Category Archives: Doctorhood Quest

Hospital White

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The stretcher looked different from the 100s of others I’d seen. It was empty and it had an unexpected metal bar at the head of the bed. I glanced in the room outside which the stretcher had stopped. On the bed was a white bag, zipped up, and just the height and length of a sleeping human. I realized the stretcher was there to take a body to the morgue.

Death has been present on many of my hospital shifts – especially in the ICU (intensive care unit) where this sighting occurred. Yet, until this moment, I hadn’t seen the patients who died taken out of their rooms. I’d pronounced them dead. I’d seen patients’ families crying at bedside. I’d seen the closed doors with butterflies on them marking that someone was dying or dead. I’d seen the strangely empty and freshly made beds where those who had died once lay.

The body in the white bag was lifted onto the stretcher. White sheets surrounded them. Then they were wheeled to the morgue – their family wouldn’t see them again. Of course, the person’s soul was gone well before the body was put in a white bag. Off to a better place. If nothing else, watching many people die has made me certain there is a soul which leaves when death calls. To where the soul goes after death, no one knows.  Long ago, I decided to believe souls always go to a better place when the body dies. No one can prove my theory wrong, so no need to worry about the journey of souls.

The sighting of the white bag made me sad. It wasn’t the kind of sadness that made me feel like crying. It was more of a sinking feeling placed on top of an already crummy night. Heaviness on the chest and shoulders. We had multiple sick patients. My co-resident had pronounced dead a patient almost every night that week. Somehow, he’d gotten that burden. I had not pronounced anyone that week; I was caring for people who were staying alive (for the time being). It was night shift, making the already dreary worse. A string of unpleasant nights with one-way transport of white bags out of the ICU. Some of these nights were so busy we only just managed to do the things most necessary. Our patient list was younger than it should have been. It’s easier to accept death when people have lived a long life. Of course, there were a couple happier cases; those patients would make it out of the ICU and then the hospital.

I don’t think one can ever get used to witnessing death. One can come to peace with it. That’s what I’ve done as my years in medicine accumulate. There is an intrinsic link between life and death. The two cannot be separated and are not whole without each other. In the US, black usually represents death. In many other places, death is represented by white. The more time I spend in the hospital, the more I think white is the most representative of life’s end. Hospital white. A blank sheet. All the shades of light together. The absence of physical color. It seems fitting that death is represented by light and not physical being.

The image of the white bag lingered in my mental peripheral vision for the night. I didn’t know anything about the person whose body was in the bag. Sometimes, one doesn’t need to know the details to understand. Death is like that. Simple once it happens. How we arrive at death is what is complicated. Everyone eventually arrives there at their own time and in their own way. Death is one of the most unifying features of being human. But that doesn’t make it easy. Some things are never easy.

The Stickiness of Capacity

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“It’s my religion, my decision!” they yelled as the elevator doors closed, the climax of their escape (though no one was stopping them) from the hospital. They often spoke in rhymes. Where they would go and what condition they’d be in when they got there were mysteries. They’d been in the hospital for almost 2 weeks as we tried to find a safe place for them to discharge to. Their house was in such disrepair that their electricity had been turned off because leaving it on was a fire hazard. They’d had frostbite before, and winter was near. Their mental state was such that we did not believe they could make safe decisions for themselves. They had no way of getting home without our help. Despite all these features they were not in immediate danger of harm and so we had no legal grounds to keep them when they decided they were ready to leave the hospital. We tried to convince them to stay, but they would not listen. They were ready to leave; they wouldn’t wait for us any longer, not even to arrange a ride home. We were worried that they were leaving without a safe plan, but the US medical system is not a jail system. Except for several clear situations, our patients are free to leave the hospital whenever they please even if their doctors think it’s a bad idea.  

Capacity, a patient’s ability to make informed decisions about their healthcare, is more complex than one might think. It’s grounded in the ethical principle of autonomy, which means that patients have the right to decide what happens to their bodies. To understand the complexity of capacity requires at least some understanding of the history of medicine and how we conduct medicine today.

Medicine was paternalistic historically (and in some places it still is). It also wasn’t, seemly, originally centered on doing what was best for patients. There are classic examples of medicine’s unpleasant history, among them: the Tuskegee Syphilis Study, Henrietta Lacks’ stolen cells, stealing corpses to supply cadavers for anatomy labs, and the history of insane asylums. Given its concerning past, there are strict laws outlining which patients can be kept in the hospital against their will and for how long. There are also laws ensuring patients are informed about the risks and benefits of their healthcare and allowed to decide if they would like to pursue or decline tests and treatments their doctors recommend.

When a patient doesn’t have the ability to make their own decisions (for reasons such as acute illness or chronic conditions like dementia) we say that they “lack capacity.” In such instances we identify a person who can legally make decisions on their behalf. Capacity is decision dependent – so a patient may have capacity to say they don’t want to eat lunch but lack capacity to decide to undergo vs. decline a life-saving surgery. Capacity also can be fluid, so perhaps an acutely ill person doesn’t have capacity initially but as they start to recover, they regain capacity. For patients with conditions like dementia, often capacity is never restored if lost.

In tricky cases like the patient described above, the healthcare system can do less than you might think. We can easily treat acute illnesses that are a complication of a patient’s confusion (such as frost bite) but we have few ways to help avoid frost bite in the first place. Hospital social workers can help find nursing facilities to offer at discharge, but seldom can we force patients to go to a nursing facility if they don’t want to go. It’s also worth noting that we do not have the ability to find housing for people experiencing homelessness – so unless they need a short-term skilled nursing facility at discharge, we often have no choice but to discharge patients experiencing homelessness back to the street once they’re medically stable.

In these circumstances, sometimes those of us in healthcare are left with unsettling discharges either because our patients discharge even though we don’t think they’re ready or because we discharge them to the street (or to an unsafe home). In the case of the patient who yelled “It’s my religion, my decision!” as they made their dramatic exit, the patient declined our safe discharge ideas. Even though their medical decision-makers agreed with us, no one could force the patient to do something they did not want to do. After discharging the patient, we (their care team) found ourselves keeping an eye out for them as we drove to and from work. Our plan was to call Adult Protective Services if we saw the patient – because we all knew they had no way to get home. We couldn’t force them to wait for a ride and they had no money for the bus. We also weren’t convinced they knew how to get home. We all suspected they’d end up wandering the streets. As I drove on the lookout, I was reminded how limited our healthcare system can be. I was also reminded that balancing patient autonomy and medical beneficence is not always easy.

The Hospital in the Forest

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Looking at the one-story entrance, the building appeared too small to be hospital. To get there, I drove down a neighborhood street. Tall trees lined the final stretch up the hill and then there were several small buildings with several small parking lots. Tall trees stood between the industrial features. The whole hospital was about the size of a city clinic. Tiny but mighty – people could get CT images, surgery, and life-saving medications within the hospital’s walls. There weren’t many specialists available and none on the weekends, but the basics were strong. There was “Emergency Department” in glowing letters on one side and there were hospital beds for patients who needed to be admitted. Though not meeting criteria to be a critical access hospital, this hospital in the forest was the only access to healthcare some people had. It was not as remote as the most desolate places in New Mexico, but the hospital in the forest illustrated the scale of healthcare available to many (most?) rural Americans.

The patients were brave and grateful for care. A large portion of the patients were also frustrating because they didn’t see doctors and didn’t take medications outside of emergencies – thanks to the stoicism of rural people and a lack of access to health resources. The full-time workers at the hospital were a blend of devotion and mediocrity – strengthened by being the only healthcare around while limited by the hospital’s small infrastructure and many slow days on the job. I found myself out of place on one hand, having come from a hospital almost 30 times this hospital’s size. While feeling at home on the other hand, having grown up in rural America.

The hospital also reminded me of the hospitals and clinics of Paraguay. The scale was more in-line with the hospitals of the world. The limited access to specialists also reflected my experiences in Latin America and growing up in rural Vermont. I found myself more interested in the functioning of the hospital in the forest than I thought I would be. When I applied to residency, I limited my search to programs at hospital that had 350 or more beds; this hospital had about 30 beds (a critical access hospital has 25 or less). At larger hospitals there are more patients, more specialists (including medical specialties and surgeons), and more treatment options. In a small hospital like the one in the forest, there is some access to cutting-edge technology but more than anything there is creativity because one must find solutions for problems with fewer resources.

As I settled into taking care of patients at the hospital in the forest, I found myself challenged in a different way than when I was at the large hospital where I spent most of my time. Caring for patients in a low-resource hospital forced me to use the full range of my training. If patients started to decompensate it was on me to figure out why and to what to do about it. If the hospital in the forest didn’t have the treatment that my patient needed, then it was my job to pitch their story and get them accepted to a bigger hospital with more capabilities. If I couldn’t transfer a patient who needed something I didn’t have to a hospital that had what they needed, they’d get worse and maybe die. So, while most days at the hospital in the forest were filled with the bread and butter of medicine (the basic, simple cases), complicated cases required more thought than they did at a large hospital where any treatment my patients needed was at my fingertips.

I felt the ebb and flow of the hospital in the forest. Many days were calm and straight forward. Those days I had so much extra time I progressed rapidly through my non-work to-do list. These lulls made up for the days of insanity when the patient list grew with lightening speed (admission after admission) and my patients were all trying to die at once. The flow was more like that of my days in the emergency room – boomeranging between busy and slow.

When my time at the hospital in the forest ended, I was grateful for the experience. Perhaps the greatest lesson was realizing that I could be happy working at a small hospital. While such a realization may seem trivial, a willingness to work at a small hospital opens the door of possibility. There are so many small hospitals in the US and the world. Knowing rural medicine is interesting to me means that there are now 1000s of miles where I could live that I couldn’t live if I wanted to work at a hospital with 350 beds or more. What a funny thing that I spent years jostling to train in an urban center to realize that rural life has its own set of challenges and joys. I can see myself being happy in either setting in the future. Big, busy hospitals are ideal for learning but now I know they aren’t the only interesting places to work in medicine. As I think about the next steps, the hospital in the forest sits laughing in my mind. It’s laughing because life has a way of sending me to places that I never expected to go.

Reading the Crystal Ball I Don’t Have

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“Will I make it until then?” the patient asked. They were referring to the cancer treatment which was their only chance at long-term survival. Their cancer was everywhere yet, likely, treatable and maybe curable…but only if they got treatment. Their social situation created roadblocks. To be approved for chemotherapy in our medical system they had many hoops yet to jump through and hills to climb.

“I don’t know. I hope so,” I said. My answer was genuine.

The patient signed. They closed their eyes for a long blink. They looked down. They slumped in their chair. Their stuffiness (from lymph nodes so large it was hard for them to breathe) made their breathing loud. The room felt small.

“You’re strong. You’re a fighter. You told me recently you wanted to do everything you could to beat this. We are trying to get you there,” I said. These were truths but they didn’t mean much.

This post could easily be about the inequities of our healthcare system. This patient was a victim of those inequities. But whether everything is going right or going wrong, the truth remains that neither I nor any physician know the future. We have probabilities and expert opinions to guide us. We have previous similar patient cases and the risks/benefits of medications and other treatments to consider.  But as much information as we have, we do not have a crystal ball that tells us exactly what is to come. We make educated guesses which are often right but also have a higher-than-desired chance of being wrong.

What is to come, the outcome, is exactly what my patients want to know. And, if I were in my patients’ shoes, that is what I’d like to know too. When thinking about my patients’ futures, I try to balance hope with reality which (for me) manifests as honesty. If I’m worried, I say so. If I’m confident in their chance, I say so. And, if I’m unsure then I will explain the contrary things I’m considering and why I’m undecided.

I didn’t know if the above patient would make it to chemotherapy. The oncologists (cancer doctors) were not offering this patient treatment when the patient and I had the above conversation. The oncologists felt that the patient had too many other things going on to start chemotherapy. Chemotherapy is hard to endure. One must be physically strong to survive it. One also requires lots of social support.

“We are trying to get you treatment. Remember the next steps we talked about?” I reviewed the follow up appointments and things lined up for the patient before they saw the oncologists.

The patient nodded. They looked out the window. “I’ve been here [the hospital] so long,” they said. They’d been in the hospital for about 6 weeks.

“I know,” I said. “You still have a long road ahead.”

I wish there was a crystal ball like in fantasy books that would reveal my patient’s futures. But part of life is not knowing exactly where it’s going. Part of being a physician is becoming comfortable with uncertainty. Perhaps that’s one reason why physicians study for so many years. Day by day my predictions about my patients’ futures are more informed and more often correct. But, on the opposite end of the spectrum, even the most seasoned physician is sometimes wrong about a patient’s future.

When the patient and I had the above conversation, their survival was unlikely but possible. The sliver of hope that remained is why I reminded the patient that they had told me they wanted to fight their cancer. That is also why, when the prediction is tragic and my patients say they believe in miracles, I say “I hope you’re right.” No physician wants their sad-outcome predictions to come true. Yet, we are obligated to provide our best guess even if it is bad news. As physicians we also plan for all the likely outcomes.

While I reminded the patient of their desire to fight, I also reminded them that if things changed there was an alternative option called “comfort care*.” I reminded them that they could change their mind about their goals at any time. I reminded them that we (their care team) were here to help them on their journey regardless of where it led them.

The only certainty about my patients’ futures is that their care team will be there no matter what. And while patients’ care teams change with work shifts and specialty, the purpose remains the same: to help as the unknown unfolds. Being a physician hasn’t given me a crystal ball to see the future. But being a physician has given me hope. While there are illnesses no human body can overcome, the body is incredibly resilient. Further, the human soul is a force of bravery and grace even when faced with insurmountable challenge. And when I witness these human strengths, my faith in life is renewed.  

*Comfort care is end of life care where the focus is treating symptoms rather than prolonging life. For example, if a patient has anxiety, then we will treat it; or if they have pain, we will treat it. Comfort care is offered to patients who have conditions that will kill them and either there is no treatment or the patient declines treatment. In comfort care we don’t treat chronic conditions such as high blood pressure or diabetes because the focus is to make the patient’s remaining time as comfortable as possible rather than trying to make them live as long as possible. Comfort care is the type of care that people receive in hospice. Hospice is end-of-life care for people whose life expectancy is 6 months or less. Comfort care is not about hastening death, but it is possible that people will die sooner on comfort care than with traditional care because the goal is no longer to cure illness.

The Last Stop on the Bus Line

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I looked out the window. I’d been here before, almost 2 years previously, it was the end of the bus line. Arriving here meant I’d taken the wrong bus. There were several buses with the same number that had overlapping routes but ended in different places. The last time I’d caught this wrong bus was shortly after I moved to my Peace Corps volunteer site in Paraguay. At that time, I was still learning my community and Paraguayan culture. The first time I ended up at this bus line end, I wasn’t sure how I’d get home. The uncertainty made my heart beat faster. I asked the bus driver for directions; he had been able to help. It took several hours but I ended up home, unharmed though slightly frustrated I’d mixed up the buses.

I’d learned so much since I first visited this bus depot accidentally. Since then, Emboscada, Paraguay had become my home. Emboscada was, perhaps, the first place I’d ever lived where I was certain it was home. As the days that added up to the previous two years had unfolded, I’d found a community and made friends. I’d been a schoolteacher and connected with youth over music, English, and dreams. In my Paraguayan community, older friends had died, younger friends had married, and I’d been to parties and celebrations of every variety and magnitude you can imagine.

I looked out the window and I laughed. I was an expert, yet I still took the wrong bus and didn’t realize it until I arrived here at this bus depot. In a few short months I’d leave Paraguay. I’d say “goodbye” to the home I’d found and created. I’d return to my native country and start the Doctorhood Quest. I laughed because arriving at this bus depot wasn’t scary like it had been the first time I ended up here. I knew it would take a few hours to catch the right bus and travel to the bus stop in front of my house. I’d arrive home eventually. My little Paraguayan house would be waiting for me.

This event was about 8 years ago, yet I’ve found myself thinking about it a lot recently. I’ve been reminded of it because I recently turned a page in the Doctorhood Quest that is like what I was turning in my Peace Corps service at that time. I feel settled in my role as a resident physician. I feel comfortable with what kind of doctor I am. I am happy with what I’ve accomplished and look forward to my future goals. I had similar sentiments about my Peace Corps service while I waited for the right bus to pick me up at that last bus stop.

It might seem premature to have such contented feelings about residency. But I know that the remaining 20ish months of residency will be over soon. I have so much to learn in those remaining months. Yet I know I will learn what needs to be learned. For the first time in my journey of becoming a physician, I’m confident that I’m where I need to be. I know how to get home even when I take a wrong turn.

Being an expert isn’t about always catching the right bus, it’s about knowing how to find your way home when you catch the wrong one. It’s about being calm even when things are unexpected. It’s about embracing the journey. It’s about laughing at yourself because experiences that make you grow and challenge you also put you in ridiculous situations.

How ridiculous is it to take the wrong bus after having taken the right one 100s of times? “Quite ridiculous” is the answer. But mistakes are what make us human. We learn from mistakes, even if the lesson is simply a reminder to laugh at ourselves. Life is serious, but not so serious that we can’t appreciate its absurd moments.

Listening to the Birds

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As our appointment was ending, I congratulated the patient on getting fitted for new hearing aids earlier that day.

“Yes, we are looking forward to the new hearing aids,” the patient’s spouse said. The hearing aids would be shipped to them soon. “They love hearing the birds. They know all the birds’ names.” The spouse paused. “I miss them telling me which birds we hear. Now I’ll say, ‘Hear that bird?’ and they’ll say, ‘What bird?’ because they can’t hear it singing.”

As my patients like to tell me, “Getting old is not for the faint of heart.” Being not as old as them, I don’t know what it feels like to be their age. But, having worked with hundreds of people as they age, I’ve had the opportunity to observe what getting old is like. Perhaps the most interesting thing is that no two people experience aging the same way. Despite the variation, there are some truths I think are universal about aging: 1) one cannot do everything at 80 that one could do at 20, 2) life experience cannot be erased, and 3) attitude matters.

The happiest old people I’ve met are those who embrace aging as life’s reality. They are flexible and willing to adapt their goals and expectations to meet their ever-changing body and mind. For some people this means that they give up the independence they once cherished. They turn in their car keys forever, accepting that their slow reflexes and poor vision have made them dangerous drivers. For others, they let their children or other trusted people help them navigate new technology that they don’t understand because navigating that technology is essential for life admin (like bills) and connectivity (communicating with others). Others relinquish their identity as the one who cares for everyone else and accept help from people they previously cared for. Going from the person everyone depended on to the one that depends on everyone else is one of the hardest transitions I’ve witnessed my patients make. Whatever transitions people go through as they age, they are huge and require self-reflection and grit.

And while aging is a lot about the mind, it is also about accepting that our bodies change with time. The most resilient old people I’ve met are the ones who are flexible not just with how they approach life, but also with what they expect of their body. Many elderly people remain healthy and independent until they die. But even in healthy old people, their bodies are not what they were at 20. They simply move slower and, perhaps, are less physically strong. The happiest old people I’ve met know that their slowed body is not a sign of weakness, but a sign of wisdom. The happiest old people I know, continue to challenge themselves in new ways that they could not have imagined in their youth. They do not have the same expectations of themselves that they did at 30 because they already mastered being 30.

As people age, it is common for them to interact with the health system more than they did in their youth. Regardless of how many diseases and ailments an elderly person develops, I’ve noticed that the ones who endure the hospital and their doctors’ appointments best are those who accept that caring for an aging body takes lots of time. They dislike spending days in the hospital, but they also know that sometimes that is an adventure they must undertake. They weather their healthcare interactions with inspiring patience and endurance.

My clinic day ended hours after the patient who couldn’t hear birds anymore left. As I walked to my car, I thought about how much I loved listening to birds sing. I thought about how hard it must have been for that patient to realize, perhaps all at once or perhaps over time, that they couldn’t hear the birds anymore. I hoped that their hearing aids would help them. What a strange goal to have, the goal to hear birds again. The goal of regaining something previously taken for granted. I wondered what my goals would be when I was that patient’s age. I hoped I had as much perseverance as they had.

The Strength of a Mother

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Her son was dying. Yes, we were keeping him alive in that moment, but he was dying anyway. We could not fix what was killing him; it was simply too progressed. There was no way out except death. We knew this and, perhaps, he knew it too as the soul peeking through his eyes became more distant and the fear that had been there was replaced by blankness. He was too sick to make his own decisions. The decision about what to do fell upon his wife. Having to make decisions about the end of her husband’s life tormented the patient’s wife. He was a fighter and he had always told his wife he wanted to live. The patient’s wife could not imagine life without her husband. She felt alone. She feared past demons reemerging when he left her. Yet, the fact remained that this wife’s husband, this mother’s son, was dying. As the plan stood, he was dying slowly.

It was under these circumstances that the mother and wife sat down to talk with us, the patient’s care team, to discuss how the plan could change to reduce suffering. We described the options. There was the option to continue forward as we were; using every medication and intervention we could to keep the patient alive. We explained that this would be futile and would still result in death, but the decision was theirs. The second option was to stop the medications and interventions keeping the patient alive and replace them with medications and interventions to keep him comfortable. We could not predict the future. We guessed he would die within days if we turned off the medications currently keeping him alive. He would die more quickly without medications to raise his blood pressure and transfusions to replace his red blood cells and platelets, but he would not suffer because we would treat every symptom he had from pain to breathlessness and anxiety to insomnia.

After we described the above options, the wife began crying. She accused the healthcare system of missing something. Of not doing everything. If emotions were tangible, then this wife was the physical manifestation of agony. That’s when the mother spoke.

“This is not their fault. I believe them… I believe that they have done everything they can.” The mother paused. “I have cared for my son his whole life. I have loved him and fed him. He is my son. I will not see my son suffer. I do not want my son to suffer like this.” The mother paused again. “My son is already gone. I see it in his eyes. He is not there. It is time to let him go.”

The conversation unfolded between the mother and wife. The care team was there as witness but it was not our conversation. It was not our right to decide what happened next.

“I am all alone. I am afraid,” the wife said.

“You are not alone. You have me,” the mother said. “And if you have me then you have my people because they do what I say. I will stand by you.”

The patient was one of this mother’s children. The mother was old enough to have grandchildren and great-grandchildren. In the days leading to this conversation, it became clear how large her family was from how many visitors the patient had. The mother sat tall and confident. She spoke with sadness and wisdom. She spoke as someone who had seen others die before.

“I will not see my son suffer. Let’s do this together. We will do this together. Let him go,” the mother said. “I know my son. He is gone. You can decide, but I will not visit again because he is already gone.” The mother paused and held the wife’s hand. “We will do this together. We will mourn together.”

The patient died less than a day after he was transitioned to medications to treat only his symptoms. Most of his family had seen him prior to his death. I will never know how the story of the wife and the mother unfolded after the patient’s passing. Yet, I believed the mother when she said she would be there for the wife. From the conversation I witnessed it was evident that the patient’s mother knew more about life and death than most people; she had a knowledge gained over her lifetime. She also knew her son as only a mother could. The guidance and support the mother offered the patient’s wife as the patient died were some of the bravest acts I’ve witnessed.

The Difference of One Day

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The Doctorhood quest is a journey with finite phases.  To reach the next phase you must pass through the hurdles of the previous phase. Like all quests, each phase must end. Now having passed 2 phases, I’ve noticed that the transition between the phases is jarring.

I recently finished my first year of residency, called “intern year.” In the Doctorhood quest, many consider intern year the hardest phase because it’s the time when you begin to practice as a physician and know the least. You are a student one day and then the next day walk into the hospital with your new title of “doctor.” You find yourself with a mountain of responsibilities that you aren’t sure how to manage. It’s a bit of a joke because one day does not make a physician. So, even though you have the “doctor” title starting the first day of intern year, the difference between an intern and a student only begins to emerge as the months drag on. By the end of intern year, you find yourself teaching medical students and realize that you are, in fact, more knowledgeable than you were 12 months prior.

A similar transition exists between intern year and the second year of residency. In my residency program, we even get a new badge declaring us “resident physician” rather than “intern physician.” One day you’re an intern, working under 2-3 layers of senior physicians and the next day you’re a resident with only a very senior physician overseeing your work. As an intern you always have a resident to ask for help. When you’re a resident you’re the one that the interns turn to with questions. Of course, there are people who teach and help you as a resident, but they are more distant and more senior than before. As a resident, you are expected to find answers to many of your questions and you are expected to make many decisions on your own.

On the second day of my second year of residency, a physician who has been teaching residents for years entered the room to lead one of the educational sessions we (residents) have weekly. Before he started his lesson, he acted out strutting down the hall as James Bond does, “Now that you’re all residents you even walk differently. You have that swagger,” he said. We all laughed. A day does not make a physician. A physician is made over years. Today I feel like how I felt during the last days of intern year because the time between today (early on during my second year of residency) and the end of intern year is short. I’ve been questing long enough to trust the process. I know I’ll feel confident as a resident by the end of this year. And, who knows, maybe I do walk the hall a little differently now than I did a year ago. I did, after all, forge intern year and live to tell the tale.

About Those Weight Loss Drugs

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Several friends asked my opinion on a group of weight loss medications called “GLP-1 receptor agonists” like semaglutide (Wegovy). Specifically, they asked me: 1) Are these drugs cheating? and 2) Will these drugs worsen stigma and mistreatment of people who live in large bodies?

These questions are hard to answer concisely. I am going to try. I will first clarify several concepts then answer each question individually.

4 Foundational Concepts

1) GLP-1 receptor agonists aren’t a silver bullet. They can have serious side effects including severe nausea and vomiting, kidney injury, gallbladder disease, and pancreatitis. Some people who try these medications can’t continue them given the side effects they experience. Another challenge is that GLP-1 receptor agonists can be too expensive for patients to afford because insurance companies don’t always cover them and there is no cheap generic version available in the US.

2) BMI (body mass index) compares a person’s weight and height as a tool to understand if their weight has a negative impact on their health. It is flawed. BMI was developed using mostly data from white men. Half of my patients aren’t white. Another half of my patients aren’t men. So, the BMI brackets of “underweight,” “healthy,” “overweight,” and “obese” don’t perfectly describe most of my patients because they aren’t white men. BMI is also flawed because it does not describe body composition (fat vs muscle vs other) which is relevant to how weight affects health. As such, BMI is complex to interpret when someone does not fall at one extreme of the scale. Despite its flaws, BMI is helpful when used with other information (like waist circumference, labs, vitals, history, etc.) to understand how a person’s weight affects their health.

3) Obesity has a specific definition based on BMI and several other factors. The most basic definition of obesity is a BMI ≥30 kg/m2.

4) Obesity is a disease with a multifactorial cause. Obesity is NOT caused by weakness or lack of self-control. There’s growing information about the genetic and environmental contributors to obesity. Additionally, there are certain medications that some people need to live given their other health problems that contribute to weigh gain. Like many other diseases, personal choices can contribute to the development of obesity. Personal choices, however, do not define or explain obesity completely.

Are these drugs cheating?

No. GLP-1 receptor agonists are useful because we know that weight loss is more effective with them than with diet changes alone. GLP-1 receptor agonists are ONLY approved for weight loss in people who have obesity or people who have a BMI ≥27 kg/m2 with a condition that is likely a complication of their weight like diabetes, high cholesterol, or high blood pressure. Weight loss in these populations is important because it will improve their overall health and, importantly, lower their risk of heart disease. Heart disease is the leading cause of death in the US so it’s serious.

Note that GLP-1 receptor agonists were first approved to treat diabetes (regardless of a person’s weight) and continue to be used for that purpose. These medications are also recommended as part of the treatment of chronic coronary artery disease in specific situations.  In other words, not everyone on a GLP-1 receptor agonist is taking it specifically for weight loss.

Will these drugs worsen stigma and mistreatment of people who live in large bodies?

They shouldn’t since they are proven treatments for specifically defined diseases (just like most other medications we use). Subjective judgements of body size that classify people as having a large body aren’t good predictors of people’s health status. It’s important to realize that what societies and individuals consider a “large body” is often based on cultural and individual beliefs and is variable. When looking at weight from the medical perspective, we use specific objective data like BMI and other medical information (like body composition, labs, and vitals) to estimate how likely a person’s weight is to negatively affect their health.

While not all people with large bodies (from the perspective of society) have obesity or negative complications from their weight, some do. If my patient’s weight negatively impacts their health, it’s my job as their primary care physician to include weight loss as part of their medical plan to help them live a long and healthy life. Weight loss medications are one tool in the toolbox.

My goal is to treat people with compassion and respect. I believe that if I continue to strive to practice medicine that is fair and kind regardless of my patient’s body size, I can help reduce the stigma placed on people with large bodies. GLP-1 receptor agonists can help people with obesity lose enough weight to lower their risk of developing heart disease and other complications associated with obesity. The opportunity to help people achieve their best health is one reason why I went into medicine. I’m excited that we have the GLP-1 receptor agonists and will continue to recommend them when medically indicated.  

References:

StatPearls, “Glucagon-Like Peptide-1 Receptor Agonists”: https://www.ncbi.nlm.nih.gov/books/NBK551568/

Cureus, “The History and Faults of the Body Mass Index and Where to Look Next: A Literature Review”: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10693914/

Clin Med, “Causes of obesity: a review”: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10541056/

New England Journal of Medicine, “Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes”: https://pubmed.ncbi.nlm.nih.gov/37952131/

CDC, “Heart Disease Deaths”: https://www.cdc.gov/nchs/hus/topics/heart-disease-deaths.htm#:~:text=Heart%20disease%20has%20been%20the,excessive%20alcohol%20use%20(2)

How does one deliver healthcare justly in an unjust system?

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I recently cared for a patient with a life-threatening bleed. They bled because their blood thinner level was too high. They were on a blood thinner to prevent stroke in the setting of a chronic abnormal heart rhythm (called “atrial fibrillation” or “Afib” for short). Afib requires life-long anticoagulation to prevent strokes. Afib puts you at risk of stroke because it increases the risk that clots will form in your heart and then travel to your brain causing stroke.

The patient’s blood thinner was called “warfarin.” Warfarin is an old, cheap blood thinner. The problem with warfarin is that its blood levels are affected by many things such as diet and other medications. Because of its fluctuating levels warfarin requires frequent monitoring (with blood testing at a clinic). Warfarin is notoriously difficult to manage. This patient’s warfarin levels were high likely because of a different medication they were prescribed for a short time.

For Afib, we have several other equally effective blood thinners that are a lot easier to manage than warfarin. The patient wasn’t on one of these alternative blood thinners because they couldn’t afford them. The most common alternatives to warfarin for use in Afib are Xarelto and Eliquis.

The manufactures of Xarelto and Eliquis each offer a one-month free coupon once in your lifetime. So, if you use each coupon (the two medications are similar enough you can use them interchangeably in this situation), you can get 2 months of free blood thinner. After that, there are programs that might help you either get a reduced price or free access to the Xarelto/Eliquis for 1 year. So, maybe you can get 14 months of cheap Xarelto/Eliquis. Let’s say you’re 50 when you are diagnosed with Afib. You’ll be 51 or 52 when you must figure out how to pay for your blood thinner for the rest of your life (likely 20-40 years).

You might ask, “Can you use GoodRx (or a similar application that compares drug prices and offers recurring discounts) and figure out the cheapest place to get Xarelto or Eliquis?”

Answer: You can. When I wrote this you could get 30 tablets (one month’s supply) of Xarelto at Wegmans for $555. This was the cheapest option on GoodRx. Eliquis was similar in price.

With the above information on Xarelto’s cost you might then ask, “How does the price of warfarin compare?”

Answer: When I wrote this you could get 30 tablets (one month’s supply) of warfarin for $4 at Walmart.

The decision (in this case) between Xarelto and warfarin isn’t really a decision because your finances determine what you can afford regardless of the medically recommended option or the comparative risks/benefits of the medications.

The average American salary was $59,500 in 2024. Xarelto at the above price would be $6,600 a year or about 11% of that average annual salary. The price of Xarelto/Eliquis doesn’t change regardless of how much money you make. Your other expenses including other medications, food, transportation, and housing don’t change regardless of how much your blood thinner costs.

I use this case as an example, however the list of medications that are too expensive for people to afford when they don’t have insurance or when the medication is not covered by insurance is lengthy. If you’re curious, check out GoodRx. You can look up any medication there, see what discounts they offer, and look at the retail prices of that medication. You’ll notice that the retail prices and the discounts are different at every pharmacy (Walgreens, Walmart, etc.). That’s how corporate healthcare works. Each corporation negotiates drug prices with drug companies. Some countries regulate the prices of medications sold in their country to help ensure more equitable access to medications – the US doesn’t.

How does one deliver healthcare justly in an unjust system?

You don’t.

You try.

You fail.

You try again.

References:

Forbes Average annual salary: https://www.forbes.com/advisor/business/average-salary-by-state/

GoodRx: https://www.goodrx.com/