An Essential Connection

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.

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?

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.

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.

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.

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.

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?

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 “family.” 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 Prop 8 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?”

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.

Achieving Physician Autonomy

The American Medical Association and the American Association of Medical Colleges reported recently that increasing numbers of medical students are seeking dual degrees. 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.

Interestingly, my dual degree, the MD/MPP was not discussed in this article. MPP 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.

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.

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 impassioned letter to the editor of the New York Times, 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.

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.

I especially remember the Spring Exercise 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.

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. 

Choosing to Practice Good Medicine

“We need you to counsel a pregnant patient about getting an MRI.”

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.

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.”

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.

“Why do you think she has appendicitis?”

“She came in with abdominal pain, hasn’t wanted to eat and has a slightly elevated white count.”

“That can be normal in early pregnancy. Tell me about her chief complaint and initial exam.”

The medical student sheepishly admitted that he didn’t have the details. The patient spoke minimal English.

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: What is the indication? 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.

I set up the translator phone, and gently tapped the patient’s shoulder to wake her up.

“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.

“How are you feeling? How’s the pain, the vomiting?”

“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.

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?”

My ER colleague was hesitant about my plan. “The MRI is already ordered. We don’t want to miss anything.”

I understood that my colleague wanted to be thorough, though critics may call it defensive medicine – 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.

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.

Malpractice litigation is a hostile, inefficient, and sometimes unjust process in our society. Most suits are dropped and most plaintiffs never get any money. Defense costs are high 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.

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.

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.”

My ER colleague sighed deeply. “Ok. I hope you’re right. Sometimes, I feel like we’re playing Russian roulette.”

“I hope I’m right too. I have a large bottle of Pepto-Bismol in my office if you need it.”

“Don’t worry. I’m prepared.” He showed me the package of Tums in his pocket.

We laughed. It takes guts and a very strong stomach to practice good medicine.

From Laboratory to Patient; From Theory to Cure

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.