Friday, December 4, 2015

San Bernardino

The recent shooting in San Bernardino called on not only law enforcement, but also health care to do their best. I am proud of how we handled the crisis. Here are interviews with some of my colleagues:
And, another:

Saturday, October 10, 2015


While this is not directly related to my journey, it is about medicine.

Many years ago, after my fellowship, I looked into volunteering for Doctors Without Borders. It was as the war in Bosnia was heating up. I had no dependents at the time, and knew that, as a surgeon, the greatest demand might be in a war zone. I mentioned that I knew two Slavic languages. As it worked out, I did not end up as a volunteer. But, I have followed the activities of both MSF (Doctors Without Borders) and EMERGENCY, a similar group. So, it greatly disturbed me that a US airstrike had repeatedly hit a MSF hospital in Kunduz, Afghanistan (

As a physician, I take seriously the responsibility of caring for all, even at some risk to myself. I have worked in inner city hospitals where I have been threatened by some gangs, but, excused that due to the drug induced impairment of those who threatened me. And, I have known that many would not have wanted to harm me, knowing that they might later need my services.

International law protects hospitals, both military and civilian, from deliberate attack. Physicians should provide impartial care, and thus, might provide care to both civilians and combatants. Like my experiences in the inner city, those who wage war are at risk of injury, and so they want hospitals and physicians who will care for them. That is why the events of last week are so disturbing. Despite the coordinates of the MSF hospital being provided, there were several bombing runs targeting the hospital reported. Hence, MSF is asking for an investigation of a possible war crime (

The US has bombed hospitals before (, and is not alone in this (; Civilians have increasingly become the victims of war during the last century.

I hope the truth about this event will come out. And, that a hospital can be rebuilt for the people of the region.

Wednesday, October 7, 2015

The R Word

Recently, I saw my oncologist for a follow-up. Mostly good news. I am coming up to an anniversary. It is becoming less and less likely that my cancer will recur. Lab tests are looking better. And he ordered the annual follow-up imaging, something that would require preauthorization. Since it's to be done a few months down the road, I began to think about when I should start calling the insurance company to explain why I needed this test. Should I wait for the denial or be pre-emptive? Each year I have been denied, then after I called and demanded to speak to the oncology reviewer, who then approved the test.
I am a physician. I know the lingo. I can talk to the oncology reviewer and explain my case. But, what of my patients? It's clear why they might slip through the cracks. If the clinic nurse doesn't "bird-dog" every study for utilization approval, call when needed, and involve the doctor when needed, studies and procedures may not get approved. The denial may slip past. The patient may return to clinic, unable to get the study, and not know why. It's unlikely for a patient to know where to start. And, even if they did, many of my patients don't know English, or not speak it well enough to address the denial themselves. They must rely on their doctors and nurses to intercede for them. Yes, that is part of the job, but on the day to day basis, it often seems there are more urgent problems to deal with.
Today, a colleague was venting about how hard it was to get things done, to get referrals or studies. We discussed the process for a patient with a herniated disc. He talked about how hard it was to get a specialist referral. Sometimes it could be months, he said. Our nurse chimed in to say that we usually schedule the patient within 2-3 weeks of receiving the referral. But, we want imaging done first. So, the patient has already had to jump through the pre-approval hoop twice. Once for the MRI (or sometimes CT), and once for the specialist consult. Maybe a third time for physical therapy. Each of these may take 2-3 weeks with someone "bird-dogging" the referral, longer without. And, then, after seeing the surgeon, maybe more physical therapy and possibly a pain clinic referral, with more pre-authorizations. Sometimes, each of these steps has to go back through the primary care provider. And, after that, if the patient doesn't improve with conservative care, yet another pre-approval process for surgery. So, it can be a slow process at times. The American version of waiting lines for surgery. For some surgeries, this may not be a bad idea, since many patients may recover on their own from some problems. Often they do with disc problems.
But, what of other problems? The answer is that it varies. Emergencies don't go through the pre-approval process, but rather retrospective review. While I was off due to my illness, and some since, I have done some of these reviews. For all, the key to approval is documentation. The provider must clearly document the reason for the test or procedure. This is good medical practice. Sometimes, as a reviewer, I have been able to infer why something is being done, but the documentation must be there, and it must fit in the boxes defined as approved by the insurance company. Sometimes, there isn't enough documentation, so there is simply a denial. Sometimes, the reviewer may need something clarified. Mostly, once the information is made available, the request makes sense. Sometimes, it doesn't. These are the tests and procedures that probably should be denied.
This process may take some time. Some patients get lost in all of this, and come back angry that "nobody cares." Their problem didn't get better, and may have gotten worse as they stumble through the system.
To me, this seems like the American version of the waiting lines for treatment in other countries. We wait at each step of the way. Sometimes, patients get frustrated and feel there is no way to navigate the system. And, so, the insurance company saves the money they otherwise would have had to spend. The American version of the "R word," rationing. It is a system of rationing that affects those who are least able to speak eloquently for themselves more than those who can. So, the most vulnerable may not get the care they need. And, so we see income disparities in length and quality of life, since income may serve as a marker for education and status. This seems why so many candidates for office don't want to address the issue of rationing, because they would need to admit that we already have rationing, that America has financial rationing of health care. And, it affects nearly all of us. Since, even with private or employer sponsored insurance, most of us have HMOs or PPOs, so our insurances have forced this upon us.

Tuesday, September 29, 2015


Today, I was just in employee health for my annual PPD (skin test for tuberculosis) and I was reminded about flu vaccines. While I am a believer in vaccines (when was the last case of polio you saw?), I do not take the flu vaccine. I am allergic. But, I encourage others to take appropriate vaccines on schedule. I have vaccinated my children. I have vaccinated my pets. I have only stopped certain vaccines for myself due to my allergy.

I asked rhetorically in the last paragraph, "When was the last case of polio you have seen?" Years ago there were rooms of patients in iron lungs at hospitals like Rancho Las Amigos in Los Angeles County. Now the hospital is a rehab hospital. Iron lungs are a thing of the past. There are pictures from this time: I remember getting polio vaccination as a child. I knew someone who wasn't so fortunate. She had polio as a child. Her disease did not get to her respiratory muscles. But, she wore long leg braces and used crutches.

I remember when I had measles. I felt deathly ill. But, I was luckier than some. I survived. Roald Dahl's daughter died, as did many others. He wrote an essay about her death: About two weeks after my bout of measles, the vaccine was released. Even as a child, I understood that children wouldn't suffer as I had. I was jealous. I was unhappy that I had suffered. And those who have suffered measles, especially when very young, may suffer another complication SSPE--subacute sclerosis panencephalitis. They then may suffer a progressive decline and death. (

Last year, there was another measles epidemic. It was small, compared to those of the past, but, it reminded us that the disease is not gone. That avoiding vaccinations carries risk. But, fortunately, for most of the anti-vaxxers, herd immunity has protected them. While they risk not only their own children, but others who have medical reasons to not be vaccinated.

These diseases are still around. Some of us must rely on herd immunity. As I do for flu vaccines.

Physician to Patient (and Back Again)

Just had another short piece published about my experiences as a patient:

I found it difficult to change roles from physician to patient, and now back to physician, or should I now admit, both. My experiences as a patient have certainly changed me. I hope it has helped to make me a better doctor. I also should apologize in advance for a few typos, caught too late.

Sunday, May 17, 2015

The costs of living

Even though I have had health insurance continuously since finishing training, I found the costs of illness significant. So that the costs of care cancelled my income for working nearly half a year. No wonder so many people have gone bankrupt due to health care expenditures. This was a major impetus for health care reform and the Affordable Care Act.
Fortunately for me, my savings and those left me by my parents allowed me to weather the costs fairly well. Yet, it has been a continual worry. Will I outlive my savings? Will I be able to afford education for my children? And, this has continued since a full return to the operating room still looks far off due to complications of chemotherapy.
Now, I am staged as no evidence of disease. A cause for celebration. But, my life is still disrupted by the fact that I have a neuropathy. My hands and feet are numb and tingling. I am sometimes unsteady when I walk. Fine motor skills are still more difficult. Will this get better or not? Will I need to find a new career? I am too young to retire. And I still have two school aged children. How much retraining should I consider? No one can answer these questions. When I see the neurologist, I am simply told to "wait and see."
But, I must live while waiting. And if I am away from surgery for too long, hospitals will worry that I have lost my skills. So, even returning to the profession I have practiced for over 20 years will require retraining. And, then there is the issue of endurance. Neurosurgery, and most surgical specialties, are physically demanding. I know my endurance is not normal. I have heard from other patients that it may be decreased for years. So, is it even reasonable to consider a return to full time practice?
It is hard to struggle with these questions. And, yet I know that I have been fortunate to have the resources to have continued without major disruption for my children. Yet, they, too worry about the future. They worry what will become of them if I die. I have tried to reassure them that this has been taken care of. And, that I plan to live to see them grown and on their own.
Many cancer patients don't have the resources that I was fortunate to have. For many, it becomes a struggle to make ends meet. Fortunately, now there is a cap on medical expenses for nearly all Americans. But, that is only half the story. Expenses like rent, food and utilities continue. And without an understanding employer, a job may be lost, or pay cut, pushing families even closer to the edge. And, sometimes, this can make it difficult for a patient to continue with treatment.
Years ago, I had a patient, a child whose parents were unable to provide the care he needed. So he was bounced from relative to relative, missing or delaying his treatments. I remember wishing that I could just take in this child, so I could make sure he made it to his treatments. But, I knew that would become a full time job. That is what his relatives had struggled with. All of them were barely getting by financially. They couldn't afford to take the time off work to care for this relative. Perhaps, if they had been able to coordinate, they would have. But, no one individual could support themselves and provide the care this child needed. So, I saw him dwindle and eventually die. He succumbed to a type of cancer that is often treatable with good success. I do think the lack of a social support system cost that youngster his life.
Another child, through her treatment, caused her middle class family to slip from a comfortable existence to needing public assistance. A part of this decline was due to direct medical care costs. It was also due to the costs of lost wages from her mother taking a leave of absence and her father cutting his schedule to part time because of health insurance costs for a small business. A larger pool could have prevented this. And then, her mother, desperate for care for a second child, said, "I know my child is dying. I wish she would just die. Only then can our family rebuild our future."
Other patients, fearing that they might have cancer delay treatment because of the non-medical costs of treatment, and often shorten their lives.
These costs are one of the reasons for cancer outcomes to vary by socioeconomic status. The poor may not have the reserves or support system to fall back on to make it through treatment. Fortunately, so far, I have had the resources. But, I must now plan for the future. I have returned to work, but not full time. I know that the work may have to be different for a long time. Sometimes, I wish writing could support my family. But know that I am a long way from that.

Paul Kalanithi

Recently I saw an article about a young Stanford neurosurgeon who wrote and videoed some of his thoughts about being a patient and a neurosurgeon. He died at 37, barely starting his career and his family. Yet he felt a need to express his feelings about life, and death. Here is a link to an obituary about him:

Friday, May 8, 2015

A delicate balance

Surgeons deal with patients who have pain on a daily basis. But pain is not a simple issue. It begins with nociception: the sensation of tissue being damaged. It causes us to recoil from whatever is causing the damage, whether it is a thorn in the foot or the heat of a fire. It is something that is designed to protect us from injury by letting us know about it quickly. From there, we add layers to the experience. Initially these may be helpful, teaching us to avoid the source of pain, but sometimes they are not. But, sometimes, people develop behaviors to manipulate others to assist them. Sometimes these behaviors even make people feel miserable from pain behavior long after the nociceptive impulse is gone.
Patients with pain behaviors out of proportion to pain and those with addictions make surgeons leery about prescribing narcotics for pain. The legal system reinforces those fears. But, more recently, there are also laws requiring the treatment of pain. And, we must remember, as physicians, one of our tasks is the alleviation of pain.
So, how does this balance work in real life. I would say that most of the time it works pretty well. Most surgeons, and other physicians, become pretty skilled at guessing the amount of pain medication a patient need. Guidelines are available based on patient size, and physicians use their experience to adjust these at times, based on knowledge about the patient.
But, what about when we are wrong? Overdosage can be disastrous, but fortunately, is most often treatable when recognized in time. They can become addicted or sell the unneeded drugs. There can significant penalties for physicians who do, including loss of license or prescribing privileges or worse.
Underprescribing can leave the patient in pain, and sometimes teach a patient to hoard narcotics or seek out other sources. It can also lead to longer hospitalization with its inherent risks and more outpatient visits. And, more states are enacting legislation requiring physicians to provide adequate treatment of pain.
Fortunately, I have never experienced an overdosage as a patient. But, I have experienced undertreatment of pain twice. The first was many years ago, before I was in medicine, when I thought I was tough and declined a narcotic prescription for a fracture. I had never used prescription pain medication before, despite some other injuries. A couple days later, I returned, thinking I would be prescribed the meds I had declined earlier. My chart was not immediately available. I was accused of drug seeking and not given a prescription. I weathered that injury with over the counter medications. And, like many patients, I decided that it was a mistake to decline a prescription, and would accept them, even if I didn't think I needed it. After all, I could decide if I needed to fill it.
The second was more recently. I had an epidural placed that seemed to have no effect, except to cause an allergic reaction to the tape used. In recovery, I told the recovery room nurse that I was in pain, and rated it more than my previous 10/10. Her response was to tell me that since I had an epidural in place, I should have no pain. And when I asked her to get the doctor and suggested that I needed medication, and even suggested a few that I have prescribed in similar situations, she disdainfully suggested to the the doctor that, "she even knows the names of several narcotics." The resident then informed her that I was an attending surgeon at a neighboring hospital. The poor nurse, who hadn't noticed that in her review of my chart, turned bright red. Since the pain was inadequately treated, I was afraid to move. Fortunately, I did not develop a pneumonia or venous thrombosis as a result, but many patients do when they aren't mobilized in a timely fashion.
I recount these two episodes simply to suggest that patients may ask for pain medication for legitimate reasons. I certainly understand the reluctance to overprescribe. But, there are also problems with underprescribing. We must observe our patients carefully so that we can appropriately adjust dosages. It is a delicate balance.