Better to Best: Thoughts on Global Health Care Systems

Difficult Patients.

Posted in Doctoring, Medical School (General) by reshmagar on August 30, 2011

A few weeks ago for my family medicine rotation, we were asked to write about a difficult patient encounter. I’ll share with you all what I wrote as this pretty much sums up how I feel on a daily basis on this rotation.

During my first few days at my site, I have not had an extremely difficult patient or interaction that has stuck out in my mind more than others. In fact, almost all of my patient visits have been a bit difficult in a strikingly similar way. None have been difficult because the patients have complex, multi-systemic illnesses or because they were extremely abrasive. Most of the patients have a trusting relationship with my mentors and get along with them well, regardless of their condition. Instead, I found the patients regardless of their age or background to be difficult not because of their presentation but because of what my mentor and I couldn’t do for them.

From one patient to another, I’ve seen a pretty similar problem list – high blood pressure, high cholesterol, and prediabetes/diabetes. Many also are overweight or obese. Many others used tobacco. The age of the patients ranged from elderly women who were now afflicted with COPD and other chronic conditions to teenagers just entering middle school. The blood pressure and diabetes were easy to manage by either titrating up their medication, refilling current prescriptions, or adding another to their daily cocktail when what they were already taking wasn’t cutting it. While my mentor and I were in the back discussing the patient and grabbing any samples they might need, my mentor would lean over to me and say, “Now comes the hard part. We have to talk to them about their weight/smoking.”

We always left the best for last, jokingly bringing up the smell of cigarettes we noticed as soon as we stepped into the exam room or asking them if they remembered what the doctor had discussed with them the last time (this usually was their cue to say “You told me I needed to lose weight…” and smile sheepishly). It was almost like watching a play where different patients played the same character repeating the same lines over and over again. My mentor reminds them of their promise to lose weight or stop smoking from the last visit. The patient would look away while my mentor reads out their weight changes or tells them again that they were at risk for COPD. Often times, the patient will then say, “I know, I know. I’m trying to but it’s just not working.” End scene.

Maybe it’s the comfort of knowing that the patient will return within a few weeks or months. Maybe it’s past experience of having patient after patient who comes in with increasing weight or no change in their smoking habits. Maybe it’s a mixture of both but this would be the point where my mentors give vague suggestions about how to lose weight or stop smoking – eat more fruits and vegetables, less carbohydrates and junk food, start exercising, stop eating out, stop smoking, do you want the patch, do you want Chantix, do you want gum. The patient nods along, answers appropriately before agreeing with the doctor that yes, things should change.

I find these encounters the most difficult. I always make it a point when talking to the patient about their treatment plan try to give them a concrete goal to achieve by the next visit that more often than not, surprises them, as they cannot give their usual responses. Instead, they now have to reserve to responses my mentor and I don’t like such as “no” or “I don’t know” or “maybe next time”. One patient came in for a routine follow-up exam was surprised to hear she had gained weight within the last month. I asked her further about eating and activity habits and found out that during the summer, she wasn’t working and instead sitting at home more. Additionally, although her portions at meals had become smaller, she was still eating a lot of starch-heavy foods and soda. When I told her about programs in her community that offered free group exercise classes as well as websites with recipes, she was startled and sputtered out “no” saying she could not see herself exercising in front of others. I instead tried to tailor some exercise around walking her dog and received a vague “I’ll try” to that. I left the room feeling frustrated and voiced my concerns to my mentor who nodded in commiseration and responded, “You did what you could do. She’s hopeless.”

This happened again the next day with a 17-year-old girl who reported smoking a pack-per-day since she was 13 years old. I was later shocked to find out that her mother had a similar history and now was suffering from severe COPD. I asked the girl if she would like to quit smoking to which she said she would but didn’t know how. I told her of the various options and suggested maybe trying to cut down on the number of cigarettes over the next few weeks before we saw her again. I set the goal as a half-pack per day and offered the patch. She nodded and said, “yeah, okay we’ll see.” I tried other tactics – bringing up her mother’s history and telling her that while her mother’s condition was irreversible, hers wasn’t. I also did a lung exam on her that showed decreased breath sounds and wheezing. She told me that she noticed she lost her breath often to which I responded that it was possible for her to not feel like that anymore by not smoking. At the end of the visit, despite the positive responses I had received from her, I got the feeling that she would return as she was today – looking older than she is and reeking of cigarette smoke. I could only hope that she would at least try this month and that my shpiel would be repeated again.

I tell myself I should be patient and that in time, there will be some patients who change and some who don’t. It’s difficult though to watch them walk out the door and wait for the next time they would come. It’s difficult to think that they will often walk out the door and my mentor will either wait till the next time or just give up somewhere down the line in order to preserve their relationship with the patient. I understand the reasoning behind this but I wish I could do more…or at least do something.

Not quite the same checklist.

Posted in Doctoring, Patient Quality and Safety by reshmagar on August 31, 2010

Last Thursday, we began our Doctoring course starting with a 2nd year orientation to what we would learn this year – the complete physical exam, counseling in difficult topics, and the underlying clinical reasons behind why we ask people to move in funny ways other than to giggle a little inside (…just kidding…sorta). I was overjoyed when our Doctoring course leader brought up my favorite topic – checklists! And more specifically. Dr. Gawande’s book, the Checklist Manifesto which she got about to reading this summer. She decided to use Dr. Gawande’s book and words as an analogy to our Doctoring course.

But she did it the wrong way.

Which made me terribly sad.

Yes, we do use checklists in our Doctoring course. Very very expansive checklists. One for taking a history, separated into its respective parts of Chief Complaint, History of Present Illness, Past Medical History, Family History, etc. There are several more for each part of the physical exam as well. These checklists help us better organize and memorize what we need to go through to get the complete picture of the patient and come up with accurate differential diagnoses.

Unlike the Safe Surgery Checklist, however, these are not bedside tools. In fact, the use of these checklists actually counters the message of Dr. Gawande who advocates for physical checklists to serve as concrete reminders to ensure that a patient’s care not become a victim of the physician’s falters in memory. The checklists we have to memorize are not the kind that Dr. Gawande advocates for at all.

That being said, I was happy that our Doctoring course leader mentioned the checklists and Dr. Gawande. She was able to say his name without gushing…which I’ve not yet been able to do.

Preferential Treatment?

Posted in Doctoring, Health Rights, Healthcare Reform by reshmagar on August 24, 2010

Day 1 of medical school. After sleeping for 3 hours, I was surprisingly awake. I didn’t unpack at all really. My suitcases, even now are lying open on my room floor. I had this grand plan of coming home after classes and meetings to unpack, do laundry, and be super efficient. Instead, I ate…and then fell asleep for around 3 hours.

My night went something like this:

Insomnia (courtesy of xkcd.com)

I made it to a class a little late…but made it. And so began our cardiology block.

During a lecture about congestive heart failure, a pioneer from Brigham Women and Infants’ Hospital in cardiac catheters was mentioned – Dr. Lewis Dexter. The lecturer brought up an anecdotal story about Lewis Dexter. Dr. Dexter suffered from severe angina and his prognosis did not look good. Due to his status as a pioneer in his field and as a physician, Dr. Dexter was able to receive immediate coronary bypass without any catheterization, which was unprecedented and something that probably would not be done with any other patient. In fact, it seemed unlikely that if he were anyone else, he would be operated on. Our lecturer ended the story with the comment about the perks of being a doctor.

This reminded me of a story of Zackie Achmat, an HIV-positive AIDS activist in South Africa who refused to take his antiretrovirals until the millions of people in South Africa suffering from AIDS got access to treatment. Quite the opposite mentality of Dr. Dexter and most doctors who mention the “perks” often.

To read an article from Samantha Power about Zackie Achmat, go here.

Today, many people in the United States are unable to get access to even the most basic treatment due to lack of insurance and high out-of-pocket fees. Would doctors around the country be willing to not receive treatment until their patients do? Would doctors be willing to not take the perks of being a healthcare provider?

The White House is still trying to get doctors on board with healthcare reform though:

White House makes health reform case to doctors
5:20pm EDT
By Julie Steenhuysen
CHICAGO (Reuters) – President Barack Obama’s administration asked U.S. doctors Monday to get on board with health reform legislation passed in March, saying those who embrace change will prosper.
Administration officials said the new law will provide doctors with information technology and incentives to improve the care they deliver, but only if they cooperate.
“The most successful physicians will be those who most effectively collaborate with other providers to improve outcomes, care productivity and patient experience,” Nancy-Ann DeParle, director of the White House Office of Health Reform, and colleagues wrote in the Annals of Internal Medicine.
The officials asked doctors not to let their disappointment over Congress’ failure to fix problems with Medicare payments affect their enthusiasm for health reform.
“The uncertainty surrounding the sustainable growth rate policy is a distraction and potentially a barrier for some physicians to embrace the Affordable Care Act,” DeParle and colleagues wrote.
“But physicians should not let their frustration … distract them from improvements that health care reform delivers to their patients and the profession.”
DeParle said the Affordable Care Act gives doctors financial support for making needed changes, including adding electronic health records and encouraging preventive care.
The act is expected to extend health insurance coverage to 32 million uninsured people, but many changes will need to take place to get patients to change their habits. For example, the legislation relies heavily on preventing disease to save money down the road.
“Because a patient is not feeling sick, engaging in prevention seems optional,” they wrote.
They said costs slow some people from getting needed preventive tests, and many patients do not get enough reminders about them.
The White House also said the act will help improve the quality of care by giving doctors more information about whether their patients are taking their medications and whether they are following through on prevention recommendations.
The act also promises to simplify paperwork for patients and allow doctors to easily check to see if a test is covered, changes that are expected to save the government more than $20 billion over the next decade, the White House argued.
“Physicians are on the front lines of the health care system and it’s essential they have the facts about the Affordable Care Act,” Nick Papas, communications director for the White House Office of Health Reform, said in an e-mail.

Come on, doctors and future doctors, shouldn’t we be the top advocate of patients instead of going against them?

Can we teach good bedside manner?

Posted in Doctoring, Medical School (General) by reshmagar on April 19, 2010

Prior to this past week, I have not been to a primary care physician in years. Yes, years. Not that I haven’t needed to. Instead of finding one in the city I am studying in, I’ve resorted myself to going to my university’s health services when desperately sick or the hospital emergency room. It’s something very easy to put off especially when you don’t have a car to take you. After telling my mother about some strange symptoms I’ve been experiencing over the past months, she insisted that I finally get a primary care physician here. My roommate made sure I did this too. With a car this year and a possible illness, I had run out of excuses.

According to my insurance company, finding a doctor in Providence, RI was impossible. Instead, I had to head to Massachusetts. Since I had to drive regardless, I decided to look up where these doctors went to medical school and residency and pick the best based on that. I finally found one and set an appointment with the receptionist in a month and a half. To save time at the office, they sent me the necessary paperwork I would have to fill out as a new patient in the mail and told me to bring it to the office. New Doc: 1-0.

So while I have not seen a primary care physician in a while, I had managed to see a dermatologist over the past years (clearly I have my priorities straight.). I had one at home since high school who I saw occasionally when I went back for college breaks. However, as I have been going home less and less and as she does not practice on the weekends, it was time to find a new dermatologist in the area. And since I was on a doctor roll, I decided to look for a new dermatologist. I found one who had a practice also in Massachusetts and surprisingly, was able to set an appointment within the following week.

My dermatologist at home has an immaculate practice with a spa and licensed facialists along with it. Large waiting room always filled with people and cool brochures of the latest dermatological treatments to make your skin tighter, whiter, tanner, clearer, etc. Upon stepping into my new dermatologist’s office in Massachusetts (after getting lost for a half hour), I was greeted by a dreary, small empty waiting room. Then when asked to pay upfront for the visit, I was shocked. I was accustomed to always paying at the end of the visit after being walked out by the doctor to the reception area.

This would have all been okay had I been satisfied with my visit. My visit lasted around 5 to 10 minutes with no past medical history taken and no real questions asked. I was given literature about new medications and procedures and told to come back in a month. I then found out the dermatologist had multiple practices and there was one in Providence. I was told I could go there and see another doctor on that visit. I decided as it was more convenient to opt to doing that.

My next visit with the dermatologist actually came up right before my first primary care visit. I went again to another dreary office and was again told to pay upfront. I paid and then waited in the examination room for the doctor. After 5 minutes, I heard a knock at the door and he walked in, introducing himself hurriedly and stuttering. He did not ask my name, my age, what I did for a living, or much else. He read the chart and saw what the other doctor in the practice had written. He avoided eye contact the entire time and stood over me making me uncomfortable. The visit here also lasted 5 minutes with the conclusion being that he didn’t agree with the other doctor and that I should come back in a month. I became frustrated having paid a copay of $45 for nothing and with the very limited funds I had, this was not okay. He simply shrugged his shoulders when I told him this and told me to again come back in a month. I doubt I’ll go back.

Two days later, I went to my primary care physician. Her office was quite the opposite. Large and bright with staff that greeted you with a smile and worried about the copayment after the visit. The doctor also had electronic medical records and was very good about maintaining eye contact and a camaraderie with me while typing away at her computer. She addressed every concern I had with not only genuine concern but also professionalism. The visit wasn’t too long here either but I left feeling taken care of. I’ll be going back to see her in 6 weeks.

Seeing both of these doctors back to back made me wonder how people will perceive me as a physician. I began to wonder how I come across to patients even now. I noticed that in my assessment of my doctors that I had focused on even the little things they did – did they shake my hand? Did they ask my name? Did they try to pronounce it at all? Did they sit down when they addressed me?

It became apparent to me that I have to now be extremely self-aware of myself especially in front of patients. If one day I wanted to open my own practice, this is what would ensure that I stayed in business. But not only that- whether or not I would get sued. A study from the Wood Institute showed that surgeons that expressed personality traits of being more friendly, more sympathetic, and more caring had less medical malpractice cases than others that were lacking in these traits.

Are these traits that can be taught in medical school? Is good bedside manner an acquired skill that will come with years of practice? Or is it something innate within medical students that can be seen in their 15-30 minute interview? Also, is it a necessary requirement for a good medical school student? If so, what about the students who go into specialities with limited patient contact like radiology and pathology? Are they not good students? These are things I wonder about. I do know that I want to be considered as a doctor with not just good, but great bedside manner, who can make patients feel comfortable and cared for and who can give them the best treatment and not just medically.

New Year Resolution

Posted in Doctoring, Medical School (General) by reshmagar on January 28, 2010

Throughout my first semester of medical school, I have spent it primarily in a lecture hall. I sit with 94 other students learning about things I might see one day in a clinical setting. Sometimes, my classmates and I have the opportunity to see what we learn in class when we go to Doctoring with our mentor and talk to patients. For me, those are the moments where I am most excited and happy to be in medical school. Those are the moments where what I thought was crazy cool in class becomes real. Those are the moments where a disease, syndrome, or a symptom becomes a person instead.

As the year goes on, I’ve been thinking about what it means to be a medical student. Academically, it means I along with my classmates and many others will have to go through four years of training, two in a classroom, two in the clinic. Even in the hospital, I’ll be going from one clerkship to another and my role will be similar to that of the one I have now in the classroom. I will be expected to learn as much as possible, take an exam, and then move on to the next set of training. Even though we see ourselves as apprentices in this field, patients see us as much more. When I wear my white coat and stethoscope in my Doctoring mentor’s office, patients see me as their future doctor.

In our medical school, I’ve had the opportunity to take an amazing elective called “Healthcare in America” where we learn about another major component of medicine- the system in which I will be practicing in. Many of the speakers have spoke to our class about what we can do as medical students in terms of issues like healthcare reform such as calling our lawmakers, making testimonies, or even something as simple as wearing our white coat to a rally. Not all medical students are in favor of healthcare reform. Nor do all medical students share similar views on implementing healthcare reform. There is a reform movement, however, that is independent of all this and is purely for the good of our patients and our medical integrity. A reform movement we are firsthand witnesses to when we step into a clinic or hospital. But to become true players of this movement, there is a new role I along with my other future physicians must undertake. This is my New Year Resolution – I will become a positive deviant.

If anyone has read Atul Gawande’s book Better, he speaks of this role and gives suggestions on becoming a positive deviant. I am going to take that concept and apply it to myself and possibly other medical students right now and not the doctor I will be years later.

SUGGESTION 1: Ask an unscripted question.

In my Doctoring course, I have learned a series of questions to get a History of Present Illness, Past Medical History, Family Medical History, Social History, Nutritional History, Sexual History, Review of Systems, etc. We get tested on remembering all of these questions and are expected to practice asking these questions in our Doctoring sites. I have noticed though when I ask a patient about something else instead, the atmosphere completely changes. During one of my mentoring sessions, I was going to assist my mentor in removing a foreign body from someone’s eye. The patient sat patiently with their reddened eye watering as my mentor went to go get the tools necessary to do the procedure. I started talking to him about what he did for a living and soon found out that he had been in the Army and now was working odd jobs. He also used to live in my hometown and shared a similar disappointment in our basketball team. He even smiled.

I will also try to do this with not only patients, but the other people in my mentor’s office such as the nurses, the physician assistant, the receptionist, anyone and everyone. Doctors are team players, not the one at the top of the totem pole. The other people in the office matter just as much and sometimes, if not more than the physician to the patient.

SUGGESTION 2: Don’t complain.

Our biochemistry block was not the greatest taught block. The lectures were dry. The lecturers were not organized and sometimes even avoided pertinent questions. Half of the class began to not attend class. After one such terrible lecture, a group of us walked out in the hallway. For the next half hour, we reamed the lecture and lecturer. It didn’t help. It didn’t make anything better. It left us drained if anything.

After each block, we have evaluations to fill out. Evaluations that are actually read by the administration and sometimes even lead to change in the curriculum. Filling out these was a much better use of my time. Talking to the head of the course about the problems and possible solutions also was a much better use. Next year, students hopefully won’t have to experience the same discontent with the block. Complaining only doesn’t make people listen – giving concrete ideas for positive change does.

SUGGESTION 3: Count something.

For our Doctoring course, we are required to fill out data regarding how many patients we saw, whether or not it was supervised or unsupervised interaction, and if we got feedback. This year, I will add a new category. I work in an Urgent Care Center and can make a list of what’s routine there. How many people come in with head and neck problems? How many people injure themselves at work? How many people above age 65 come into the clinic?

This was how the Safe Surgery Checklist was started. Someone asked how many patients were getting harmed during surgery, how many times something was left behind in their body, and how many times a timeout was done. A pattern was found, a project was formed, and now lives can be saved. In doing this, I hope to learn something too.

SUGGESTION 4: Write something.

This blog is my effort to write something. I hope that in writing that I can put everything in perspective, that I can consolidate my own personal feelings with what I’m learning and what I aspire to be. My classmates often put up something that happened at school that was awesome (like removing the brain from our cadavers) as their Facebook status. We also have to write field notes for class to give reflections on things we do. This is how we keep sane and let people we care about know what we do.

I know, I slacked off in January. But I’ll keep it up, promise.

SUGGESTION 5: Change.

In terms of healthcare and healthcare reform, the one constant has been the reiteration of rankings and statistics. Yes, there’s always room for improvement. But what kind of improvement? Medicine is constantly evolving both clinically and politically but it will always be our duty as physicians to give the best possible care in our power. And to do this, we should be able to change and adapt to the shifts in medicine and the system. I want to be apart of this change, this flux towards better quality, better care. I can’t say right now I know exactly what to do. But I know that I want to change myself at least for the better…and maybe even one day, the best.

Playing Dress Up

Posted in Doctoring by reshmagar on November 22, 2009

On October 17th, I had my white coat ceremony. My parents, younger sister, and friends came to watch me receive a brand new coat from my Dean of Medicine. During the ceremony, my name was called signaling me to walk across to meet the Dean and awkwardly place my arms into the sleeves. As soon as the coat was placed on my shoulders, I became acutely aware of it. What was this stiff thing sitting on my shoulders? How many pockets were there? Six? Was my name spelled correctly on the coat? Would I be able to not spill anything on it today? Why did it feel so unfamiliar to wear it?

Photo courtesy of Matt Francis Photography

I walked back to my seat feeling uncomfortable. I tugged on the collar every so often watching as others put on their coat, walking confidently back to their seats looking like, well, real doctors. Looking at everyone else, I felt twelve years old again after my mother had draped a sari on me and stood back only to laugh. I didn’t look like them. I was only playing dress up and at the end of the night, was relieved to put it away in my closet.

The Tuesday after the ceremony, just three days later, I took the white coat out to go to my mentor’s office. Outside my car, I put on my white coat gingerly, feeling its weight once again. At first, I placed the stethoscope around my neck like the other students in my class only to remove it 5 seconds later and place it in my white coat pocket. I walked in, wary that my mentor would say something to me about wearing the white coat and how ridiculous I looked in it, but he only smiled and motioned for me to come with him to a patient’s room. He introduced me to the patient and left, leaving me to take the chief complaint and history. At the end of the interview when I asked if the patient had any concerns about his visit that day, he looked at me and said “I’m worried that it might be something with my heart or lungs. My dad died of a heart attack and my mother has heart problems too. What do you think, Doc?”. Flustered at being called “Doc”, I hurriedly told him not to worry and that my mentor would be able to tell him better if anything was wrong and help him. The patient looked instantly reassured and I left, the weight from the coat a little less now on my shoulders.

Later on in the afternoon, I went into a patient’s room to take vital signs. After introducing myself, the patient, who was a pregnant woman in her early 20s, went on to tell me a long list of symptoms she had been experiencing and kept on referring to me as “Dr. Reshma”. I was again taken aback, laughed a little, and told her that I was only a medical student. In that moment, I realized that the white coat is every doctor’s cape or piece of spandex. Even though I was so self-conscious and even felt a little silly wearing my white coat, it was a signal to those around me that I was there to help them, that I might know the answers, and maybe that I cared. It was my secret weapon for getting patients to listen and value my opinion.

Even after wearing my white coat countless times to my Doctoring sessions, to the hospital, or to see my Assisted Living Facility patient, I still feel like I’m playing dress up. Outside of these times, I learn about medicines and their mechanisms, proteins and pathology, and practice the medical interview and physical exam on standardized patients – all of which I am supposed to incorporate into practice outside of an exam or class. In fact, one of my proudest moments during Doctoring was being able to read a chest x-ray of a real patient after staring at them for my anatomy class. I know that I am far away from having the right answers for patients. I just hope that there will be a day where the white coat won’t be as stiff anymore or the stethoscope around my neck as heavy.

Traumatic Experiences (Monday Night)

Posted in Doctoring by reshmagar on November 18, 2009

I have just come back home from a 4 hour shift working at an Urgent Care Center here in Rhode Island with my Doctoring mentor. I learned a lot today about various conditions ranging from tenia crurus or “crotch rot” to pneumonia to shingles. Today, though I had a slightly traumatic experience with my last patient. Near the last hour of my shift, one of the nurses came up to my mentor and said “There’s a woman in Room 5 that seems to have really bad bug bites. Really bad. She needs someone…experienced.” When hearing that, I didn’t think much of it. When I had first walked in, there was a woman who had gotten a tick bite and needed to be tested for lyme disease and afterwards, another woman had come in with a bad rash as a result of a possible bug bite allergy. I chalked this up to another case like that.

We finally got to this woman and my mentor looked at the file only to frown. He looked at me over his glasses and said “Let’s go and see this one.” Usually, I had gone in alone to take the history, take the vitals, and do some of the physical exam but in my excitement and my exhaustion, I was just curious about what this woman might have.

We walked into the room and there sat a middle-aged woman scratching at her arm. As soon as my mentor stepped in, she began to hurriedly explain what had happened. On her arm were circular lesions, some scabbed over yellow, others still open. She touched them as she talked saying “There are some bugs that bit me. You see these black dots [referring to the brown spots of pigmentation on her skin] – I tried to scrape them out at my dermotologist’s office…they were burrowing into my skin. They keep on biting me. I didn’t have these beforehand.” At first, I was in disbelief wondering what kind of bugs could have caused these lesions. Then she said, “They’re all over my towels, crawling around everywhere. They’re on my arm too.” and pointed at the brown spots on her skin. My mentor hurriedly reassured her that no bugs had bitten her and asked her calmly if she had been scratching her skin to which she hurriedly replied that bugs had did this to her. I looked at her face and noticed around her lips and mouth were white spots and discolorations. As we left the room, she continued to talk hurriedly about the bugs and wanting medication to make them go away. I went outside, shocked with my mentor afraid to verify what I thought was the problem. He wrote a prescription for flu-like symptoms as she was presenting with high fever and sinusitis. I looked at him and he looked at me simply saying, “Well, that was scary.” And that’s when I knew. She had done that to herself. She had scratched those lesions into her arms thinking that bugs were biting her. My doctor told the other doctor on call “to not get in any further and tell her to go see her primary care doctor.” I was even more shocked. Were we just going to let her go? Hope that she would book an appointment with her primary care doctor? I sputtered out, “Why?” to which he said “She needs her primary care doctor- In fact, her doctor is very good.” I left after that patient, almost running out to my car only seeing her scratching her arms and her discolored lips frantically telling us about the bugs that bit her. I drove with my hands tightly on the wheel, knuckles white from trying to concentrate on the road and not think of her.

Who’s responsibility was this patient? Was my mentor right in letting her go? Could he not have done anything else? If the patient actually goes to her primary care doctor, would that make this okay? I don’t know. All I know is that tonight, she will be my last thought before going to sleep.

Here’s a quote I hope that people will comment on that was made in regards to what we do when bad health care happens:

“Indeed, I suspect that our collective search for villians- for someone to blame- has distracted us and our political leaders from addressing the fundamental causes of our nation’s health care crisis. All of the actors of health care- from doctors to insurers to pharmaceutical companies – work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health <em>care</em> over any other aspect of health and well-being. That emphasizes treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that – most important – remove consumers from our irreplaceable role as the ultimate ensurer of value.”

– From “How American Health Care Killed My Father” by David Goodhill in the ATLANTIC Monthly Magazine (September 2009)