malpractice litigation is a
hostile, inefficient, and sometimes unjust process in our society. <a href="http://content.healthaffairs.org/content/30/7/1343.abstract" rel="nofollow" target="_blank">Most suits are dropped</a> and most plaintiffs never get any money. <a href="http://www.nejm.org/doi/full/10.1056/NEJMc1114805?rss=searchAndBrowse" rel="nofollow" target="_blank">Defense costs are high</a> whether or not there is a payout. Existing laws try to pin the blame for failures of a broken health care system on individual physicians. My OB/GYN
counterparts working in underserved areas get sued more, not because of bad
outcomes, but because the patients are poor enough to become easy targets for solicitations on TV, public transportation, or the hospital
doorsteps. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Despite this harsh reality,
defensive medicine, or shifting the burden onto the sick, is not the answer for anyone involved. The solutions are
tort reform, better communication, and meticulous documentation. While doctors
push for change, we can’t budge on our responsibility to make the tough
judgment calls that match the right tests to the right patients. It’s not acceptable
to create an illusion of excellence by doing more; we have to provide actual,
evidence-based, clinically rigorous quality care. More is just more, not better.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">In this case, I chose the
diplomatic path. “I don’t think your approach is unreasonable. Given my
observations, I think she is safe to be discharged for outpatient management.
Here is my full consult note. I won’t be offended if you don’t use my recommendations.”<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My ER colleague sighed
deeply. “Ok. I hope you’re right. Sometimes, I feel like we’re playing Russian
roulette.”<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“I hope I’m right too. I have
a large bottle of Pepto-Bismol in my office if you need it.” <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“Don’t worry. I’m prepared.”
He showed me the package of Tums in his pocket. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">We laughed. It takes guts
and a very strong stomach to practice good medicine.</span><span class="Apple-style-span" style="font-family: Arial;"><o:p></o:p></span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-27548592981318913972012-04-03T06:17:00.001-07:002012-04-07T23:52:37.651-07:00From Laboratory to Patient; From Theory to Cure<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Less than a year ago, I packed my belongings into my MINI and drove towards the Pacific Ocean to begin a three-year fellowship in gynecologic oncology. I passed through the diverse landscapes and cultural environments of the South, Midwest and West to arrive at my final destination – a cancer research laboratory.</span><br />
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<a name='more'></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Within a month, I went from meeting the needs of ill patients to studying a single protein on the surface of an organelle inside of a microscopic cancer cell. Lab meetings, where PhDs rattled off molecular mechanisms in jargon and abbreviations that were a foreign language for me, replaced clinical rounds. One year of lab research is required of all ‘gyn onc’ fellows. The certifiers at the American Board of Obstetrics and Gynecology believe fellows need to investigate cancer at all levels to become well-equipped specialists.</span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Perhaps it was for the best that my first <i>in vitro </i>experiments failed over multiple tries during the early months. Because without having the preliminary data this work provided, I could not graduate to animal experiments. The few times I visited the “mouse house” with the lab technician, I found myself worrying more about the living conditions of the genetically-engineered mice than about their potential to elucidate the causes of cancer. Clearly, I had no future in <i>in vivo</i> studies. I couldn’t bring myself to master the skill of sacrificing these obliging creatures in the name of science.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Despite avoiding one mousetrap, I found myself fully entrenched in the rat race of academic research. The desire to generate reproducible, relevant data was constantly overshadowed by the pressure to publish quickly and often. How many projects are you working on? How many abstracts will you be presenting at the national meeting? Is it an oral presentation or just a ‘science fair’ poster? Are you the first author on your publications? These were the stresses of scientists seeking tenure positions and federal grant funding. Learning the art of translating data into items on the résumé was key to holding onto coveted lab space.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Amidst the politics of ascending the academic ladder, I started to miss my patients. Outside the lab, I wondered to fellow clinicians how research translated to actual benefits for people suffering with cancer. Most cancers don’t give us decades to find a cure. They claim their victims while researchers are organizing figures and tables to present to their colleagues at professional meetings.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Attending the recent national conference for gynecologic oncologists reminded me that the last notable victory in advancing patient therapy occurred way back in the 1990s when a specific, 2-drug chemotherapy regimen showed obvious efficacy. More contemporary agents have proven to be too toxic, unaffordable, or lacking the required survival benefit to gain government approval for human use. Circulating within the ivory towers are many promising theories and <a href="http://www.cancer.gov/cancertopics/factsheet/NCI/research-funding" rel="nofollow" target="_blank">billions of taxpayer dollars</a> to test those theories. However, I feel frustrated by how long it takes for useful information to be generated and then trickle down to patients to improve their lives.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I have started to question the structure that measures academic value by quantity, more so than quality, of publications. Thousands of journals now house hundreds of thousands of manuscripts, most of which will never be read by other researchers. In fact, the <i>literature review</i>, in which a PhD candidate or junior instructor summarizes the available data on a topic, has become its own genre and résumé-builder. Concentrating on the hard numbers seemed superficial and shortsighted to me, given the ultimate mission to cure cancer. How did volume translate into impact? Where was consideration for the patient in this paradigm?<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">To be fair, scientific discovery is a long, grueling journey, filled with more crushing failures than laudable successes. I have great respect for the brilliant minds that have devoted a lifetime to adding to our knowledge of disease and treatment. Even those who haven’t directly participated in the rare breakthroughs have contributed with their negative results by steering us down more productive paths. However, I craved a closer connection between science and the patient. I need to look back on my lab year and see more than an esoteric journal citation. I want to be able to say to my next dying patient and her family that we don’t have all the answers yet, but there are meaningful, immediate ways to alleviate the suffering because of the societal investment we’ve made in research.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Serendipitously, I found the way to link my research to the frontlines of patient care, not at a medical convention, but at a birthday party. Over Korean BBQ and loud music, the friend of a friend of a friend, an artist-physician, asked me about my work. I shared that one project focused on health care utilization of cancer patients one year before death. His face lit up and he said, “My friend directs the palliative care and hospice department at your hospital. She could really use your data to change the culture of cancer care there. She’s been wanting to speak to the administration for years, but never had the resources to collect evidence to make her case.”<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I leaned in eagerly to hear her name. Having a year of research time suddenly seemed much more worthwhile.</span></div>
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</span>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-69872962407664236012012-03-11T23:48:00.000-07:002012-12-02T08:23:15.120-08:00Cancer 1, Doctor 1 (Part 2 of 2)<div style="text-align: left;">
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<span style="font-family: Arial, Helvetica, sans-serif;">I left work after my
dermatologist broke the bad news that I did indeed have cancer. He had said that
my type of cancer wasn’t so deadly that I should drop everything and find the
nearest qualified surgeon; however, he added he wouldn’t wait too long. He gave
me two names to look up, experts he’d trust with his own face. I appreciated
how he fed me the information in digestible bits, and then gave me a
straightforward task. It distracted me from thinking about how we don’t really have
a cure for cancer.</span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">At home, my partner and I
set to work decoding our insurance coverage. We searched through hundreds of
network physicians and learned that none of them performed the surgery I
needed. In fact, none of the health plans available through my employer – HMO,
PPO, POS, union-run – would cover the treatment. So, we called up the two
specialists recommended by my dermatologist and asked for quotes. Would it be
hundreds, thousands, or tens of thousands of dollars?</span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">At the university hospital,
no one could answer the question. One friendly nurse philosophized that our
hospital should be offering comprehensive insurance for its own providers. I
wish one could assume, but I wasn’t in the mood to ponder the capitalist,
for-profit nature of our health care industry. Imagine going into a store and
being forced to buy something for the sake of your life. What incentive do
suppliers have to keep products accessible and prices low, when consumers have
to make a purchase regardless? I just needed to be cancer-free, ASAP. I didn’t
have time to wait for health system reform.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The private office we called
next connected us to their billing person, who briskly listed the costs, line
item by line item. Encouraged by the office’s efficiency, I requested the
earliest available appointment...four weeks away. A good friend of mine confirmed
from people who had worked directly with this surgeon that he was among the best
in his subspecialty. My parents agreed to help me with the bill.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I attempted to relax as I
counted down the days. In preparation for my treatment, I reviewed the latest
literature on my cancer and informally consulted colleagues to make sure I was
making the right decision. I wrapped up loose ends at work. I purchased a
wide-brimmed hat. The weekend before, I stocked the refrigerator with fruits,
vegetables, and ice cream, and cooked a large pot of chicken soup. I bought the
recommended list of wound care supplies. All in all, I was ready. The goal was
to stay in control, keep everything predictable. My cancer didn’t have to be
any more disruptive than getting my car washed. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My surgeon good-naturedly
obliged my need for order. While I laid stiffly on the operating table, he gave
a detailed timeline of how the surgical site would change over the next weeks.
Even when the affected area turned out to be much larger than expected, he
explained that the gaping wound could be hidden with a special skin closure
technique. I stole glances at the vital signs monitor and was pleased to see my
blood pressure and pulse remain normal. My surgeon finished by commenting with
satisfaction that my case was done on time. I liked him precisely because he
was a skilled technician who didn’t get too caught up in the emotional
messiness of illness. He affirmed my desire in that moment to believe in “magic
bullets” – cancer => cut => cure.<o:p></o:p></span></div>
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<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My cancer experience thus
far had been running like Swiss clockwork. So, it was an unwelcome surprise when
my methodical façade broke down only hours after the procedure. At home, resting
with an ice pack on my face, I found myself spooning rum raisin ice cream into
my mouth as if I were in an eating contest, all the while fighting back tears.
What is going on, my brain raced in confusion. The cancer is gone. Everything
went smoothly. Why the drama now?<o:p></o:p></span></div>
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<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I replayed the events of the
day in the doctor’s office. At one point, a nurse had come in, put her hand on my
shoulder, and stated that my surgeon was confident he had gotten all the
cancer. I should do “just fine.” Her smile was warm and sincere. I wanted to
believe her, but I had seen healthy women almost bleed to death from routine
vaginal deliveries. I had dealt with minor office procedures that turned into ICU
stays. I have had to admit to patients that we have no explanation for their
diseases. Doctors can’t give guarantees. Most of the time, we don’t have cures,
just symptomatic remedies. Rather than comfort, the nurse unwittingly reminded
me that science, technology, and medicine have more questions than answers.<o:p></o:p></span></div>
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<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">So, it was not in the
doctor’s office, but at home when my healing truly began. Twice a day, I cleaned
and dressed the incision that started in the middle of my forehead and ran into
my hairline. I carefully washed over the small stitches with saline, applied
antibiotic ointment, and taped down the large white bandage. The wound started
off angry and inflamed, causing swelling down to my cheeks until I looked like
the cross between a Klingon and Frankstein. I hid from the outside world,
mortified by the blatant sign of illness on my face. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">But in the quiet and in my
embarrassment, I slowly came to acknowledge my physical limitations. I sought calm
in daily rituals. I sipped nourishing stews and ate fresh fruit. I napped on
the couch with my dog at my feet. I replied to emails and texts from family and
friends. I took medications as prescribed. I listened to birds chirp and
watched the sun light stream through different windows throughout the day. I
took deeper breaths and just closed my eyes from work whenever I wanted to. I
started playing with Twitter. I let myself cry.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The vulnerability was
awkward, but therapeutic. I thought about the disconnect of expectations that
can occur between doctors and patients. I think most doctors realize the
shortcomings of our craft. We have a set of tools that sometimes work and
sometimes don’t, and we try our best to do some good. In the end, we are not
someone’s parent or best friend or spiritual guide. Many patients, though,
demand more. They want to be <i>healed</i>. They seek meaning, connection,
and hope, when they are sick. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I didn’t ask my own doctor
for such existential reassurance. But then, my illness has a defined, effective
treatment. The cancers I deal with at work are usually mysteries, filled with
uncertain disease courses and treatment responses. They cause patients to
question their essential womanhood and values. Who am I if you take out my
uterus? Will my partner still find me attractive? Am I more afraid of never
being a mother or dying of cancer? I listen to the stories patients tell about
themselves, because in there, are the clues to how they see their bodies, how
they make sense of their lives, and ultimately how I can best contribute to
their healing experiences, if they want me to.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I think my doctor picked up
on my pragmatism and knew intuitively that I just wanted to get out of there as
soon as possible. He mumbled during the initial consultation that doctors have
a hard time being patients, that illness is extremely humbling. I have not made
peace with illness, but I have gained a new respect for the process of healing.
There are no magic bullets.</span><span class="Apple-style-span" style="font-family: Arial;"><o:p></o:p></span></div>
</div>
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<span class="Apple-style-span" style="font-family: Arial;">
</span></div>
Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-91168240799878086012012-02-26T18:49:00.021-08:002012-03-04T20:56:10.744-08:00My Two Cents<br />
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<div style="color: #262626; font-family: Arial, Helvetica, sans-serif;">
<span style="color: #1d1d1d; font-family: Arial;">February has been a hectic month for
women’s health issues. First, there was a fall-out and reconciliation between
the Susan G. Komen Foundation and Planned Parenthood. Then, religious
organizations fought back against the Obama administration’s plans to mandate
free contraception coverage through employers. Now, the news cycle has turned
to controversial legislation in Virginia and Alabama requiring transvaginal
ultrasounds for women choosing abortion. I have followed each of these
discussions with interest, but what has really bothered me was another story
that got relatively little attention yet indicates a troubling trend in health
care politics – the “doc fix."</span></div>
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<span class="Apple-style-span" style="color: #1d1d1d; font-family: Arial;">On February 17th, Congress
passed a bill, more widely known for extending the middle class payroll tax cut
through 2012, that also included a “doc fix,” a stipulation that would prevent
a significant decrease in Medicare reimbursement to physicians. Reading the
fine print, this “win” for doctors came at the price of a $5 billion cut in
health prevention programs. In essence, the basic interests of doctors were
pitted against that of patients. It’s easy to imagine that the patients who
will be affected are the most vulnerable groups – the unemployed, working poor,
urban minorities, and the uninsured.</span></div>
</div>
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<div style="color: #262626; font-family: Arial, Helvetica, sans-serif;">
<span class="Apple-style-span" style="color: #1d1d1d; font-family: Arial;">What aggravates me most about these
policy conversations isn’t the exact decisions that are made by our elected
officials. Rather, it is the immense <b>silence</b> of doctors in these
debates. Bishops, talk-show hosts, special interest groups, and even
comedians chime in, while doctors observe passively from the sidelines.
Shouldn’t doctors want to engage in the crucial discussions that impact our
daily work? It seems to me that physicians could be quite an influential voice,
if only we spoke up. So, why don’t we?</span></div>
</div>
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<br /></div>
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<span style="color: #1d1d1d; font-family: Arial;">I believe that the passivity is a bad
habit. Starting with the first two years of medical school, trainees spend
almost 24/7 hiding in the library, cramming our brains full of facts and
algorithms. We rigorously reduce illnesses to short-answer responses. We learn
to quote journal articles to earn extra credit. During our clinical rotations,
we are rewarded for being able to rattle off the longest list of possible
diagnoses, or show up earlier and stay later than anyone else. We are never graded
on how well the patient does. Our existence is consumed by paperwork and
licensing exams. It is drilled into our heads that doctors should be scientists
– objective, data-driven, and emotionally-contained. Compassion and social
awareness are just other competencies to check off our graduation requirements.
Whatever passion brought us to medicine is put on hold while we jump through
all the hoops.</span><span style="font-family: Times;"><o:p></o:p></span></div>
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<br /></div>
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<span style="color: #1d1d1d; font-family: Arial;">Eventually, we emerge from that rigid
program. Suddenly, we are faced with an irrational and political world. We see
that taking care of our patients require more than knowing their diagnosis and
treatment options. Mothers with cancer fail to show up for care because they
can’t find someone to watch their autistic child. Undocumented immigrants are
afraid of entering an emergency room with their bleeding masses. Struggling
small business owners can’t afford vaccines for their children. Working parents
are concerned about losing their jobs if they go to too many prenatal
appointments. Prescriptions often go unfilled. Sanitation, food security, and
safe streets do more for the public’s health, than high-tech surgeries. </span><span style="font-family: Times;"><o:p></o:p></span></div>
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<span style="color: #1d1d1d; font-family: Arial;">So, physicians are faced with a
choice. We can keep our heads in the sand, and hope someone else will fix the
problems. Patients will probably still get adequate medical attention, and we
will make a good living for ourselves. Or, we can choose to become
well-informed citizens, take a side, and lead the charge in health reform. In a
democracy, when you don’t choose to speak, you give up your power. We doctors
have largely forfeited our influence as patient advocates, and allowed
lobbyists, insurance administrators and pharmaceutical executives to determine
how we practice.</span><span style="font-family: Times;"><o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="color: #262626; font-family: Arial, Helvetica, sans-serif;">
<span style="color: #1d1d1d; font-family: Arial;">Recently, my division director
happened to be in Washington D.C. for a meeting, and she took the time to visit
members of Congress to talk about the shortage of chemotherapy drugs for women
with cancer. She shared stories about patients with disease progression because
of treatment delays. She didn’t show complicated graphs or write a big check.
She offered what she knew – the struggles of her patients and her sense of
social justice. She threw her voice in with the critical mass of other citizens
who also wanted the system to change. And the federal government is responding
with measures to make more drugs available.</span><span style="font-family: Times;"><o:p></o:p></span></div>
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<div style="font-family: Arial, Helvetica, sans-serif;">
<span style="font-family: Arial;">Speaking up is a simple solution, but it's not
easy. We need to break old habits of waiting to be told what to do. We have to
realize the fallacies of a culture of neutrality. Just the other week, I was
telling my best friend that I needed to apply for a health care policy
fellowship in Washington D.C. so I can really learn how things work on Capitol
Hill. She looked me in the eye and stated matter-of-factly: “You’ve spent
enough time in school. You need to go out there and do something now." </span><span class="Apple-style-span" style="font-family: Arial;">Of
course, she is right. It is time to make our voices heard, as we are. </span></div>
</div>
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</span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-42287088071557401092012-02-09T09:16:00.006-08:002012-03-12T00:27:24.864-07:00Cancer 1, Doctor 0 (Part 1 of 2)<br />
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<span class="Apple-style-span" style="font-family: Arial;">
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<span class="Apple-style-span" style="font-family: Arial;"><span style="font-family: Arial;">The doctor leaned in to study the lesion on my
forehead. I could see his easy demeanor fall away into a frown, his brows now
tightly knitted in concentration. The air was suddenly sucked out of the room.
I was afraid I’d vomit on his pristinely ironed white coat. I recognized the
expression on his face. It was the same one I’ve worked to control before
breaking bad news to my patients. I took a deep breath, bracing for the doctor
to substantiate the diagnosis I had already suspected.</span></span></div>
<a name='more'></a><span class="Apple-style-span" style="font-family: Arial;"><o:p></o:p><br />
</span><span class="Apple-style-span" style="font-family: Arial;">I had watched the pimple transform into a friable,
uneven mark. The day after my 35th birthday, I decided that enough was
enough. I felt stupid as an oncologist-in-training to stare at it day after day
and continue to ignore the obvious. Clearly, it met all the criteria for
lesions that should scare you to take action. So, I had ended up at the
doctor’s office, determined to put an end to my denial.</span><span class="Apple-style-span" style="font-family: Arial;">
</span><br />
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<span style="font-family: Arial;">Finishing his examination, my doctor launched
into a knowledgeable discussion about my options. Clinical language is
pleasantly distracting when facing huge amorphous entities like c-----. I
swallowed my thought. I still couldn’t mouth the word, even as it started to
encircle me like a boa constrictor. The doctor emphasized that I could go the
more aggressive route, a biopsy, but that would most definitely result in a
permanent scar. I nodded silently, but was outraged that he would even mention
such a trivial cost of the procedure. Why would I care about a blemish when it
could be c-----? I gulped for air.<o:p></o:p></span></div>
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<span style="font-family: Arial;">“I want to be certain of what it is as soon as
possible.” There was a pause. For a moment, I wondered if I had said that out
loud. Then, I was given a consent form. Eyes glossing over the fine print, I
dutifully signed where the “X” was, thankful for the hint. Who can read legal
documents in moments like this? My brain was awash in a messy torrent of
emotions. My doctor had excellent surgical technique. I barely felt the scalpel
against my skin.<o:p></o:p></span></div>
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<span style="font-family: Arial;">Walking outside into the world afterwards, I
immediately cringed in the powerful southern California sun. The rays no longer
felt warm and inviting. In fact, those rays had probably morphed my skin cells
into relentless monsters, growing and perpetuating out of control. I ducked
into the underground parking structure and counted off the seconds of life lost
to waiting for the valet – 378 to be exact.<o:p></o:p></span></div>
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<span style="font-family: Arial;">The first thing I wanted to do when I got home was
walk the dog. I didn’t want to talk to anyone. What I craved more than anything
was an instance of peace amidst the war in my head. My sensitive, furry dog was
as much as I could handle. Watching him frolic nonchalantly in the hills, I
thought about my great grandmother. What would she do? She’d cook a pot of
gingery, sesame chicken with bamboo and medicinal herbs, with a side of
long-life noodles to soak up the broth. Then, she’d insist that I eat it while
it was piping hot, so the soup could free up my obstructed “chi.” What reason
did I have to doubt her tonics? She lived well over 100 years.<o:p></o:p></span></div>
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<span style="font-family: Arial;">I headed home and started cooking. My mind fixated
on folk remedies, even though I have devoted myself to Western medicine. Fear
took hold, and I needed something, anything weighty, like millennia of ancient
Chinese wisdom, to keep me grounded and comforted. I read the National Cancer
Institute’s literature on the cutting-edge treatments for all my potential
diagnoses, but the science felt cold and inadequate. Instead, I was calmed by a
large bowl of sesame noodles and gingery cabbage that I devoured ravenously. I
washed it all down with a pot of green tea for good measure.<o:p></o:p></span></div>
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<span style="font-family: Arial;">I suffered through two weeks of vivid warrior
nightmares. Battle-worn and injured, I tried to beat back insidious cancer
cells. They had the latest stealth technology, but I could only throw sticks. I
spent a lot of time staring at the ceiling at night, resenting pathologists.
Seriously, how long does it take to write a two-line report? Time was too
precious to waste. The cells were dividing and replicating unchecked, while the
health care system creaked along its inefficient ways. There was nothing
rational about the way my mind waded through this time of waiting. I started to
hug people longer. I talked to my family more frequently. I celebrated my
birthday, surrounded by friends.<o:p></o:p></span></div>
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<span style="font-family: Arial;">I was being forced to look at Cancer in a
different, more humbling context. For me, Cancer had stopped being an exciting
area of medical research. It could very well be a physical part of me,
intimately attached and unwelcomed. I wanted to run away to a silent retreat.
But that was the problem exactly. There would be no more running away. When the
pathology report came out, it could confirm that Cancer had invaded my body --
my personal, private sanctuary. It would no longer be at a safe, analyzable distance.
I could not contain it neatly at work. There would be no leaving it behind to
go on vacation. I couldn’t turn off my pager and hand off care responsibilities
to a trusted colleague. Realistically and statistically-speaking, this Cancer
wouldn’t threaten my life. But merely the prospect of having it had shaken my
way of life, and wantonly collapsed the compartments I’d so meticulously set up
to maintain order.<o:p></o:p></span></div>
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<span style="font-family: Arial;">Just minutes before I learned of my diagnosis, I
was working in the shady hospital courtyard, cramming to meet a research
deadline. A Chinese man approached and asked me, in Chinese, to translate his
English prescription. I looked at the prescription and saw that it said, “Mr.
Chen has leukemia and should receive chemotherapy.” In alarm, I thought, does
he know how sick he is or am I going to be breaking bad news in my
grade-school-level Chinese? Mr. Chen looked at me expectantly, with trust and
friendliness. I marveled at this man’s courage, venturing to this hulking
institution to seek treatment, relying on the kindness of strangers. I
translated the best I could. Then, he excitedly pulled a letter out of his bag,
another mystery to him. This one read, “Mr. Chen has finished chemotherapy, and
needs a bone marrow transplant.” He bowed with gratitude and chatted with me
about Taiwan. “I knew you were Taiwanese. I could tell by your accent.” His
eyes twinkled, enlivened by a touch of familiarity in an unknown place.<o:p></o:p></span></div>
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<span style="font-family: Arial;">As Mr. Chen walked confidently towards the
hospital’s entrance, decoded papers in hand, I felt like the universe was
sending me a message. I still had so much left to do here. In connecting with
Mr. Chen, I finally stepped out of my own head and experienced the peace I had
been searching for in two weeks of waiting.<o:p></o:p></span></div>
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<span style="font-family: Arial;">My phone rang. It was my doctor.<o:p></o:p></span></div>
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<span style="font-family: Arial;">“I would usually have you come in to talk, but I
figured you’d want to know without delay.”<o:p></o:p></span></div>
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<div class="MsoNormal">
<span style="font-family: Arial;">I heard a huge gong being struck, too close for
comfort. Round 1 goes to Cancer.</span><span style="font-family: Arial;"><o:p></o:p></span></div>
</span>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-38124923811361296692012-01-31T18:36:00.003-08:002012-03-04T16:29:06.111-08:00Redefining Success<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My Monday morning belongs to “Tumor Board.” In this weekly meeting, gynecologic oncologists, radiation experts, radiologists, pathologists, nurse managers, fellows and residents join forces to develop treatment blueprints for our cancer patients. Crowded into an old conference room, our collective mission is to tackle the challenge: “What can we do for our patients?” Pathologists scrutinize slides of tumor under the microscope. Radiologists show images to elucidate the extent of cancer invasion. Researchers critique the merits of the latest clinical trials. Radiation experts evaluate the opportunity for radiotherapy. A senior clinician summarizes the action points, and the fellow meticulously documents the discussion in the chart. Then, the residents get their marching orders to execute the strategy. We are a fiercely technical and data-driven army, churning out evidence-based recommendations for 20+ patients in under 2 hours.</span><br />
<a name='more'></a><br />
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Invariably, one or two of the patients we are talking about will have exhausted the full spectrum of treatment options. For a brief moment, the cancer-fighting machine grinds to a halt. A frustrated clinician will break the awkward silence by declaring, “Fine. I guess she goes to hospice.” We quickly move on to the next patient. No one wants to dwell on the defeat.</span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Recently, I embarked on a research project to look at the health care resources our patients received in their last year of life. I reviewed 100 medical charts of patients who had died from cancer. It turns out our patients spend most of their final days in clinic or awaiting diagnostic tests. Some have over 50 blood draws, 20 clinic visits, 5 chemotherapy infusions, 2 CT scans, and an MRI in the last 2 months of life. I imagine them in immodest hospital gowns, sitting in cold hallways, nervously fidgeting before their 10+ invasive procedures that may or may not buy them more time. Stepping back and looking at these raw numbers made me question what sort of environment we have created for our patients’ final days. Must our patients be rushing around the hospital, or could they be at home with their families and friends? <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">In fact, in all the years I’ve sat in Tumor Board and listened to the hundreds of plans being hatched, I have never heard anyone recommend doing nothing. Even when we are dealing with incurable cancers, we can’t help but think ‘doing nothing’ or even ‘doing less’ is equal to admitting defeat. It is never voiced that maybe the patient should NOT spend their final days with us. We assume that all patients want everything done until they explicitly state otherwise and sign the appropriate documents. When cancer enters the picture, we act as if the rest of life stops. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I understand why we are reluctant to talk about the end. After years of making personal sacrifices, surviving sleepless nights, performing complicated surgeries, requesting hundreds of hours of nursing care, and ordering hundreds of thousands of dollars of medications, tests and hospitalizations all to beat back death, we have no tolerance for failure. So, we construct intensive defense tactics that basically make patients’ last months about conquering cancer. It is unthinkable that anything else could be more essential. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I remember Debra, a true warrior patient in the fight against ovarian cancer, the most destructive and fatal of all gynecologic cancers. Debra endured 5 different courses of chemotherapy only to discover that the cancer had obstructed her intestines. She proceeded to have a surgical opening created in her abdominal wall where feces could be collected in a plastic bag. When the cancer overtook her lungs, she consented to having thick tubes inserted into her chest to drain out the malignant fluid. Debra would come in and out of the ICU multiple times in her final month, battling infections, kidney failure, and loss of consciousness. With each episode, she acquired a new device to support the function of another failing organ, including feeding tubes and larger IV access for daily blood draws. She slipped away quietly in the night, fighting to the very last moment. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">When a cancer patient dies in the hospital like this, she often has a variety of artificially created holes in her body to get air, fluids, food, and drugs in and out. After the tubes and gadgets are removed, all that remains is a shell, hollowed out and replaced by cancer. While I have seen this many times, for the patient, it’s her only shot at death. She doesn’t have the benefit of stepping back and seeing what all the interventions will add up to. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The reality is, we oncologists are not trying to gain control of a chronic disease like high blood pressure or diabetes for which there are proven therapies and the time to check out various regimens. Advanced cancer almost always kills, and kills swiftly. What would happen if we leaned into the truth that we can’t save particular patients? Is there space in Tumor Board for social workers and palliative care experts? Is there room for death planning instead of disappointedly turning a patient over to hospice? Rather than obstinately sticking to pre-existing algorithms, what if we redefined what it means to succeed at providing exceptional cancer care? <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Perhaps optimal care is more than chasing down every last cancer cell, packing patients’ schedules so full of appointments that there is no time to wonder if this is worth it to the patient or society at large. I believe that patients do come to us for answers. They are terrified of their cancer. They need help figuring out what to do about it. They will listen to practically everything we say because we see this every day and they have never seen it. So, it seems that when we don’t have cures to offer, it becomes crucial to support the patients and their families through the experience as compassionately as possible. The ultimate marker of success might not be days of survival, but something less measurable and infinitely more meaningful -- something like helping a patient fill every remaining moment with joy, peace, and connection, instead of blood tests, imaging studies, and hospital visits.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My research this week forced me to pause and realize that my role isn’t just to be a cancer expert. I also have the responsibility to manage a patient’s hopes, a family’s need to feel like they did everything they could, research scientists’ necessity for experimental data, and my personal mission to “do no harm.” Being successful in striking that balance means purposefully keeping “do nothing” in the arsenal of therapeutic options. Sometimes, that may be the most aggressive thing I can do for a patient’s wellbeing.</span><span class="Apple-style-span" style="font-family: Arial;"><o:p></o:p></span><br />
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</span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-56330963235510183272012-01-13T00:19:00.004-08:002012-02-27T22:50:16.463-08:00What I Learned from Standing in Your Shoes<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Last week, I flew to Milwaukee to witness the long-awaited birth of my niece. I’m happy to report that mother and baby are doing just fine…and this OB/GYN aunt – who knows too much about the birthing process for her own good – survived the experience as well. I have never been one to mix the personal and the professional. In fact, I compartmentalize to cope with the stresses of my work. But in this case, it was impossible to avoid being both a sister and a doctor.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Throughout my sister’s pregnancy, we emailed and phoned regularly, discussing glucose tolerance tests, car seats, breastfeeding, and hemorrhoids. I interpreted ultrasound images for her and explained what labor contractions would feel like. When the baby became breech, I assured her that a Cesarean section was the safest way to go.</span><br />
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</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">On the day my sister scheduled her c-section, I met her doctor for the first time. I was faced with a tricky question. Do I announce that I’m an OB/GYN, or do I let this well-established, competent doctor do his job without my interference? I stood quietly in the back of the room as my sister’s obstetrician counseled her on much of what I had told her the night before. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The day of surgery, my only task was to carry a backpack of my sister’s things and wait. I have lived and eaten and slept in hospitals for 6 years, but walking those familiar hallways as a patient’s family member was surprisingly disorienting. Hospitals are places where I generally feel in control, and here I was, knowledgeable yet powerless. Sitting by the window, I made mental notes about the facility, the names and jobs of every person who came into the room, and whether or not staff washed their hands – just to satisfy myself that everything was up to standard. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">When a friendly, enthusiastic resident introduced herself as someone who would be “assisting” during the c-section, my brain went into overdrive. I wanted to ask the resident what training year she was, and anxiously searched her ID badge for clues. Should I suggest to my sister that no interns be involved in her surgery? Would my sister get better care if they knew I was an OB/GYN, or would that unnecessarily complicate the issue? This was a teaching hospital afterall. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I thought about the times my fellow residents and I whispered behind the backs of patients who demanded ‘special treatment,’ i.e. no students or residents in their rooms. “Then, why did they come to a teaching hospital?” we’d ask. They clearly didn’t appreciate that the residents are the ones who run the floor, put in the orders, kept an eye on the vital signs, and made it possible for the attending to do the surgeries. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">With deep resignation, I forced myself to go with the flow. I sat on my hands and bit my tongue when the nurse failed to get the IV into my sister’s plump veins. I scrutinized the fetal monitor; contemplated the anesthesiologist’s overview of pain management; hovered over the family practice resident who did an ultrasound to double-check the baby’s position; and yes, took a peek at the orders in the chart when the nurse left the room. When I stepped off of the elevator to go to the family waiting room while my sister went to surgery, I squeezed her hand and told her that she’ll be fine; there was nothing to worry about.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">For what seemed like forever, I paced the waiting room. I googled the residency program and tried to assess if the residents were above average. I googled my sister’s doctor…again. I listened intently for overhead announcements calling for additional staff to help with an obstetric emergency. I imagined what was happening to my sister: sitting up for regional anesthesia, lying down, being draped, being cut, baby emerging from the abdomen. I would never know whose hand made the incisions, the attending’s or the resident’s. But, did it matter? <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I was an intern once. I too fought to legitimize the “M.D.” after my name in front of skeptical patients, behaving more confidently than I truly felt. I used vague phrases like ‘assist the attending’ when I knew I was doing the cutting. I learned to not take it personally when a patient, usually someone with connections to the health care world, asked that no residents be involved. I had added respect for the more senior doctors that stood up for my education.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">People don’t have to seek care at teaching hospitals. There are private community hospitals that have no trainees in-house. In those generally smaller facilities, the nurses would directly call your doctor and take orders over the phone or if more serious, your doctor would come in to see you. These facilities tend to be less resourced and do fewer surgical cases. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">At teaching hospitals, residents are present 24 hours a day. The more junior residents are essentially ancillary staff, while more senior residents are often licensed physicians who can manage most clinical situations, but defer to the attending for the big decisions. Teaching hospitals have full doctor and nurse staffing at all times, and do more cases and more difficult cases. They are better prepared for serious complications.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The reality is, surgery is a collaborative endeavor that requires a primary surgeon, but also a surgical assistant, nurses, technicians, anesthesiologists, up-to-date equipment, and a well-stocked blood bank. For the surgeon, experience is key, but age or number of years in the OR is not necessarily the best marker for skill. After the initial learning curve, other things like innate fine motor control, hand-eye coordination, grasp of anatomy, leadership ability under stress, maintaining high surgical volume, and staying abreast of medical advances probably play bigger roles. The knowledge of a senior physician combined with the younger eyes and hands of a junior physician may be an optimal scenario. Ultimately, the surgeon is just one member of an interdisciplinary lineup.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I breathed a sigh of relief when I saw my sister with the baby in her arms, coming back down the hallway, exactly one hour later. Given the short operative time, I concluded that either the attending or a senior resident had done the surgery. But again, did it matter? Everyone was smiling, and I finally started to relax. I gave myself away soon after by reflexively checking the urine output and asking for the baby’s Apgar scores. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I learned something that day about myself. When push comes to shove, when the situation isn’t just professional but deeply personal, I trust the system that trained me. Quality care and education are synergistic. I’m willing to bet my and my family’s health on it. </span><span class="Apple-style-span" style="font-family: Arial;"><o:p></o:p></span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-6695758888922352172011-12-31T15:22:00.003-08:002012-02-27T22:50:47.428-08:00A Techie New Year’s Wish<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My dad gave me his fetal stethoscope as a gift at the start of residency. It’s a slender, wooden stick with a cup on either end, one for the doctor’s ear, the other for the pregnant woman’s abdomen. During his career, he had used it hundreds of thousands of times to listen for fetal heartbeats. I can tell from the well-worn nicks and scratches, and the smoothness of the stem, that the tool has served a meaningful purpose in my dad’s hands.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">When I trained, I had electronic fetal monitors. Instead of holding a wooden instrument to my patient’s abdomen, I used a small ultrasound probe, and all of us in the room listened together to the galloping fetal heart tones. Moms and dads invariably got emotional when they heard their babies for the first time. I enjoyed those beautiful moments of bonding. Simple technologies triumph in our clunky health care system.</span><br />
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</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The American health care system is notoriously archaic when it comes to technology. Even in the era of the Internet and cloud computing, <i style="mso-bidi-font-style: normal;">fax machines</i> are still the mainstay for the transmission of medical records and insurance paperwork. I shudder to recall the hours lost during residency to locating the rare functioning fax machine so I can get patient records -- assuming it was normal business hours and an actual human being on the other end of the phone graciously agreed to find, copy and feed in the requested documents. Without the information readily available, patients often had to have lab work and imaging tests repeated. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Even now, newly-renovated hospitals run on an inadequate number of computers that chug along on Windows 98 and lack the infrastructure to accommodate physician order entry. In the United States, people move 11+ times and hold 15+ jobs during the course of their lives, meaning they frequently switch their employer-based health insurance and hence their doctors. For the sickest of the sick, they could be brought by ambulance to different emergency rooms within the same city during the same month, and receive the same million dollar work-up because the two institutions have no direct way of sharing information.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Modern sociocultural and economic trends demand that doctors efficiently manage and piece together fragmented data. While media companies are fighting to redefine the boundary between privacy and networking, hospitals balk at harnessing the potential of interconnectedness, citing security concerns. Surely, corporations and the military industrial complex have created the technology to guard their secrets across the globe. Why are we so nervous about wiring our health care system for the 21<sup>st</sup> century?<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Health care professionals are responsible for some of the ambivalence. When I speak to physician-administrators about this question, they lament the younger generation’s desire for costly gadgets. We want to stare at computer monitors, rather than interact with human beings. Instead of honing observation skills, we just process people through machines for diagnoses. They condemn the Internet as a reckless source of misinformation. They equate clinical algorithms with inferior “cookbook medicine.” For many decades, they had few tools and hand-written notes, and healed people. Why complicate something that works?<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">True, we sometimes overestimate what technology can offer in promoting quality of care and patient safety. Doctors may order too many tests hoping more data will point to an answer, when perhaps we should first pay closer attention to the patient’s story. Residency programs have tried giving PDAs to trainees and found no significant patient or provider benefits. Despite the growing popularity of robotic surgery, there is minimal evidence that patients do better or that the hi-tech approach saves money.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">However, I also hear in these naysayers the fear of becoming obsolete, the unspeakable dread that it is a matter of time before doctors, like factory workers and chess champions, are replaced by supercomputers. I don’t believe that day will ever come. The human aspects of doctoring can never be replaced with intelligent machines. Breaking bad news should always been done in person, not relayed over Skype. Few would want to text about whether or not they would choose CPR if their heart stopped. The art of healing requires face-to-face conversation and skilled clinical touch. The process of making tough choices demands empathy, experience, respect for spirituality, and the creativity to adapt to unpredictable circumstances. Even Siri can’t embody those essential characteristics.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My dad’s fetal stethoscope is an exquisite, timeless symbol of the art and history of medicine. It will always work. Yet, looking ahead into the New Year, I wish for technology that improves the connection between doctors and patients, and helps people manage the joys and uncertainties of their physical conditions. I imagine a ‘Facebook’ for doctors and interactive apps for patients. I dream about an invisible network that eliminates the bureaucracy of our health care system and makes its services accessible to the most vulnerable populations. And maybe there will even be a cloud that finally ends the era of fax machines.</span><span class="Apple-style-span" style="font-family: Arial;"><o:p></o:p></span><br />
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</span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-77872870288673331852011-12-24T09:47:00.004-08:002012-03-04T16:27:45.871-08:00Breaking Point<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">During my third year of OB/GYN residency, I became determined to subspecialize in gynecologic oncology. I realized that I enjoyed taking care of cancer patients the most. Despite being overworked and perpetually exhausted, I always had the energy for the long surgeries and involved patient-family conversations. I reveled in the challenges and the teamwork. I knew I wanted to do this for the rest of my life.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The first surgical case of the day was Margaret, an adorable, delightful lady with advanced cancer. Her husband of 60 years, Charlie, stuck close to her side. They hobbled down the hallway, arms around each other, free hands holding matching canes. Charlie asked us to take good care of her; she was all he had. I assured them that her attending surgeon was someone I would trust to operate on my own family members. Charlie and Margaret shared an extraordinary, palpable connection. Their hearts and souls were so clearly intertwined I knew they couldn’t survive without each other.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The surgery went smoothly. The day after, Charlie was there first thing in the morning, wearing a full-body, neon jogging suit. “You gotta get out of bed and walk. That’s what the doctors said,” he nudged Margaret. When I looked in, they were giggling and whispering to each other.</span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Margaret was only in the hospital for 4 days. She didn’t want to go to a nursing home, but Charlie needed minor knee surgery and wouldn’t be able to watch over her. We worked out a temporary stay at a nearby facility. After his surgery, they would go home together.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">A week later, the nursing home sent Margaret back to the hospital with a fever. Margaret and Charlie were excited to see us and wanted her to remain under our care. We kept her over the weekend for observation.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">On Monday, Margaret felt much better, but her stool looked abnormal, as if she was bleeding in her colon. We checked her blood level and found that it was unexpectedly low. We started a blood transfusion while we investigated possible causes. As a matter of protocol, I sat down with Margaret and Charlie to discuss the course of action for the worst-case scenario. “Of course, she wants everything done, right, honey? We still have to see the pyramids!” Charlie answered. Margaret nodded, petting his cheek. I was confident Margaret would pull through, and told Charlie, “She’ll be fine in the morning when you get here.” <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I stayed late that night because Margaret’s 88-year-old veins were thin and spidery, and rejected our best efforts at getting consistent IV access. I tried. The charge nurse tried. We asked the anesthesia and ICU teams to try. I suggested to the ICU fellow that he place a central line, basically a large IV direct to the heart. He felt that Margaret looked well, and didn’t require such an invasive procedure. I finally went home at 10 pm after we secured one small IV line.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">From home, I checked Margaret’s repeat lab work and noticed that she was missing a lot of the usual blood clotting factors, which means she could have a fatal bleed at any moment. I called into the hospital to see how her blood transfusion was going, and found out that her IV had stopped functioning. We nagged the ICU team again to help and they were able to place another small IV. We redoubled efforts to get the blood products in. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Margaret looked exhausted in the morning from the overnight commotion, but still gave us a cheerful smile. My team was getting breakfast, when we heard an emergency overhead announcement for the rapid response team to Margaret’s room. We dropped our food and ran. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">When we got there, the nurse was already doing CPR. I took over the chest compressions, attempting to pump Margaret’s heart through her rib cage. I could feel ribs cracking under my palms. I pushed myself to keep going more than one compression per second. I watched blood pouring out of her mouth for 40 minutes. It had been obvious that Margaret could not be revived, but I couldn’t stop. I wasn’t thinking about her welfare anymore. I was wondering how I was going to tell Charlie. I think people might have tried to get my attention, but the necessarily detached ‘doctor’ in me was gone. I was acting out of pure emotion. I promised Charlie he would see Margaret this morning, and I couldn’t fail him. I talked myself into believing in miracles and resurrection. When we called time of death, Charlie had not yet arrived. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My team sat in the nursing station to piece together what had happened. A fax had just come through with Margaret’s medication list at the nursing home. It turns out she had been started on a blood-thinning pill that was very high-risk for a cancer patient after surgery. I assumed any doctor would have asked her surgeons before starting her on such a drug, but clearly, this slipped through the cracks. Now, it was obvious why Margaret had bled to death so quickly and tragically.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“You killed her with your carelessness,” an attending spat out in anger. “How many times do I have to tell you to get outside records immediately?” Paralyzed with fear that she might be right, I walked away. The weight was too much to bear. This was my breaking point.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Watching Charlie walk down the hallway by himself literally broke my heart. I told him Margaret’s heart had stopped, and we couldn’t get it back. He cried into her neck, and then on my shoulder, and said this is worse than being in the war. We shared a box of tissues. Charlie mumbled about cemetery plots and their new apartment being too big for him alone. I couldn’t stop apologizing for not getting the records earlier, for figuring out the diagnosis too late, for not being able to resuscitate Margaret, for leaving her bedside to eat breakfast, for not running up the stairs faster, for not making sure she had better intravenous access, for underestimating her body’s reserve…. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Clearly shaken, I marched into the division chair’s office and asked to reassign my surgical cases for the day. I wanted and needed to help Charlie get things in order. Charlie and I sat quietly in the waiting area with our separate thoughts, mourning together. He looked lost and frightened, and I worried about him. I called him every day, until he told me he was moving into an assisted living facility where an old war buddy also lived. He thanked me for taking care of the two of them, and made me cry again. He didn’t blame me, but I couldn’t forgive myself. I tried calling him once more, but his phone number no longer worked.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Margaret’s case was presented at the monthly ‘Morbidity and Mortality’ conference which reviewed unexpected deaths in detail. As I recounted minute-by-minute what transpired over those days, my colleagues argued about fragmentation of care and poor inter-doctor communication. When they asked me what I could have done differently, I said I wished I could put in a central line myself. After the meeting, people came up to console me. They said the usual things. You are not God. It would have happened anyway. Death is an occupational hazard when you have elderly cancer patients. You treated her correctly even without knowing the cause, which is all that can be expected. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">For many nights, I second-guessed if I was qualified to be a surgeon, playing cat-and-mouse with questions I was too afraid to ask myself. Did I have what it takes to hold someone’s life in my hands? Maybe I should have stayed overnight and not left Margaret’s bedside. How much of yourself do you sacrifice? What’s reasonable? Would the world be a safer place if I got a desk job? Am I being selfish and arrogant to think <i style="mso-bidi-font-style: normal;">I </i>can care for cancer patients? Maybe oncology isn’t for me. It’s all fine and good to be human, but what if my imperfections costs someone her life? <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">It took me a while to make decisions confidently again. Being a doctor is all about sorting through a multitude of complex, nuanced choices and then bearing the inevitable weight of responsibility. I went to my chief resident for wisdom beyond the facts that I’m not God and the system is flawed. She said, “Not everyone is cut out for this. But, I know you will be one of the good ones, because I have seen you work and you dare to ask yourself this question 8 years into the game.”<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">So, I’ve stayed, and I’ve kept reaching for a deeper understanding of humility and forgiveness. I strive to balance the beauty of connecting with patients with the burden of potentially losing them. I have found that I am willing to carry the load.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Every holiday season, I still think about Charlie.</span><span class="Apple-style-span" style="font-family: Arial;"><o:p></o:p></span></div>
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</span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-16022147970797837722011-12-18T02:46:00.007-08:002012-02-27T22:55:34.634-08:00We Do Not Stand Alone<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The Supreme Court has stepped into the health care fray and will hear a challenge to the individual mandate in the Affordable Care Act early next year. The main questions under debate are whether the federal government has the authority to require that people obtain health insurance and if they can impose a penalty for those who don’t comply.</span><br />
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</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Indeed, no one likes the government telling them what to do, especially when it comes to our bodies. It doesn’t matter that the bill grants exemptions for financial difficulty, religious reasons, low income, and temporary loss of coverage; or that the penalty is as low as $95 in 2014; or even that law enforcement would miss most offenders, just like the IRS only tracks down a tiny percentage of tax evaders. The very idea that anyone’s autonomy is compromised is repulsive to most Americans. National polls show that a clear majority views the controversial mandate unfavorably.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">As this debate brews over the next months, I want to offer my vantage point for why I believe the individual mandate serves the public good.</span></div><div class="MsoNormal"><br />
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Imagine Christy, an otherwise healthy young woman, who comes into a hospital emergency room for fever and abdominal pain. She doesn’t have insurance because she felt it was a waste of money at this stage in her life. We find that she has an infectious abscess, which requires hospitalization with intravenous antibiotics. Christy won’t sign up for Medicaid, the state-funded safety net program for low-income individuals, to get the full treatment needed because she doesn’t want to take public aid. She opts for a suboptimal choice, an oral prescription.</span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Chances are, if Christy had insurance, she could have seen her primary care doctor when the symptoms first started. That may have cost the system $500*. If she stayed at the hospital and used Medicaid, that may have cost $5,000*. However, by choosing an inadequate treatment, she will likely face long-term health damage, such as infertility, which will eventually cost $50,000* to manage. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal" style="mso-list-ins: "Loren Fenton" 20111218T0141; mso-list: none;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Whether Christy’s health costs are $500, $5,000 or $50,000, it is uncommon that people pay 100% of the actual cost of their treatment. Even if Christy had gotten insurance along the way, it would have only accounted for a small fraction of what she required. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">While our ailments and medical decisions are private, the way we tap into the health care system impacts everyone. I see cancer patients who put off chemotherapy to visit family abroad, and then come back months later with metastatic disease, necessitating more resources with decreased odds for survival. I remember a middle-aged man I met as a medical student, a cocaine addict, who showed up in the emergency room every night with chest pain and received a full cardiac work-up, warm bed, and two meals before he slipped out the next morning. He did this for months. We may get to do what we want with our bodies, but we should know that our decisions affect the whole community. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">In the end, someone has to pay for the consequences of these personal choices. Health care utilization and delivery is not an individual endeavor. The costs trickle down to all of us, because only the rare patient has the money to go it alone. As much as we are repulsed by mandates, we would be more morally disgusted if we let people suffer or die on the street unattended, even if they had willfully refused to get insurance when given the opportunity. We don’t kick people out of hospitals even when we suspect they are loitering for social reasons. We’d rather err on the side of giving the sick the benefit of the doubt. So, ultimately, we all end up paying for each other’s health care.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Recent studies show that a small percentage of people expend most of the domestic health care dollars. People who are uninsured tend to cost more when they present to care. They require extensive work-ups and often more intense treatment due to worse disease. The mandate compels us to acknowledge that our fates are interconnected in health care. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">In return for getting essential services when and how you need it without judgment of your preferences, you should contribute your fair share, a mere portion of what you will consume over a lifetime. The government is doing its job with the individual mandate by protecting the public good, not allowing people to take advantage of their humane, law-abiding neighbors.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I ask people like Christy to take a look at the bigger picture beyond a moment of insolvency or episode of illness to recognize the systemic ripple effect of their singular actions. This is what is means to be a responsible citizen. It’s a fallacy to think anyone stands alone.<o:p></o:p></span></div><div class="MsoNormal"><br />
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</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">*Note: Dollar amounts are hypothetical and meant only to illustrate a concept. It is near impossible to obtain actual costs. The complexity of health care financing is beyond the scope of this blog post.</span></div><div class="MsoNormal"><span style="font-family: Arial;"><br />
</span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-42071773140377282552011-12-10T12:29:00.012-08:002012-02-27T23:04:32.504-08:00The Seduction Minefield<div style="font-family: Times; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My first job out of college was as an entry-level research associate at a health care consulting firm. I wrote glossy briefs for CEOs and COOs of hospitals, pharmaceutical companies, and insurance firms, answering their questions on wide-ranging issues from how to alleviate emergency department overcrowding to how to cut costs with disease management programs. Usually, I had two days to scour the Internet and interview sources before producing a memo of highlights that could be skimmed by a busy executive between </span></span><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">meetings.</span></div></div><div style="font-family: Times; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div></div><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><div style="font-family: Times;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">At my first performance review, my manager told me that my analysis and writing were excellent; but I “wasted” too much time looking for references. I would be more productive if I filled out the templates without trying so hard to validate new data. Time is money, she emphasized.</span></div><a name='more'></a><br />
<div style="font-family: Times;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I left that job in less than 6 months. I couldn't accept that money should wield so much power, especially in health care, which I thought was about taking care of sick people. My short stint in the for-profit world taught me that business is never personal and always about the bottom line.</span></div></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><br />
</div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I returned to academia to study health care policy. I remember attending a debate between Professor Jeffrey Sachs, the leading international economic advisor of this generation, and the vice president of marketing from PhRMA, the pharmaceutical industry’s lobbying group. The debate was about providing AIDS medications to developing nations at lower cost. The audience was predominantly sympathetic to Dr. Sachs’ position that it was the moral responsibility of wealthy drug companies to lend a hand in the AIDS crisis. We were all there to watch a brilliant mind squash a greedy corporate entity.<o:p></o:p></span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><br />
</div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Unexpectedly, the VP stole the show. Stunningly beautiful and flawless in a gray tailored suit, she started off with a self-deprecating joke and a string of accolades for Dr. Sachs, which made him smile. She deftly parried his arguments with her own research and talking points. The VP knew how to communicate to an audience unfamiliar with the industry’s inner workings. She broke down technical ideas and told stories; tied her points to basic principles like merit and fairness; and reframed all the classic human rights arguments in such a way that her clients’ position seemed reasonable. Without ever attacking Dr. Sachs, she made him seem like an out-of-touch academic who didn’t know how things <i>really</i> worked outside the ivory tower. The performance was impressive. After the debate, the won-over audience crowded around the VP to get her business card. It was the 1% charming the 99%. For a moment, I wondered if I could affect more change in the health care system if I returned to the private sector…despite my former experience preparing slapped together briefs that probably was the core of the VP’s presentation.<o:p></o:p></span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><br />
</div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Instead, I moved further away from the corporate world and became a doctor. From this new angle, I watched the practice of medicine and the pharmaceutical industry grow increasingly interdependent. Industry has the resources. Scientists have the techniques. Doctors have the network of colleagues and the patient base. They all relied on each other in essential ways to make medical progress. Furthermore, with managed care, malpractice insurance, and student loans cutting into physician income, industry’s generous honorariums for “educators” and “consultants” to help shape product development became more attractive to doctors. I worried about my profession being seduced by the slickness of business, and by the money. I had seen how easily it could happen.<o:p></o:p></span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><br />
</div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Last year, I attended a professional conference replete with bottomless coffee pots, sit-down lunches with silver utensils, free Wi-Fi on the premises, schedule and program apps, multimedia presentations, and a golf tournament. Corporate signs lined the hallways, not advertising any specific product, but with colorful logos announcing the companies that gave “unrestricted educational grants.” Some of the most well-attended symposiums featured a panel of top researchers in the field, sharing their latest findings. The sponsoring company’s reps hovered over the attendees, chatting pleasantly, making their business cards abundantly available. I remember the very nice lady who made me her project. We spoke about the weather and where I was from before she seamlessly transitioned to whether I knew my district’s rep and what brands my hospital used in the operating rooms. I was on guard, but she was decidedly friendly, attentive, and professional. The interaction made me feel so uncomfortable that I left my filet mignon unfinished and skipped dessert.<o:p></o:p></span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><br />
</div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Rather than boosting my ego, this lavish display reinforced for me that the problem with our health care system isn’t scarcity of resources. It's that we have a lousy way of distributing what we have. Cancer patients are on waiting lists for chemotherapy drugs restricted due to a national shortage. Uninsured patients can’t get indicated diagnostic tests in a timely manner. Outdated equipment in public hospitals provide substandard care. Yet, industry invests so much time, money and effort to entice doctors to develop loyalty to their brand or win over policymakers by appealing to their sensibilities. It felt so obvious to me that money, flattery and luxury were being used to obscure my mission – to care for the sick.<o:p></o:p></span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><br />
</div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Having experienced both sides of the game, I no longer question money’s seductive power in health care. I am wary as I pick through the minefield.</span><span class="Apple-style-span" style="font-family: Arial;"><o:p></o:p></span></div><div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-69270564558617943262011-12-03T20:29:00.003-08:002012-02-27T22:57:26.418-08:00The American Character<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Hinna’s husband escorted her into the emergency room. He looked suspiciously at the young women purporting to be doctors. A pool of fluid was collecting at Hinna’s feet, staining her modest, ankle-length dress. The husband said in broken English that Hinna was having a baby. At that moment, my co-resident yelled from the exam room: “Cord prolapse!” I looked in and saw the umbilical cord hanging out between Hinna’s legs, which meant the fetus was getting little to no blood flow. I put Hinna in a wheelchair and ran for the operating room. There was no time to get an Urdu translator to explain to the stunned couple that Hinna needed an emergency Cesarean section. In the next minutes, antiseptic was splashed over Hinna’s abdomen, she was put under general anesthesia, and a baby boy was born. When I shared the good news with the husband, he looked me in the eye for the first time and thanked the staff for saving his wife’s and baby’s lives. He doubted that they would have survived if he were still in his village.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">At my old hospital, we used to joke that there was a direct shuttle from the airport to our emergency room. A seasoned nurse introduced me to the term “anchor baby.” According to constitutional amendment XIV, article I, section 1, “All persons </span><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><i style="mso-bidi-font-style: normal;">born</i></span><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"> or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States….” Somehow, even low-resource individuals in remote villages, sometimes speaking dialects unrecognized by professional translators, have discovered the generous implications of the legal definition of American citizenship. These patients showed up at our doorsteps regularly, and trusted that we would take care of them without questions.</span><br />
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</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">And we always did. For people like Hinna, I am grateful to have trained in a state that doesn’t require an ID for people to receive acute medical care. I treated every patient simply as a human being with a health need, not as someone on the right or wrong side of bureaucratic boundaries. For a long time, I adamantly protected my right not to know if my patients were legally or illegally here in the country. I didn’t want to complicate my doctor-patient relationships with the possibility that I was a conduit for criminal activity. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">However, practicing medicine, especially obstetrics, means that you can get drawn into people’s lives and families. Sometimes, you find out that the patient plans to stay beyond their visa, and the baby is their insurance policy against deportation, like Merlene.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Merlene came in wearing a smart blazer over a floral dress. Except for her sharp intakes of breath with painful contractions, one might have missed that she was pregnant. She had just flown in from her home country to go shopping with her cousins; as a precaution, she carried her prenatal records. I raised an eyebrow. She decided to take an international shopping trip two days before her due date? Merlene avoided my gaze. She soon delivered a vibrant baby boy. By then, she had made friends with some nurses who were also from her country and they were speaking in their native patois, sharing updates about “back home.” Merlene’s boyfriend had left her recently for another woman. She saw the break-up as a chance for a new start.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I liked Merlene. She was fun and high-spirited. But, knowing her intentions, I had a nagging feeling that I was an accomplice. If a mother tested positive for drugs, I would be legally bound to report this information to a social worker, who would alert the appropriate authorities. The same goes for child abuse, sexual abuse, and testing HIV positive. There are no reporting requirements for undocumented immigrants.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">On the human level, most would agree that immigration status should not be a barrier to urgent medical care. However, willfully traveling to the United States to give birth and gain a foothold on citizenship isn’t the usual, involuntary situation that sick people face. It actually feels a little like strangers have broken into your house and think they can help themselves to your possessions. They have contributed nothing to your society, but consider it acceptable to use your limited health care resources.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My parents won a green card lottery in Taiwan and brought me to America at age 8 in pursuit of better educational opportunities. When I take care of patients who are recent immigrants, I see the same aspiration in their faces. Most often, I remember patients like Ana Maria, a migrant worker, who came to my hospital to deliver all her babies, and I happened to deliver two of them. Each time, she lamented that she was missing valuable harvest income; she was already saving up for her kids to go to college.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Immigrants, like Ana Maria, give up the comfort of familiarity to create their own tomorrow. They craved freedom enough to transplant themselves to a different land. In that light, framing immigration and citizenship as purely legal issues is too narrow. What is ultimately at stake is our collective definition of what it means to be an American.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">America is a nation of immigrants, people who take risks, challenge tradition, and generate new ideas. Diversity has value here. Self-determination is prioritized. Social mobility, not entitlement, motivates progress. The rest of constitutional amendment XIV, article I, section 1 reads: “…nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.” <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Merlene, Hinna, and Ana Maria are not legal Americans, but they remind me of the essence of America, the longing to change one’s inherited status for something potentially greater. That ideal can’t be fully codified into law, but it is worth honoring when someone dares to live it. While immigration laws are necessary and should be obeyed, I hope the energy and promise of the American character remains preserved in the legislative process.</span><span class="Apple-style-span" style="font-family: Arial;"><o:p></o:p></span><br />
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</span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-39652127921201199942011-11-26T17:47:00.004-08:002012-02-27T23:06:07.736-08:00When Loyalties Clash<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Dr. Jones had excellent bedside manner. She listened empathetically to patients and exuded a comforting energy. The staff liked her. Her patients were devoted to her. The residents enjoyed her easygoing style.</span><br />
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</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The first time my chief resident assigned me to be Dr. Jones’ surgical assistant, I was relieved. As an intern fresh out of medical school, you always breathe easier operating with a laid-back attending. My chief resident reminded me that I should call her for help at any time. She didn’t expect any trouble though. It was a routine minor procedure.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The case started out well. Dr. Jones told the anesthesiologist the whole surgery would take 15 minutes. We would be filling the uterine cavity with sterile fluid, looking inside with a small camera, and then sampling the lining for pathological evaluation. I maneuvered the camera into the uterus easily, but couldn’t see certain areas, so I handed the instrument to Dr. Jones. She also struggled with visualization. At this point, an alarm sounded on the machine that monitored the amount of fluid we were injecting into the uterus. I commented to Dr. Jones that the number looked higher than expected and asked if she would like me to call for a more experienced resident. She said we would be done shortly and was annoyed that I seemed to suggest she couldn’t handle a simple case. The alarm continued to beep. The patient’s oxygen level was decreasing. I quietly asked the nurse to page my chief resident. I didn’t know what was wrong, but I’d rather be the naïve intern who overreacted than the doctor who missed a serious complication.</span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My chief resident came immediately and argued with Dr. Jones to end the surgery. The patient’s oxygen level was still low. Dr. Jones ignored her pleas. My chief told me to find another senior attending NOW. Panicked, I went into the neighboring room where a cancer surgery was starting. I sheepishly asked the oncology attending if he could please come help. This attending looked at me with extreme irritation, but when he heard what was happening, he relented with a deep sigh. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Back in the operating room, the oncology attending took one look at the patient’s vital signs, the fluid on the floor, and the alarm, and firmly told Dr. Jones to stop the case. Dr. Jones glared at me. I felt like a traitor.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">In the recovery room, the patient was found to have excess fluid in her lungs. Dr. Jones looked on nervously. I waited for her outrage, but she merely instructed me to call her with an update in two hours. After Dr. Jones left, the nurse patted me on the shoulder and told me I did the right thing. She stated vaguely that Dr. Jones had a “pattern” of surgical mishaps.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Over time, I learned that Dr. Jones’s surgical inadequacy was an open secret. Her family was well connected in the medical community. The staff didn’t want to bring complaints against an established surgeon, perhaps fearing for their jobs. The residents were in no position to criticize a higher-level physician. So, we all compensated for her incompetence, finding quiet ways to protect her patients from real harm.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Where does a doctor’s loyalties lie? Recently, this question of allegiance has come up in a very public way in executive boardrooms and on legendary sports teams. It’s a serious conundrum anywhere powerful figures are entrusted as stewards and held to high ethical standards. What do you owe to your colleagues, versus what do you owe to your constituency? <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">In medicine, this conflict of loyalty has direct consequences. Doctors have a fundamental duty to their patients; that is the job. The stakes are high. However, we, as a society, don’t have a good system for accurately and objectively assessing surgical skills. If colleagues can’t or won’t grade each other, patients are even less likely to know how to make good choices.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">There is an unspoken code in medicine that you don’t rat out another doctor. Instead, you watch each other’s backs, especially in the current litigious environment. People devote over 8 years of their lives to medical training, and then it’s a lifelong commitment to remain board-certified. You never want to destroy someone’s career, especially people whom you spend 80+ hours a week with, good people who are your friends. Moreover, you could easily be in that person’s shoes. We all make mistakes. You would wish that others would treat you with a measure of grace. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">A year after that initial experience with Dr. Jones, I was on call with her when a patient required emergency surgery in the middle of the night. I grappled with the issues of Dr. Jones’ questionable abilities, professional camaraderie, and moral responsibility to the patient. Would this be one of those times when everything turns out fine despite the imperfect doctors involved? Or would it be a catastrophe I should have had the insight to prevent?<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I called my chief resident, who assured me that she could be at the hospital in 10 minutes if I needed her. To date, that is what I have learned about managing conflicting loyalties in medicine. Good doctors have the humility and confidence to know when to ask for help. There is no shame in acknowledging human limitations.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Emboldened by the reminder that my team had my back, I picked up the scalpel. </span><br />
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</span>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-71143286447256222272011-11-18T22:57:00.014-08:002012-03-04T16:45:58.644-08:00Broken Trust<!--[if gte mso 9]><xml>
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<span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 16.0pt;">The first time I met Nikki she lied to me, omitting
key aspects of her medical history and denying substance abuse. When I
confronted her with lab results, she demanded that I repeat every blood and
urine collection because the hospital must have mixed up her specimens with
someone else’s. She had a ‘don’t-mess-with-me’ attitude from the start. I was
up for the challenge.</span></div>
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<span class="Apple-style-span" style="font-family: Arial;">Nikki was admitted to the hospital with heart
failure and a highly desired 20-week pregnancy. She had severe shortness of
breath and retained so much water in her legs they looked ready to burst.
Despite her pain, Nikki adamantly dismissed my assessment that the physical
demands of pregnancy pushed her sick heart beyond its limit. An ultrasound
showed that her heart was functioning at less than 10% capacity. She wouldn’t
survive carrying the pregnancy even to 24 weeks, the cut-off for viability
outside the womb. Her only option was to end the pregnancy before her heart
completely deteriorated and wait for a transplant. Nikki refused to discuss her
treatment, cursing and demeaning the medical staff any time we broached the
topic.</span></div>
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<span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 16.0pt;">Several times a shift, I checked in on Nikki,
reviewing vital signs and monitoring the fetal heartbeat. Propped up on 6
pillows, she was working so hard to breathe she couldn’t feed herself or speak
in complete sentences. Her face softened only when she heard the baby’s
heartbeat. One afternoon, she gasped through the oxygen mask, “I just want
someone to really love me.” I heard the deep longing in her voice, and realized
that clinical facts didn’t matter to her. More than health or life, Nikki
wanted a guarantee that she would not be alone. Persuaded by her resolve, I
started to prepare myself for my first maternal mortality.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></div>
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<span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 16.0pt;">The next morning, Nikki announced that she wanted
an abortion. She gave no explanation. Her face was guarded and unreadable. We
performed the procedure as requested, and Nikki was soon breathing more easily.
She was able to eat on her own and take maintenance medications for her heart.
We never revisited her decision. She made it clear she didn’t want to talk
about it.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></div>
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<span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 16.0pt;">The last time I saw Nikki, she was gathering her
things to leave the hospital before her medical condition had stabilized. I
tried to reason with her, saying it would only be a few more days of
observation and then she could be officially discharged. My statements were met
with a string of expletives. I didn’t take her reaction personally and tried to
respond with the nurturing she desperately needed. This wasn’t an endpoint,
just another hurdle to conquer. Her nurse returned with a hospital
administrator and security guard. The administrator had forms for Nikki to sign
out against medical advice (AMA). I balked, but my objections were ignored.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></div>
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<span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 16.0pt;">For me, AMA forms indicate a failure of the ethical
bond between physicians and patients. The forms are meant to protect doctors
and hospitals against malpractice lawsuits for bad outcomes. While I appreciate
the precautionary legal measure, I feel they conflict with my oath to put my
patients first. I don’t mind patients disagreeing with me. In fact, I often
recommend seeking a second opinion if patients remain skeptical. When people
are that sick, they need to be surrounded by a team they can trust, literally
with their lives. Presenting legal ultimatums, however, severs relationships.
Once the forms come out, communication stops. The patient gets the clear
message we are no longer on the same team.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></div>
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<span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 16.0pt;">Nikki asked for her prescriptions as she signed the
AMA forms. The administrator explained that she could not receive any, given
her noncompliance with suggested inpatient treatment. I interjected that she is
welcome to come back anytime, that we were there 24/7, no hard feelings. But
with the legal paperwork in her hands, my words sounded hollow.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></div>
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<span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 16.0pt;">I still remember watching Nikki, holding on to the
hallway railing as she slowly walked out of the hospital, stopping frequently
to rest. She looked back once, her gaze noting yet another betrayal in her
life. I thought about sneaking the prescriptions to her, but by now, the legal
counsel had been made aware of the heated situation. The hospital’s interests
to contain a difficult patient had effectively superseded my fiduciary role.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></div>
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<span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 16.0pt;">A few weeks later, Nikki died on the way to the
emergency room.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></div>
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<span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 16.0pt;">Nikki didn’t let me take care of her. She was an
adult who made her own decisions and was fully responsible for the
consequences. I rarely dwell on my culpability in a patient’s death, because
usually, I know I had done everything I could.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></div>
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<span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 16.0pt;">In Nikki’s case, I have regret. Long after the
fact, I think I should have given her the prescriptions. Maybe it wouldn’t have
been legally prudent. Maybe it wouldn’t have prolonged her life. Or maybe, it would
have kept her strong enough to get to the hospital where we could do more for
her. I don’t know. Perhaps it was more important for Nikki’s sense of agency
that she alone controlled her fate. I met her when she was too emotionally
damaged to trust anyone, when she believed her only saving grace would be
having a baby…and then she lost even that faint hope. Giving her prescriptions
probably wouldn’t have changed anything, but at least I would have the peace of
knowing I went beyond my legal responsibility and stayed true to my moral code.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></div>
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<!--EndFragment-->Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-34978622233927219722011-11-09T10:55:00.006-08:002012-02-27T23:18:07.600-08:00Missing the Obvious<div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The first time I met Ms. B, I found a turkey sandwich hidden under her right breast. <o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“I left it there for safekeeping,” she explained, chuckling. Ms. B had to sweet-talk an eager nursing student into getting it from the cafeteria. “Shhhh,” she gestured with her index finger up to her lips.<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Ms. B had just come out of the ICU, having been admitted for heart failure, blood clots in her lungs, and uncontrolled diabetes. Weighing almost 450 pounds, she needed help to turn over in bed, so she rarely moved. It wasn’t until her transfer to a cardiac unit that her new nurse noticed something she didn’t recognize between Ms. B’s thighs. An in-hospital OB/GYN consult was promptly ordered, and there I was.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Doing a pelvic exam for Ms. B required 4 to 6 people – one or two people to hold each leg, one intern to hold back the abdominal soft tissue, and one gynecologist to do the exam. As I suspected, what I found between her thighs was her uterus outside of her body. The prolapsed organ, moist and abraded, looked generally healthy. My intern and I washed it and gently placed it back in anatomical position.</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Over the next few days, I got to know Ms. B better. Every time she budged or coughed, the intra-abdominal pressure ejected the fist-sized uterus, and I would be called to maneuver it back into place. While we waited for the necessary staff, Ms. B told me her life story. She had been a social worker and a church choir leader. She organized the neighborhood kids to visit the elderly in the summers to make sure they had working fans. <o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I started to wonder how this capable pillar of the community ended up in such bad shape. Five medical teams attended to Ms. B every day, taking turns to evaluate their specialty body part. She received imaging tests from head to toe. Her heart was continuously monitored. A nurse checked her blood sugar every few hours and administered the appropriate amount of insulin. Her upper arms and thighs were dotted with bruises from the blood thinner she needed twice a day. Ms. B’s uterus was actually the least of her problems. <o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Ms. B endured this extreme level of testing and intervening without complaint for weeks. Something didn’t make sense in the picture of this patient though. She wasn’t a naive person who neglected herself. She kept a neat notebook of her medical history, medications, doctors, hospitalizations, and treatments. Her chart showed that she was a reliable patient who didn’t miss appointments. How did she end up hiding a sandwich under her breast?<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I re-reviewed her chart and noticed that her presenting chief complaint a week before I saw her was: “My chest feels heavy.” She didn’t say chest <u>pain</u>, but chest <u>heaviness</u>. That seemed odd to me.<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“Ms. B, is your chest still heavy?” I asked one day, deliberately repeating her adjective.<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">She stared hard at me, and didn’t answer.<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I asked more directly, “Why did you come to the hospital?”<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Ms. B told me that day, that she had woken up the morning prior to her admission and wanted to end her life. A couple of months before, she had lost her job. She had horrible nightmares of children crying for help but she couldn’t get to them. She couldn’t sleep, couldn’t get out of bed, couldn’t bother to shower, and couldn’t stop thinking that her mom was looking down from above, disappointed in her. The same malaise had happened to her a few years before, after her mom’s death. This time, she just lacked the willpower to pull herself together. She was too ashamed to tell anyone.<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The parade of doctors who marched in and out of Ms. B’s room several times a day had missed the obvious. In medical school, it is drilled into our heads that the number one priority is to address the chief complaint. All the specialists had gotten so caught up in fine-tuning Ms. B’s cornucopia of physical ailments that we failed to see the elephant in the room: the profound wreckage of major depression.<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I was devastated. It’s easy to rationalize that I was merely a consultant. I was assigned a very narrow set of questions to answer: what is this between her legs, and can you fix it? Technically, it was Ms. B’s primary care team’s responsibility, not mine, to put all the puzzle pieces together. But technicalities, in moments like these, are of little importance.<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">We all tried our best. We were invested in Ms. B and spared no time or resource in her care. However, it is still infuriating to me that even with the best of intentions, so many doctors can still fail to pinpoint the chief diagnosis. The initial impact of confronting her overwhelming obesity derailed us from the basics of taking a comprehensive patient history. Entangled in imaging tests, blood draws, injections and procedures, we forgot about the one area that fancy technology couldn’t touch – mental health. And it wasn’t for lack of clues on the patient’s part. We treated Ms. B in fragments and fell short of restoring her whole person. <o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div><div class="MsoNormal" style="mso-list: none;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Ms. B’s mental health healing process could not have been completed in an acute care hospital. As is often the case, people go to the hospital with vague physical complaints when they reach the end of their ropes. I offered to set up a consult with a social worker or a psychiatrist, but Ms. B refused. She assured me that she would ask for help if she <i>really</i> needed it next time. I hoped for her sake that it would be that clear cut.</span><br />
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</span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-62995867183840955302011-11-02T13:38:00.006-07:002012-02-27T23:20:38.667-08:00Faith in Real Life<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Mike was a towering man with army tattoos who clearly felt out of place on a labor and delivery floor. He carried a pink bag filled with baby supplies, a bulky car seat, and an overstuffed leather purse. His wife, Kerry, clung to him, cursing and digging her manicured nails into his arm with every labor contraction. He was relieved when the anesthesiologist came to place Kerry’s epidural.</span><br />
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</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I liked the two of them right away. Mike was good-natured and cheerful. He called me “Doc,” and bragged that he once helped deliver a baby in a cab. Mike and Kerry’s first child was delivered by c-section because “the baby was sunny side up.” The couple wanted to try for a vaginal delivery this time.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Kerry mentioned that they adhered to a religion that did not allow blood transfusions. Receiving the blood of nonbelievers would deem them “unclean,” and they would be cut off from their community and an afterlife in heaven. I counseled them on the risk of postpartum hemorrhage and described a list of standard blood products, confirming that she would not accept any of it, even at the point of death. We discussed death directly to ensure they understood that the medical staff only recommended blood transfusions in extreme circumstances. The two of them remained unwavering in their refusal. I went straight to the computer to check Kerry’s bloodwork results. Luckily, her blood level was on the upper end of normal for a pregnant woman. Kerry was a low-risk patient. She and Mike had the odds on their side, regardless of their spiritual beliefs, and that made me feel less anxious.</span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I whispered a quick thanks to my God, who does not object to blood transfusions. I, too, am a person of faith. My belief in both medicine and God are humble attempts to grasp Truth, contain fear of loss, and manage uncertainty. Both shape my intuition and guide my judgments.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Hours later, Kerry’s labor stalled and a c-section was now required. Mike whistled while putting on his paper scrubs to go to the OR with his wife. When the baby came out crying, Mike tried to reach over the sterile drapes to give me a high-five. The charge nurse had to put him back in his seat. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My attending and I proceeded with the routine surgery. Kerry’s uterus, however, was not contracting as it should, which caused excessive bleeding. I called for vessel-constricting medications, and started to manually massage the uterine muscle. My brain rapidly cycled through the algorithm of medical options. We attempted the usual surgical maneuvers. The uterus continued to pour out blood, like a faucet on full blast. Her blood had stopped clotting and was now dripping to the floor. Mike looked confused as he was ushered out of the room. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I took off my surgical gown to talk to Kerry. Leaning in towards her face, I explained that we would need to put in a tube soon to help her breathe. We were removing her uterus. She nodded weakly. I asked her again about blood transfusion. “Mike,” she murmured, and lost consciousness. My attending was working quickly with two other senior surgeons to control the bleeding. The nurse had placed a blanket on the floor so no one would slip. “Get the husband to consent to blood transfusion,” my attending barked at me.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I walked outside. Mike was talking on his cell phone. He hung up when he saw me. “I called the pastor. He’s starting the prayer chain. How is she?” “She needs blood,” I said simply. He looked tormented. I updated him on her life-threateningly low blood level, which may not be enough to deliver oxygen to her brain. She was on a breathing machine. The surgeons were doing a hysterectomy. She had received fluids to keep up her blood pressure, but her vital signs were unstable. Mike looked at my bloody scrub pants. “That’s hers?” I secretly pleaded with my God that he would change his mind. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Mike started to sob and gasp: “Oh my God, I can’t lose her. What am I going to do without her. And the babies. Oh my God.”<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“Patient records are confidential. No one will ever know,” I reasoned.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“No one will ever know,” Mike repeated, “God sees everything.” He was searching his faith for an answer.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“God forgives.” The words were tangible and weighty. I still remember the feel of them in my mouth. There was no taste of doubt.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">At this moment, a nurse with bloody shoe covers rushed out to get supplies. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“Ok,” Mike said and buried his head in his lap to hide his tears. “Will we have to tell her?”<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">“She should know,” I replied, keeping ‘if she makes it’ to myself. This is the reality of medicine. You can do everything right and the patient still dies. You can do everything wrong and the patient lives. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I ran down to the blood bank. Carrying back a paper bag filled with packets of red blood cells, plasma, and platelets, I sprinted up the stairs, praying that God would give me strength to make it up the 8 flights. Hospital elevators always seemed too slow in moments like this. I burst into the OR and handed the anesthesiologist the paper bag. The transfusion tubing had already been set up. The surgery was almost done, but Kerry was still in grave condition. No one knew if she would suffer permanent brain damage from the long oxygen deprivation.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Kerry spent the night in the ICU. I sat with Mike to keep him company until his church family arrived. They embraced him without suspicion. Then they all laid hands on Kerry and prayed. The pastor thanked the medical team for our hard work.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Kerry was awake and breathing on her own the next day. When I told her about the blood transfusion, she just nodded and squeezed Mike’s hand.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Two days later, Kerry was back on the regular postpartum floor. She looked pale and drained, but was cuddling with her baby. Mike had his arm protectively around them. Church ladies were there again with flowers, sandwiches, diapers, and happy chatter. An opened Bible sat on the side table. I looked from the door and decided not to go in. Mike was the only one who noticed me. He subtly smiled, and winked. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I don’t know what saved Kerry’s life, if it was the skilled surgeons, the timely blood transfusions, the fervent prayer, or God’s sovereign will. That, I suppose, is the essence of faith. I sometimes wonder if what happened was the best outcome for them, if they have been able to hold on to the promise of heaven. </span><span class="Apple-style-span" style="font-family: Arial; font-size: 11pt;"><o:p></o:p></span><br />
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-39876789280761231712011-10-30T23:36:00.001-07:002012-02-27T23:22:07.524-08:00Why I Support Universal Health Care<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Home for the holidays, Elisa was a college student, who arrived in the ER with severe abdominal pain. After blood draws, radiological tests, specialist consults, and an invasive diagnostic procedure, we finally learned the source of her pain: cancer.</span><br />
<div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">A determined young lady, Elisa was going to be the first in her family to finish college. Her parents had made significant sacrifices to help her achieve this dream. In fact, they stopped paying for health insurance to save for tuition. I offered our social work services to assist with coverage issues. Elisa declined, saying she could not put her family further into debt.</span><br />
<a name='more'></a><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Elisa didn’t come back for her follow-up appointment. A few weeks later, a doctor from a hospital near her school, called asking for medical records, stating that Elisa was in critical condition. The cancer had spread. She received emergency surgery, but she rapidly deteriorated despite heroic efforts. Like many others who get care too late, her final days were spent in the ICU.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Elisa is a poignant reminder that our health care system continues to fail people who deserve better. I can’t say for sure if Elisa would have survived if she had health insurance from the start, but her care wouldn’t have been delayed. Most Americans believe that health care is a right. Yet, the United States remains the only developed nation that doesn’t ensure basic coverage for all its citizens. Over 16% of American adults are uninsured and we have the poor health outcomes to show for it. Of all the reforms needed to fix our broken system, universal coverage is actually one of the more clearly defined problems with an identifiable solution. The Affordable Health Care Act of 2010 was designed to put this issue to rest. However, certain factions are trying to dismantle it before it fully takes effect, and public support is declining due to the contentious election year climate. I think if more people grasped who the uninsured are and how insurance works, we would be less distracted by the politics and be able to solidify our support for the issue.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">First, the uninsured population is multidimensional, diverse, and looks a lot like you and me. It includes the growing number of people who are unemployed, because our society links health insurance to jobs. There are people who are self-employed or work in small businesses, who can’t afford insurance. There are people who work in large companies who still find the reduced premiums prohibitively expensive. There are people who lose coverage due to pre-existing conditions. There are young people, especially men, who forego insurance by choice. And there are a lot of children without coverage because their parents belong to one of the above groups. A much smaller number are undocumented immigrants and freeloaders. In brief, the uninsured population isn’t marginalized or hidden. For the most part, it is our well-meaning, hard-working neighbors.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Second, insurance works by pooling risk. Everyone has some risk of getting sick. Most people will want to prepare for the uncertainty by saving up while they’re healthy. Instead of having people hoard large sums of money, it benefits society for people to spend most of that money to improve their current quality of life and circulate it back into the economy. Besides, as a reality check, most people could never put away enough, even with generous tax credits, to pay for a typical diagnostic work-up, not to mention a full course of treatment. So, it makes sense for a group to organize collecting a relatively minor contribution from each individual and then portion it out as needed. Individuals are generally willing to pay a small amount for this sense of security. Insurance harnesses the power of collective resources to mitigate the financially disabling effects of illness. It is economically efficient, and reduces the cost of lost workdays by getting people the care they need in a timely manner. It is most effective when everyone participates. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Elisa’s situation infuriated me. The most prosperous nation in the world should not tolerate having an uninsured population. Universal coverage makes moral sense, human sense, and fiscal sense. It not only improves the health outlook of the individual, but also benefits families, communities, and domestic productivity. Instead of weakening the Affordable Health Care Act, we should get it up and running as soon as possible.</span><span class="Apple-style-span" style="font-family: Arial; font-size: 11pt;"><o:p></o:p></span><br />
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-2343072184628983592011-10-25T15:33:00.002-07:002012-02-27T23:22:58.543-08:00The Veil of Ignorance<div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">My patient was veiled in layers of heavy black cloth from head to toe. I could see blood staining her white socks as I waited impatiently for a female Arabic translator. Slowly, I told the patient and her sister that I was worried about her pregnancy, and would need to do a pelvic exam. As feared, I soon saw that she had a miscarriage. “Can I see the baby?” she said, gesturing to the container I discreetly covered with a clean towel. “We need to take him home for burial,” the sister added. I hesitated. A 12-week fetus wasn’t an easy image to prepare someone for. I laid it on clean gauze and explained, “It’s very early. It won’t look like a baby.” My patient nodded and held out her hand. At the sight of it, she shrieked, then clutched the fetus to her chest and began to pray.</span><br />
<a name='more'></a></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Later that day, I saw another patient in the ER, again bleeding vaginally. She had taken a pill from the corner bodega to “make her period come down.” She got scared when the bleeding started and came to the hospital. The patient did not look me in the eye while she spoke. Sure enough, my ultrasound exam revealed a healthy-appearing 12-week fetus. Sharing this observation with her, she finally admitted, “My husband just lost his job. We already have 3 kids.” I told her if she wanted, he could come in and we could all talk together. She gratefully accepted. I counseled them extensively on their options and where they can safely follow-up, whatever their final decision.<o:p></o:p></span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">It’s all in a day’s work for an OB/GYN to sit with couples devastated by lost pregnancies; or lay out the decision-making process for a pregnant woman with newly diagnosed cancer; or listen to a distraught patient confessing that she just can’t have a 7<sup>th</sup> baby but her husband won’t let her use contraception; or admonish a young lady requesting her 5<sup>th</sup> abortion because she thinks birth control will make her fat.<o:p></o:p></span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Whenever I see ideological debates about abortion in the media, I remember these real women. I find myself wrestling with paradigm shifts, engaging in the arduous task of putting myself in my patients’ shoes. In one instance, no maternal sacrifice would be too great to save a pre-viable fetus. In another, self-preservation trumps bringing new life into the world. I don’t always succeed in empathizing with my patients. Sometimes, I am dismayed by their choices and arguments. Often, I balk at pleas that I lie to their families on their behalf.<o:p></o:p></span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">What I have learned from my patients is that violent protesters, graphic descriptions, or philosophical discussions about when a fetus becomes a person don’t sway their decisions. Whether or not they can articulate their moral, cultural, or religious beliefs, they already follow some internal creed that brought them to my doorstep. They came seeking a doctor, a counselor to guide them through a difficult, confusing choice because they have been inundated with political sound bites, folklore, and patriarchy. What they need are facts and a confidential, nonjudgmental space to work out their apprehensions about pregnancy and motherhood.<o:p></o:p></span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">What about the fetus though? Who protects him? I won’t pretend to have the wisdom to argue the fine points of those existential questions with you. My internal compass leads me to focus on treating my patients with as much compassion as I can muster. I think about John Rawl’s <i>veil of ignorance</i>: to create a just society, you need to presume that you don’t know what your status will be in it, whether you will be rich or poor, powerful or weak, someone who will one day need an abortion or not. Unbiased, you are free to devise policies that are good, just, and beneficial for society.<o:p></o:p></span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">To date, I have yet to meet a pregnant patient, faced with the tangled web of voluntary and involuntary reasons to continue or end a pregnancy, who didn’t take a good look in the mirror and ask herself what she can live with. I can usually see in her body language, the hunger for certainty, the fleeting shame, or the hardened resolve. She alone carries the lifelong burden of her decision. Only she can appreciate the intricate calculus of the costs and benefits at stake. As a doctor, I get to decide if I will add to her pain or start her healing right away.<o:p></o:p></span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div></div><div class="MsoNormal"><div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I believe it is my duty to meet my patients wherever they are, and alleviate their suffering. My personal comfort is not in play, but my ability to counsel without judgment is. Issues of morality, after all, should be imbued with equal parts rigor AND grace. Holding on to this simple truth is what helps me sleep at night.</span><br />
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br />
</span></div></div>Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.comtag:blogger.com,1999:blog-883198132854527.post-39282056564493220562011-10-22T07:00:00.002-07:002016-03-10T23:23:40.040-08:00A Question of Worth<span class="Apple-style-span" style="font-size: 15px;">
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<span style="font-family: Arial, Helvetica, sans-serif; mso-bidi-font-family: Arial; mso-bidi-font-size: 15.0pt;">Cheryl was a cancer survivor, recovered drug
addict, HIV carrier, and devoted mother of 3 kids. At age 35, she had been
cured from cervical cancer after surgery and radiation therapy. However, due to
treatment-related fistulas, she had been in and out of the hospital for most of
the year. I was taking call for the gynecology service the last time her family
brought her in, delirious and with black, sticky stool oozing from an opening
in her unhealed abdominal incision. She needed wound care and close monitoring
in the intensive care unit (ICU). I called my attending and paged the ICU team
simultaneously.</span></div>
<a name='more'></a><span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;"><span class="Apple-style-span" style="font-family: Arial; font-size: 15px;">The ICU fellow came promptly, and briskly refused
to accept her to his unit…again. “She is a poor use of scarce resources,” he
stated matter-of-factly. “Further treatment is <i>futile</i>.” Without missing
a beat, I looked him in the eye and countered, “What if this was your sister?
Your mom?” He relented begrudgingly, but added, “This is why health care is so
expensive in this country. You surgeons don’t know when to let go."</span><span class="Apple-style-span" style="font-size: 15px;">
</span></span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 15.0pt;">Thanking him for accepting my patient, I went back
to Cheryl to clean up her wound site. She grabbed my arm and whispered,
"Dr. Wu, I'm scared. Don't leave." I assured her that we would do
everything we could to get her back to her kids. Afterall, her cancer was gone,
she had controlled her heroin addiction, and her HIV viral load was
undetectable. She had fought hard to get to this point and wasn’t quitting now.
Two days later, Cheryl was leaving her room to sneak a cigarette. One day after
that, she was found dead in her hospital bed by a nursing assistant checking
vital signs. Cheryl had quietly passed away in her sleep from a massive
gastrointestinal bleed.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 15.0pt;">My experience with Cheryl was one of the most
difficult and meaningful moments in my residency. I still wonder if I made the
best choice. Had I gotten too attached and lost sight of the big picture, as
the ICU fellow purported? Who deserved that last ICU bed that night? Someone
who would have only cost taxpayers $10,000, $100,000, or $1,000,000 during her
stay? Would it have mattered to the hypothetical taxpayer that Cheryl had lost
her job and employer-based insurance due to her long treatment, then lost her
home, then spent down her income and thus qualified for Medicaid? Was it my responsibility
to be considering broader health care resource allocation while my patient was
critically ill? Besides, the ICU fellow abandoned his cost-conscious argument
quite quickly at the mere suggestion that he would do otherwise if it were his
own family member on the stretcher.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 15.0pt;">I had worked in the private, public, and
not-for-profit sectors prior to going to medical school. I had pondered the
roles of corporations, governments, and single-issue foundations in shaping our
health care system. I knew about the slippery politics, limited data, legal
pressures, and economic realities. I had armed myself with the academic tools
to appreciate the context before becoming a doctor. Yet, time and time again
when my patients come into the emergency room or are lying on the operating
table or get better or worse after some intervention, I struggle to see the
forest for the trees.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 15.0pt;">On some level, I don’t think my patients want me to
be thinking about the sustainability of the health care system when I’m
counseling them about their options. They want to know that I am their
unwavering advocate. Their interests are my top priority in that fiduciary
relationship. If I suggested more or less, it would only be watching out for
them, not for the general public.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 15.0pt;">Yet, my experience tells me that providers, the
people who oversee these cherished doctor-patient interactions, must play a
principal role in revamping this overwrought and overpriced health care
structure that does not produce the quality and safety outcomes any moral
society would demand. Doctors wrestle with the nuances and inefficiencies of
the institution every day. Medicine is not mathematics, but it is prudent to
inject a measure of cost-awareness into our diagnostic work-ups, treatment
algorithms and clinical trials. It may seem distasteful to knowingly put a
monetary value on life, but we already do that calculation with each clinical
decision we make. Higher quality can be affordable and accessible. Creativity
and adaptive skills are the bread and butter of survival in an academic medical
center; ask any intern.</span><span style="font-family: Times; mso-bidi-font-family: Times; mso-bidi-font-size: 16.0pt;"><o:p></o:p></span></span></div>
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<span style="font-family: Arial; mso-bidi-font-family: Arial; mso-bidi-font-size: 15.0pt;"><span style="font-family: Arial, Helvetica, sans-serif;">So for now, I continue to navigate that difficult
space between being a good doctor and a conscientious citizen. I will see many
more patients like Cheryl in my career. They will always be pushing me to do
better.</span><span style="font-family: arial, helvetica, sans-serif; font-size: 15px;"> </span></span><span style="font-family: "arial"; font-size: 15px;"><o:p></o:p></span></div>
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Eijean Wu, MDhttp://www.blogger.com/profile/05920054137811067584noreply@blogger.com