My last action as a US medical doctor was further affirmation of my decision to leave this country and this system.

In two months my wife and I are moving to Canada for me to start a job working in primary care and long term care in Rossland, British Columbia. When someone asks me, “why the move?” my answer is always “Oh…a lot of reasons.” And I’ll say fully, we are consciously moving toward something, not away from something as Missoula has been really great for us. We are moving to an incredible place with a lovely town with amazing recreation and community. But one of the reasons to leave the US is that the healthcare system in this country is fundamentally broken and I cannot imagine a career fighting against capitalist interests in an innately and necessarily humanist profession.

Yesterday as I wrapped up with my last patients I got a message in my in-basket telling me a patient’s CT scan had been denied after she had already completed the scan. The insurance company offered me the option to complete a peer-to-peer as the only option for potentially having it approved. So I called the physician that they contract with/employ and who undoubtedly has financial interest in denial of claims. I explained the patient’s medical situation to her, that the patient had two chest xrays in the years prior for these symptoms but she explained that the patient needed a chest xray in the prior three months per insurance requirements. The doctor I spoke with affirmed that medically a CT scan could be justified but per their algorithm she could not approve it.

A peer-to-peer is a facade. It is two highly trained physicians discussing a patient’s case and the appropriateness of certain testing while being beholden to an arbitrary algorithm that does not account for nuance. I told her I was likely decreasing costs to their company and decreasing radiation to the patient and the doc agreed. But her hands were tied. A peer-to-peer gives us physicians the illusion of an intellectual conversation about appropriateness of medical care. But a well trained monkey could go through an algorithm and deny the claim. If the doc agreed it was medically indicated but still cannot approve it, then why waste 30 minutes of my time at the end of my day with the conversation? Just to appease me; to make me feel like I have some semblance of power.

They put up barriers at every turn. A peer-to-peer is just another one of those barriers. The insurance company is incentivized to deny, deny, deny as long as it doesn’t inevitably increase their costs in the long run. Even the act of getting a peer-to-peer is exhauting. You are put through a heinous phone tree and required to give about ten different 10+ digit identifying numbers several times. You speak with a non-medical person first. Then an RN. Then you are patched through to the doc. You have to provide identifiers, your name each step of the way as if that information cannot be passed on to the next person. They hope you will give up and the patient will foot the bill.

You may wonder why an insurance company doesn’t want to improve the health of its clients because that would likely decrease cost in the long run. The reality is, insurance companies want to keep you cheap, not healthy, until you turn 65. That is when almost everyone transitions to our socialized healthcare- Medicare. In addition, if you get sick enough, say need a transplant or go on disability, you will almost certainly transition to Medicare. Most chronic disease has the bulk of expensive consequences after the age of 65. This conservative misguided notion that “I don’t want to pay for other people” is delusional. You are paying for other people. And more expensive at that because we are prioritizing profits for shareholders over health of the population.

That CT scan was denied and the patient will foot the bill in full. The imaging company has certainly chosen a completely arbitrary price out of a hat that the insurance company typically pays a fraction of, which they call “negotiation”, but the patient will pay the full, exorbitant price. I am the face of this patient’s care so I will take the blame and frustration from the patient. We cannot continue on like this. This system is fundamentally, at its core, not viable.

I feel like a deserter in some ways. I think about the docs who go on mission trips to provide care to underserved communities globally. I think about the US as analogous to those communities in some ways, especially rural communities. Those docs probably feel the burden of under-resourced systems and resultant poor outcomes for patients. In the US we are heavily resourced but it’s completely unaffordable. However, in this system we are subject to vitriol from leadership, skepticism, and complete ungratefulness. The patient’s express distrust in our guidance while simultaneously pounding supplements pushed on social media by shill chiropractors and fringe docs.

I know the system in BC will have its flaws. But those flaws are not innate to the system and they are continually working to improve the system whereas in the US it seems the opposite is occurring. I’m eternally grateful to British Columbia and the community of Rossland for welcoming me and prioritizing their health and the health of their neighbors and community and am ecstatic for this change. My coworkers in Missoula have been absolutely wonderful and I’ll miss them dearly.

I went to a drug rep dinner tonight discussing a new PrEP medication tonight at one of the most expensive restaurants in Missoula this evening. It is honestly an incredible field of research and has the potential to eradicate HIV from the planet if allocated appropriately. However, I can’t help but leave the evening with a feeling that I sold my soul to big pharma.

For the last 6+ years I have avoided drug reps completely, refusing to take their merchandise, samples, pamphlets, meals, whatever they shove in our faces on the reg. Early on in med school, after enjoying several free meals provided by pharma companies, I learned the truth and started packing a lunch. The reality is always: it is the patient who pays for those meals. Big dog CEO makes bank off these meds and displaces any of these extravagant dinners onto the patients. If the patient isn’t paying for it, their insurance company foots the bill for it (ie the patient still pays for it in their premiums/copays/deductibles/taxes). So to all my patients on PrEP, thanks for the dinner tonight and I’m truly sorry.

I realized tonight though that me declining these advertisements/bribes/incentives is a privileged thing. My staff at my clinic routinely take the lunches while the docs refuse to engage with these salespeople. We, as the docs, never pay for our staff to have lunches yet we willingly allow reps to come in and feed out staff. Even though I am uncomfortable with eating the food myself, I allow them to come in because it makes the employees in the clinic happy and well fed. The solution to this is to decline reps and have the docs/clinic fund lunches several days a week. Easy problem to solve.

The problem with pharmaceuticals in 2024 and the extremely unregulated marketing with them in the United States is weirdly that the drugs are too good. A doctors job has always been a difficult one due to difficult to treat conditions. Mortality rate for all of us is, in 2024, still 100%, the common cold has practically no really useful treatments, cancers are still often debilitating and fatal, etc. But with each passing year, pharma companies develop incredible disease altering meds. They can often, with minimal side effects, practically cure ulcerative colitis, rheumatoid arthritis, lupus, psoriasis, HIV, hepatitis C, type 2 diabetes, eczema, and a whole host of other previously debilitating diseases. Thanks to GLP1 agonists (injectable diabetes and weight loss medications), for example, the national rate obesity will likely start declining for the first time. Medications historically were relatively crappy. They had atrocious side effects and were not that effective. We as docs looked like idiots because most things were largely untreatable. That is quickly changing and with these incredible meds, pharma companies are making bank and it’s only going to get better for them. Patients really want these meds and often all but standing in line to receive multithousand dollar a month medications.

With these incredible new meds, these companies can charge a fortune. They advertise predominately to people who they believe can afford the medications and direct their efforts to high yield audiences where they can make the most money. The problem, specifically in PrEP is that the populations that are most likely to benefit from these meds are the least likely to receive them. The black and latino populations in the US are being disproportionately affected by HIV. But the healthcare system, including pharma companies are massively failing them. We have all these contrived, extremely exhausting workarounds for getting insurance coverage, prescription coupons, federal grant funding to afford these meds but all of this takes privilege, support, allies, community and legislator support.

I’m not sure of a solution to all of this. Capitalism and greed have prompted pharma companies to research and develop these incredible meds knowing there is an astronomical amount of money to be made. Capitalism has served a role here. I wonder about abandoning the capitalistic system and just providing taxpayer funded research for meds. It for sure would be cheaper, would probably provide more equitable research and research meds that are to treat rare conditions more often, but with our social regression recently is certainly one of my socialist pipe dreams.

Whatever the solution, I know we can abandon drug marketing. We can seek our own knowledge from our professional societies, colleagues, government agencies, and other academic resources. We can outlaw the expensive direct to consumer advertisements and refuse the tasteless bribes to healthcare professionals. I will go back to avoiding drug reps. I will hang my head in shame over my acceptance of a bribe this evening and hopefully do some good tomorrow to make up for it. If someone ever grills me in front of a congressional committee as they did to Dr. Fauci, asking him how much money he accepted from pharma (shocker, he accepted none), I will hang my head and disclose this dinner.

I just got done obtaining a mortgage for my first big boy house, Yay!

But I learned a lot about lenders and obtaining a mortgage and some tricks. I haven’t been able to find a post similar to this so I figured it’d be helpful to write my own. So here is a list of tricks and realities with mortgages that I think might be helpful. I used a conventional loan and have a good credit score so some of these tricks may not be applicable to other types of loans.

The reality is, like car insurance, mortgage lending is now extremely regulated so the product that they are providing you and the tricks they historically had to scam us do not fly anymore. So you’re pretty safe to go with any lender. Just make sure you read the loan estimate thoroughly and don’t give them money until you are ready to pay them for something.

1. Don’t get sentimental about your lender. They are selling you a loan and you are almost certainly not going to have a long term relationship with them like you will with your real estate agent. Treat a mortgage like a commodity like rice or corn-consider buying the grocery store brand rather than the brand name. Shop around to find the best rate. It will save you possibly tens of thousands.
2. Apply with multiple different lenders, local credit unions, local banks, and large multi-state banks such as Mutual of Omaha, Sage, Better, Old National, etc. Sometimes the local lenders will have the best rates but sometimes it will be the large online lenders. Once you have all the documents you need for an application it takes minutes to apply and the little extra time it takes will be worth your time and it costs nothing to apply. If all your credit pulls for a mortgage are within 30 days it will only ding your credit score once.
3. Lenders will do a “rate lock” for you meaning they will lock in the terms that are available on that day that you are discussing with them. You can do this at any point after you’re under contract and if you don’t do it, you may risk rates increasing and losing out on the best option. I recommend rate locking with the lowest rate lender on day 1 of you having that available and not rate locking with any other lender at this point. Pin them against each other on day 1 to get them to give you the lowest rate. They are almost always charging you a higher rate than they will be willing to offer. If they are going to play this game by not being transparent with their pricing, don’t feel bad about pinning them against each other.
4. Do not use the lender’s quoted APR. Use the interest rate and tally up lender costs separately. These will include sections A and B under your loan estimate. All other costs are estimates early in the process and are irrelevant and going to be the same independent of the lender. Some lenders will estimate the taxes or insurance artificially low to make the APR looked better.
5. You can have multiple lenders go through underwriting, sometimes with a cost but usually without a cost to you. It’s unfortunately extra work for them if you decide to go with a different lender but this is unfortunately the game. To get underwriting started you probably either need 1. an appraisal waiver or 2. to pay for an appraisal of the home you’re purchasing at cost to you (in my city about $750. I highly consider getting an appraisal from two lenders if rates are pretty volatile. That $750 additional cost will allow you to leverage two lenders against each other up until the very end.
6. Lenders can “re-lock” rates. So if rates drop before closing date and you have two lenders competing for your business you can ask them to beat the next guy. The way I did this was I watched rates drop and then plateau and then told lender B, who had the worse rate, if he could beat lender A with the better rate. He beat the rate of lender A, I went back to lender A and they beat the rate of lender B again. Without having that leverage lender A would never have budged because the rate was “locked”. I re-locked with the lender about 10 days before closing, most of the underwriting was already completed for both lenders and this small move toward the end of the process saved us $12,000 over the life of the loan.
7. Origination fees and points are two ways lenders will parse their cost for a specific loan but it is always just cost to you. Consider them in the same boat when comparing lenders.
8. To calculate whether additional cost to you up front is worth it, use an amortization calculator to divide the total costs (points+ origination fees) by the decrease cost per month to see how many months it will take it to be worth it. This estimate will be artificially high however because 1. you should take that upfront money saved and reinvest it and 2. mortgage interest is tax deductible. If you expect to refinance or sell your home within a couple years, don’t buy points that will take 5 years to be worth it.

It’s a complicated process and such an annoying game but is a good one to play. This is the most expensive purchase most of us will ever make in our lives and the difference in cost for us over the life of the loan between the best and worst lenders was $40k and between the best and second best was over $40 a day for the next 15 years. Lenders will try to understate that difference because compared to your monthly payment it looks small but I will never consider $40 a day a small amount of money, even when we are talking about thousands of dollars. Penny pinching should be applied to huge amounts of money just the same as small amounts.

In my job I have the privilege of getting to see people age. As a family med physician who has prioritized chronic disease management, most of my visits are caring for a population over 65 years old. I get to see people at all stages of life but focusing on an older population has really driven in how precious our lives are.

I saw a cute comic from Anna-Laura Sullivan where all the characters are commenting on it being there first time being alive. They are struggling and making mistakes and admitting that this is all their first time’s doing this. It was such a beautiful sentiment and I think made me realize that no matter which patient I am treating, this is there first time having this exact experience. I sometimes hold patients to impossible standards, question the med regimens that they are on, want to shake them to have better habits, or engage more with their health. But I realize, this is their first time having hypertension or diabetes, maybe their first time having to see a doctor regularly. They may not have grown up seeing these chronic diseases, don’t fully grasp the potential outcomes they may have.

I get to see a dozen or more people a day deal with hardship, disease, contemplate their health. Some are facing terminal disease, some age related changes, some anxiety and stress, depression, loss of loved ones. I get a glimpse into my future with each of these cases. I know I will have friends and family die, will have my own injuries and sickness, will struggle with my weight and with habits, with time management, with prioritizing my health. I often can’t fix these problems that patients face. A lot of it is just the reality of life. Our joints degrade and ache, blood vessels narrow and clot, cells mutate and become cancerous. I can do my best to prevent these things from happening, delay them, or heal them, but medicine is limited in 2024.

My patients bring me a beautiful bit of foreshadowing and appreciation for each moment I have now. I know that’s not why they come to me but in the moments that I cannot fix, like death of a spouse, it makes me greatly appreciate my partner. When I lay in bed next to her I hold her tightly, knowing that at some point I may not have her. I hike or ski or bike and think about my 80 year old patients who could’ve kicked my ass in all those sports in their heyday and I appreciate these moments my mobility is preserved. Often, I get to see some patients get better. Their back pain will dissipate with time and when my back aches, I look at it more academically and objectively, knowing that I will likely get better too.

I also hope, despite my sometimes being paternalistic, or tired, or unempathetic, that each visit I have with a patient is also exactly the first time I have had this visit. While it may be a routine visit, the same med I have prescribed dozens of times, it is never exactly the same. I am trying to grow as a provider, to recognize that each patient is and individual with personal goals, risk tolerances, and wishes. It’s hard enough to keep up with the evidence for each decision we make it medicine. But to apply that to an individual who has lived a whole life differently than me is where the real difficulty lies. I just hope for forgiveness from patients when I don’t get it right. I care and I am trying.

I am finally at a point in my life where I get to reap the gratification I deferred for so many years. I have struggled through school most of my life to get to a stable career, stable housing, stable relationships. With things being lovely now I do have a bit of clinginess to the present moment. But I know what my future holds and I just hope to age gracefully, to live this life, my first time here, as well as I can.

I am working on implementing a different type of scheduling in primary care. I know that is probably the most un-exciting way to begin a blog post so bear with me for a second because I think it is kind of interesting. Every other primary doc I know of is booked out for weeks. They have different backlogs of patients with half a dozen queues for patients. They have different slots for different types of visits each day, for example: two annual exams a day, one procedure slot, two same-day appointments, two medicare wellness visit slots, six follow up slots. They may be booked out for months for medicare wellness visits but their same-day slots may not even get filled. Continue reading Open access scheduling →

I was talking with one of my former co-residents tonight, reflecting on our practices with regards to lab and imaging investigations on various patients. In residency I was probably one of the most conservative providers. I ordered only a handful of MRIs my whole residency, rarely ordered X-rays, avoided routine laboratory blood work, and rarely follow up imaging or labs on various mild abnormalities. She is in line with me, one of the least investigative providers in our residency. As interns we classically order very little imaging and labs, and often they were inappropriate if we did order them. As we get further along we learn what really truly needs investigating and are asking more questions, balancing more diseases and patient concerns and our ordering goes up. Continue reading The harm of the over-attentive doctor and the incidentaloma →