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The sin of the rvu

I could never have fathomed how badly residency and medicine in the US could try to beat the compassion out of me. We all went into medical school with bright eyes, touting our love and desire to help people as our primary motivation for pursuing this career. It is likely what made us special, what marketed us as exceptional beyond the grades, MCAT scores, and extracurriculars. And yet a year and half into residency I am finding persistently berated by moral injury of a desire to help people in a system that seemingly strives to make it nearly impossible to do that.

A few months ago my residency transitioned all of our appointments to 30 minute slots, a subtle but heinously impactful change from a mix of 30-45 minutes appointments prior. Independent of new patient or established, routine or presenting with a dozen chronic diseases, we have 30 minutes to meet another human being, learn what makes them who they are and why they strive for health, and make recommendations to help influence their lives. The system is set up this way because of financial incentives to decrease duration of visits while maintaining revenue, a meaningless need to reach the arbitrary number of 1650 patient encounters before the end of residency, and a need to supply care for seemingly infinite demand with extremely limited supply.

The population we manage at mine and most residencies’ clinics are infinitely complex with housing insecurity, polysubstance use, complex mental health issues, and frequently very severe despondency and suicidality. It is a population that rarely comes to healthcare for routine health maintenance; that is a privilege of a wealthier population with stable employer subsidized health insurance, ample childcare, free time, and transportation. Our population on the other hand comes to us when they are desperate. I love them and I want to help them but when attempting to discuss blood sugars and substance use to a patient who often has had the crap beat out of them by life, I feel wholly inadequate. This system is infuriating and nearly daily I go home pulling at my hair and wanting to scream at the dissonance between the care I want to provide and the total joke of healthcare that I am able to give.

I take these patients’ stories home with me and think about how best to help. I think about what I may have missed in 30 minutes of attempting to influence the health of a person I have never met. I laugh at the infinitely specialized care this country provides to the well off, where a gynecologist is recruited for a simple pap smear, a cardiologist tweaking blood pressure meds, a psychiatrist adjusting a simple anti-depressant. Meanwhile I face having a patient with a likely skull fracture coming into clinic who refuses to go the emergency room for a CT scan because she cannot afford it. She may have bacteria creeping into the fluid around her brain but even a $30 copay racks up debt. I think about my obstetric patient who left a hospital 150 miles away against medical advice and drove herself to my hospital instead of getting the ambulance because there is no way she would be able to afford diapers for her newborn if she had to pay off medical transport bills. I routinely encourage people with horrible PTSD from awful domestic violence to establish with a therapist only to face the frustrating reality that therapy is a luxury to help middle to upper class depression, not a service accessible to those often in desperate need.

It is an infuriating system that feels designed to break me. I realize and know wholeheartedly that despite its flaws, there is no viable solution for this beyond single payer healthcare. No for profit healthcare will ever result in beneficial or even reasonable care for patients. Even I, as a physician, who is well insured will persistently avoid going to the doctor. Despite having insurance, I have absolutely no idea what the bill will be walking out the door of another physician’s clinic. That fear that I have just from visiting another clinician’s office undermines our credibility too. I frequently have patients comment on the benefit of their visit to my wallet. How completely jacked up of a system do we have that patient’s are thinking about the transaction in healthcare rather than pure empathy of their provider and my desire to help?

The system is forked for all of us but some frequently justify it in comparison to worse alternatives. Some of my attendings have touted 30 minutes appointments as luxurious compared to most family medicine providers as if pointing out how royally moronic other people’s schedules are justifies how subtly less moronic ours are. The crazy thing is, they’re right. My specific residency is super cush. But my god, do not ever justify atrocities by pointing out worse atrocities. Others blame the younger generation, calling us soft, saying 80 hour work week restrictions are silly. Maybe we just care more; maybe we care more when we feel that compassion slipping away in the face of exhausting work. The “that’s how it’s always been done” argument pervades through our culture like a festering sore. It needs to be revamped. Our population is suffering because of it.

When to hold back?

Yesterday I led a case conference regarding ambiguous care for a complex patient. It was with regards a patient with shoulder pain with a small labrum tear, multiple comorbidities, severe illness anxiety who was maxed out on medical therapy, pain refractory to physical therapy and other conservative interventions. I hesitated very much on referring her to a surgeon because I knew she would likely get a surgery of questionable benefit with possibly worse outcomes. There is gross incentive for the surgeon to still perform surgery and it’s hard to refuse a patient when they likely will just go find a surgeon who will do it. I know that was the pathway and that is what happened. And then she got worse.

I don’t think we think often enough about the ambiguity in health care, probably largely from social pressures with expectations to have answers and be perfect. One of the things that was mentioned was the spectrum of testing for everything and missing nothing and testing for few things and missing some things. I mentioned this to an intensivist and he related it to the aggressiveness of care sometimes in the ICU. You can withdraw care from everyone who is seeming like they are going down a poor path or you could continue full force interventions all the way up until death is obvious.

What this is getting at is this idea often tossed around that we should test if we can and we should intervene if we can. People think getting an MRI is benign and if they had the option most would likely want to get an MRI of their whole bodies to find any possible disease. The problem with this is that we often find things that look suspicious but will never be problematic and have no way of knowing until we biopsy them or resect them. This is largely why most of us in healthcare are reluctant to pursue tests that don’t have clear purpose. Patients don’t often understand this ambiguity however so therein comes some need for paternalism to protect patients from themselves. Patients want the most educated care, the most testing, the most interventions and while we as healthcare professionals are sitting there desperately wishing they would back off and accept fate, they continue pushing.

In the ICU we often will do full force care on patients who are extremely ill and more often than not it is futile. But sometimes, every now and then, a patient pulls through and we’re terrified of how many patients we have backed off care for who may have made it out of similar circumstances. That is a terrifying prospect for a physician and very similar to the fear invoked by a test not ordered that would’ve revealed a cancer that could’ve been treated. This is horrifying at my stage of my career. I desperately want things to be more black and white but the ambiguity of medicine is what makes it so academically intriguing. If there were clear answers, algorithms and pathways would takes our jobs.

Part of me wonders what good we’re actually doing. Repeating biopsy after biopsy after biopsy on a somewhat suspicious cervical lesion, following year after year after year, all while the patient is dreading coming to see us, wondering which time they’ll find out they have cancer or find out that everything is fine and all the probing was for nothing. Most patients it seems want answers; that at least seems fairly universal. And a lot of doctors will justify that when they go down these abysmal pathways that are certainly causing harm.

I feel like we as medical professionals in the midst of trying to prevent disease and fix everything little problem have created this global illness anxiety and health awareness that is causing more harm than good. I worry more for the joy of life and the end of life prospects of the patient who pathologically exercises and eats a pristine diet full of the latest fad supplements and whose BMI is perfect who tries desperately their whole lives to prevent heart disease with fish oil and to stifle the effects of antioxidants with Acai than the rural Montana farmer who hasn’t seen a doc since they were a kid who comes in at 82 with a raging terminal cancer. One of those people perseverated over their health their entire lives and often I am concerned those people forgot to live. And the other lived a good life and is often content to pass.

Maybe I am too cynical. Maybe I am jaded. But after witnessing the atrocities that the health care system puts people through with aggressive management, and especially the discrepancy between the care the wealthy get for unnecessary interventions and the crumbs the less well off get, the limited support available to the young and otherwise healthy compared to the insane expenditure on people who will inevitably die soon, I understand my cynicism. It isn’t unfounded. And understanding where this introspection comes from I think is even more important. I see the suffering we invoke on a regular basis, the number of people we strip from their homes to die alone in a cold, stale hospital. I went into this job to help prevent suffering. I want to help people’s lives be a bit better. And I don’t think we’re doing as good of a job of that as we could be.

A moral dilemma of placebo in american healthcare

I have been caring for patients for nearly a year and a half now in residency and have come across some of the more subtly haunting realizations in American healthcare. Recently I watched a presentation by Lorimer Moseley on pain psychology which highlighted some of the variables in placebo effect. Early in my training I naively believed in the therapies I was providing. Things needed to be more clear cut and I sought evidence based medicine by tracking down randomized controlled trials or meta-analyses relentlessly. The further along I am the more I have realized that a significant portion of the things we do in medicine are either completely useless or of questionable efficacy. Because of this I realized that largely my patients were having benefit because of natural history of their disease process (aka they were going to get better independent of what I did) or due to placebo.

The impacts of these findings is not insignificant. I think it is fair to say the ambiguity of efficacy of therapies in medicine are not only misunderstood by patients but horrendously understated by medical professionals. The perfect illustration of our inability to provide confident care is a statistical measure called number needed to treat or NNT for short to evaluate how many patients we need to treat for one person to have benefit. To tell a patient, “I would have to treat two of you to obtain this therapeutic benefit,” and to make them aware of potential adverse events would likely turn off several patients to those therapies. To make it transparent that most of our therapies are horrendously worse than an NNT of two would likely create total distrust in the healthcare system, especially when we are talking about unfathomably expensive and invasive things like organ transplant or orthopedic surgery. The reality is that even with a solid diagnosis and a good treatment, the chances of patients having quantifiable benefit is still very low. Add in diagnostic ambiguity and it makes evidence based treatment a total crapshoot.

The reason I bring this up is because I am battling an ethical quandary. Placebo is effective in many cases but very dependent on a whole host of variables. I know that the more I sell my placebo, the more I tell a patient that a therapy is likely effective, the more “doctorly” I am dressed, the neater my hair, likely the better placebo effect I may have for my patient. My patient would by all accounts benefit from those things. The ethical dilemma comes in when I am facing the infinite complexities beyond the quantified therapeutic benefit. For example, is it okay to tell a patient that I believe a therapy will work for them when I am unsure? When placebo works for approximately one out of three patients for many given conditions, is it okay to tout a mild therapy as likely beneficial to increase the chances of benefit even if it may be minimal?

Additionally, what is my obligation to help my patients with my appearance? If you google image search “physician” you’re bound to get countless stock images of doctors of all races, genders, sizes likely wearing a stethoscope and a long white coat. Interestingly there is an appearance of a physician that elicits the greatest placebo response. For example, a female physician was able to provide greater placebo effect than two males colleagues in a trial of 120 people being treated for IBS. The reason this matters is because this appearance actually impacts quality of care delivered. As a younger, frequently clean shaven and youthful appearing physician my judgement is frequently questioned and likely my therapeutic benefit for patients suffers as a consequence. And now I know that, as a male provider, referring to a female colleague for treatment of my patients with IBS would likely promote better outcomes for my patients.

I have dealt with many horribly inappropriate comments on my appearance in the clinical setting by patients and other healthcare professionals. I had a nurse ask me if I had gotten my driver’s license yet, countless obstetric patients decline my care because of my apparent gender, a physician’s assistant tell me I needed to iron my shirt because I looked unprofessional, dozens of patient’s commenting on my age, and a frequent distrust of my credibility as a generalist practitioner. These verbal patients and colleagues are the easy ones to deal with because they state their opinions and I am able to address them. The subtler, less vocal biases are likely the ones that compromise my therapeutic impact. Am I obligated to iron my shirts and wear a white coat to appear more as the classical image of a physician? Should I keep my beard year round to appear older to appeal to the ageism in my older patient panel? How in 2020 are we advocating so hard for dissipation of discrimination based on gender identity and yet so many patients declined my care because I identify as a male? Am I obligated to shape my appearance and refer to differing appearance providers to better help my patients?

To add complexity, our medical system is based on fee for service similar to a car mechanic. In mechanic work the model is that the diagnostician is the same as the interventionist and we know this model creates tension and likely frequently unnecessary interventions and cost to the customer. In medicine I could derive direct financial benefit from a certain treatment and likely I would receive variable compensation for various therapies independent of their indication or efficacy.

These questions are not new but I think not as discussed as they ought to be. Placebo effect is infinitely complex and I certainly will wrestle with it for the entirety of my career. More related to the financial incentives of treatment, currently the American healthcare system by nature absolutely prevents me from feeling like I can practice ethical care for my patients. So long as there is a financial incentive for any healthcare providers to deliver care, with well documented greater financial incentives for less evidence based, more invasive care, we will not be able to rest knowing that the career of a physician is a fundamentally altruistic one.

Super ultralight backpacking: What it takes to carry a 3.5 pound pack – Appalachian Trials

Check out my post that was published on Appalachian Trials on what it takes to carry a 3.5lb pack for the northern third of the Appalachian Trail.For me, super ultralight backpacking isn’t about materialism; it’s about minimalism. Whether you’re looking to chase a FKT or just enjoy tweaking gear lists, tailoring a gear list to a specific trip is an incredibly fun challenge.

Source: Super ultralight backpacking: What it takes to carry a 3.5 pound pack – Appalachian Trials

11 reasons you may want to switch to tarp camping – Appalachian Trials

Cooped up in a nylon wrapper can be disorienting and uncomfortable. Tarps can be pitched with ceilings high enough to stand under and open on all sides. For drastically less weight, they can be outright tremendous, big enough to sleep a dozen hikers, or just to give yourself a comfortable vantage of the torrential rain outside. And with a simple lean-to tarp setup, you’re open to quickly and easily pinpoint exactly what that rustling is in the distance.

Source: 11 reasons you may want to switch to tarp camping – Appalachian Trials