The Last Stop on the Bus Line

Posted on by

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.

Stand Up for Yourself Sister

Posted on by

“Stand up for yourself sister…because if you don’t stand up, no one will.” This was the theme of my thoughts as I walked home recently. I’d learned this lesson over a series of experiences, most significantly the Peace Corps and the 20ish jobs I had before medical school. It’s a skill improved with the help of pivotal women throughout my younger years who showed me how to advocate for myself (not just others). And it’s a skill I’m always improving.

Medical school forced me to practice standing up for myself over, and over, and over again. Medicine isn’t designed to be kind to its trainees. The journey to doctorhood is fraught with unpleasantries. A self-aware and self-confident person can minimize these annoyances if she chooses to face them and address them as they arise.

“Stand up for yourself sister” had popped into my mind after chatting with a younger co-resident who described several instances where she was asked to do work that wasn’t her responsibility by senior trainees and didn’t feel comfortable saying “no.” These instances were like the time in medical school when I found one of my classmates in the hospital hours after her work was done because a resident asked her to do a non-medical errand (meaning it was a personal favor and had nothing to do with the student’s learning). The student had also not felt comfortable saying “no.”

In both of the above cases, if the junior trainee has said “no” to their superiors they would have been in the right and may have prevented their time from being wasted. Further, both cases were examples of misconduct by the senior trainees as defined by the governing bodies that oversee medical trainees. Because of the hierarchy of medicine there are clear guidelines of conduct designed to protect junior trainees from abuse by senior trainees and physicians. The above cases were not reported to governing bodies.

Weird and questionable situations arise all the time. What I’ve learned is that being confident to say “no” is important. It is possible that there will be ramifications when one says “no,” but if one is in the right it is often worth the risk. Further, reporting unreasonable requests to the governing powers in our institutions is another form of self-advocacy that has the added benefit of helping to prevent others from being put in similar situations in the future. I don’t think it was coincidence that the two above examples happened to female trainees.

America calls itself “land of the free and home of the brave.” I find this tagline misleading. One reason is the different way many fractions of America raise their women and men. Even in a place that screams equality as its core value, many American sub-cultures (including my own) teach their boys to be confident, embrace conflict, ask for things, and demand better. At the same time, these sub-cultures (including my own) teach their girls to be cute, create harmony, strive for pleasantness, advocate for others (especially the weak), and be tactful. The lessons we teach girls are fine except they don’t cultivate the skills girls need to stand up for themselves the way the lessons we teach boys do.

American women from these subcultures are then at a disadvantage in many situations including when they negotiate employment contracts, ask for promotions, and define boundaries in relationships. Of course, many girls and women learn to negotiate and advocate for themselves anyway. But, what I’ve noticed, is that these skills aren’t default from culture in America like they are for men. Many of the women I know who stand up for themselves are self-learned after facing challenges or inequitable treatment next to men. A lucky subset of women are great self-advocates because other women took the time to teach them (despite American culture) in the hope of sparing them some frustration.

There are women who never find a way to feel comfortable standing up for themselves. I feel for these women because I know what it is like to be averse to conflict and scared to speak up. I know what it’s like because that is the default American subculture from which I come. But, like I told my co-resident, we can learn new skills and grow our personalities if we choose to do so.

I’m thankful I invested in cultivating my ability to self-advocate. American women are often amazing advocates for others (such as their children, their parents, their patients, their friends, and many other groups) while being uncomfortable advocating for their own needs. But, advocating for oneself is just as important as advocating for others. There is no reason to believe self-advocacy is a fixed ability or a trait only man can have. Even as I write this, I’m still not as good at self-advocacy as my husband is. Thankfully, I have many years left to practice… You better believe I’m striving for self-advocacy excellence.

35 for 35

Posted on by

My white hair is coming in faster than ever, but it hasn’t brightened my dark hair yet. It’s only a matter of time before the salt-and-pepper sets in – a signal to the world of the wisdom I’ve gathered. I’ll miss my dark hair when it goes, but I’ll embrace my wise look when it arrives.

When I turned 25, I posted 25 goals for 25. Below I’ve reviewed them, annotated, refreshed, and added to create a new 35 for 35 goals list.

Key:

  • Italic font: the 25 goals I had at 25-years-old
  • Crossed out: 25-years-old goal that I completed
  • Regular font: annotation
  • Bold font: my goals at 35-years-old

35 for 35, listed in no particular order:

  1. Ask for it. Done. REPLACE WITH: Finesse effective negotiation skills. Remember to apply these skills not just when negotiating for others but also when negotiating for myself.
  2. Initiate: Don’t expect someone else to do it. Done. CARRY FORWARD: Initiate: Don’t expect someone else to do it.
  3. Look for opportunities to be helpful. Done. REPLACE WITH: Advocate for underserved and marginalized populations represented within the patient population I serve.
  4. Focus on living in the moment. Note the positive things. Done. CARRY FORWARD: Live in the moment. Note the positive things.
  5. Take time to be thankful. Done. CARRY FORWARD: Take time to be thankful.
  6. Get my novel ready for review. I did this then I threw it out. I have other novel ideas for the future should I wish to pursue that kind of writing again someday. REPLACE WITH: Create a home to call my own. By age 45 that home should include a plot of land.
  7. Rock the GRE. Done plus the MCAT, all my med school exams, STEP 1, STEP 2, and STEP 3. REPLACE WITH: Pass my Internal Medicine board exam on the first try.
  8. Be diligent about journaling. I journaled throughout my time in Paraguay. I lost the habit after I returned to the US until I started residency. I’ve been journaling at least weekly almost since I started residency. UPDATE TO: Journal using daily short snippets and weekly 1-pagers.
  9. Read more. >> I read a lot of medical writing. UPDATE TO: Read more fiction and nonmedical writing.
  10. Focus on health: Eat less sugar. Control portions. >> This is still a goal and a challenge. CARRY FORWARD: Eat less sugar and control portions.
  11. Exercise every day. >> I’ve learned that exercising every day is not necessary or realistic. Exercise is, however, essential for health. Anything related to health is especially hard during residency. My current hypothesis is that residency shortens one’s life expectancy. I’m trying to dampen residency’s effect on me. I’m also trying to be healthy in general. UPDATE TO: Exercise multiple times weekly such that I feel healthy and strong.
  12. Publish consistently on Connecting the Dots. Rocking it. Hit 10 years blogging in 2023. So far, my blog has documented my entire Peace Corps service, my premedical studies and getting into medical school, medical school, and now it’s recording my thoughts as I chip away at residency. CARRY FORWARD: Publish consistently on Connecting the Dots.
  13. Learn Guaraní. >> I know some phrases, never did become fluent. Learned the important words for me. If I return to live in Paraguay I will reactivate this goal. REPLACE WITH: Stay current on the latest medical information relevant to my practice as a physician. Review uncommon and complex topics periodically to keep them on my differential and understanding.
  14. Become fluent in Castellano. >> I made great strides while in Paraguay. I’ve used so much energy to learn medicine since I returned to the US that I’ve lost some of my Spanish. UPDATE TO: Practice and study Spanish to achieve better fluency with a focus on medical Spanish.
  15. Stay in touch with my US network. Now I have an international network which evolves and changes like all living things do. REPLACE WITH: Create more opportunities to connect with family and friends.
  16. Reach out to friends in Paraguay; don’t always go it alone. Done. Remember that time I lost my key in Paraguay? I didn’t have water and needed a shower in Paraguay? Got an upset stomach and asked my Paraguayan friends for the right herb to sooth my stomach? REPLACE WITH: Get involved in several activities/organizations to diversify how I spend my time and to meet like-minded people.
  17. Hone patience. Done. REPLACE WITH: Work on calm, clarity, and patience in the setting of becoming a better teacher of medicine.
  18. Smile more. Done. REPLACE WITH: Take at least one international vacation yearly. Travel abroad as much as is possible.
  19. Learn biology, chemistry, and math. Done. I also learned medicine. REPLACE WITH: Learn to identify more local plants, trees, and birds.
  20. Make listening to podcasts part of my routine. >> I like this idea, but I don’t think it will ever happen given how I live my life. REPLACE WITH: Learn about herbal medicine and explore what role alternative medicines play in helping my patients achieve their health goals.
  21. Solidify a positive self-image. Done. Seems like forever since this was a challenge. REPLACE WITH: Push myself to learn about people who are different than me to expand my horizons and to understand others better.
  22. Listen to understand, not to respond. Done. CARRY FORWARD: Listen to understand, not to respond.
  23. Share more. Done. REPLACE WITH: Protect time to be quiet and reflect.
  24. Let the little things go. Done. CARRY FORWARD: Let the little things go.
  25. Ask more questions. Done. REPLACE WITH: Remain curious. When things become routine remember to be curious about new ways, new views, and new opportunities.
  26. Explore every national park in the US.
  27. Hike the length of Chile (chunking it is fine, though it’d be cool to do it in one go).
  28. Hike the PCT (chunking it is fine).
  29. Visit every state in the US. A visit is defined as: at least 24 hours with 3 meals, one night stay, and at least one activity other than travel.
  30. Explore every country in Central and South America that is reasonably safe for US citizens to visit.
  31. Start traveling to countries in Asia and Africa.
  32. Retrace Darwin’s path on the Beagle.
  33. Cultivate my nuclear family – which will metamorphose as time unfolds.
  34. Attain financial independence by age 55.
  35. Stay open to opportunities in my career. Push myself. Be brave enough to change and adjust as my goals and priorities evolve.

Heat Wave and Other Environmental Concerns

Posted on by

A co-resident of mine recently gave a presentation on how global climate change is impacting health at one of our residency educational sessions. As someone who grew up in a Vermont family who thinks a lot about the environment, it was a basic talk. Basic as it was, the presentation was effective in starting a conversation about the health impacts of climate at my residency program.

In their wrap-up, the presenter mentioned that there isn’t much we can do as individuals about climate change because it is a systemic problem. As I left the presentation a different co-resident mentioned how they didn’t see the relevance between the presentation and our work in medicine. These comments reminded me of an interaction with yet another co-resident I’d had the year before – when that resident mentioned that they “don’t believe in recycling” when I was talking about recycling and compost programs in Richmond, VA.

This presentation on global climate change came right after a heat spell that broke summer temperature records across the US. In one week, my 3-person team admitted 2 patients for illnesses related to heat exposure. In the post-presentation discussion, my colleagues who work with adults and children mentioned how they can guess a child’s home zip code based on how bad their asthma is. Per those residents, since the bus depots moved to certain neighborhoods to “clean up” the center of the city the children in bus depot zip codes now have frequent asthma exacerbations.

Like most terrible things, the dangers of climate change are overwhelming. To slow the process and fix the problem does require global systemic change and political dedication. But, as Margaret Mead said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”

As a child my mom told me stories of how when she was a kid there was trash everywhere on the side of the road. And, while we still see trash on the side of the road, it’s improved a lot since her childhood. This shift occurred partly because individuals stopped throwing so much trash out their windows and dumping trash on the roadside and partly because we established systems to clean up trash. So, the less-roadside-trash-effort was a combination of individual effort and system change.

 “Green Up Day” in Vermont is a concrete example of combining individual and systemic effort to reduce roadside trash. Green Up Day is a yearly event in spring when Vermonters go out with trash bags and collect trash along the roads around their property. The trash bags are put in piles on the roadside and the towns pick up the bags. Because of Green Up Day, Vermont enters summer with minimal litter on the roadsides. Vermont is a state of natural beauty – their ability to keep their state beautiful fuels tourism and protects the land Vermonters love.

Slowing, stopping, and reversing global climate change is a lot more complicated than simple trash management. But the only way to address complex problems is to break them down into pieces. Below is a list of some things we can do on an individual level to help. The below list isn’t exhaustive, revolutionary, or original. BUT it’s a list of things I’ve been able to do despite being a medical resident with a terribly busy schedule, not having much physical or mental reserve, and abiding by a relatively tight budget. I share it with you because I disagree with my co-resident that we can’t do much on an individual level. Think about what could happen if the >144,000 medical residents in the US did these things. Think of what could change if even half of the >300 million people in the US did these things. And think what could happen if we each also demanded environmental responsibility from our networks, cooperations, and politicians.

  • Recycle. Even if you don’t have home recycling collection. Take the time to drop it off at a recycling center.
  • Compost. This can be organized compost or home compost. For example, Richmond has city-operated composed bins throughout the city – there’s even one at the public library. If you own property, you can set up a composed bin or pile of your own.
  • Limit your use of single-use cups and utensils. I bring my bamboo utensils, travel mug, and water bottle to work every day to minimize my use of single use items.
  • Use soaps, laundry detergent, dish soap, shampoos, and conditioners that come in paper containers. You can get bars or powdered soap. BlueLand sells soap tablets that dissolve to make foam hand soap if you don’t like bar soap for hand washing.
  • Get spices from bulk pins or in glass bottles to minimize all the small plastic bottles spices come in.
  • Use reusable bags when shopping, including vegetable bags. Remind your cashiers that you brought bags if they aren’t used to reusable bags yet.
  • Say “no” to plastic bags on your take-out food. Instead, use a reusable bag or no bag at all.
  • Buy things in paper, metal, or glass contains whenever possible. Avoid plastic containers as much as possible.
  • Re-use plastic bags. They’re easy to wash; I promise.
  • Make sure your sponges aren’t made of plastic. Even mainstream grocery stores sell compostable sponges.
  • Walk or bike to work as much as possible.
  • Don’t idle your car when stopped. If it’s hot, just get out of it and go stand in the shade. If it’s cold, stand and wiggle.
  • Think carefully before using single-use equipment at work and at home.
  • Turn off your lights when you leave the room, or you don’t need them.
  • Limit your AC use to what you need. Turn off your AC when you leave.
  • Change your lightbulbs to energy-efficient bulbs. LED bulbs are cheap these days.
  • Use reusable batteries and rechargeable gadgets rather the single use ones when you can.
  • Use paper party decorations rather than plastic ones. I think about sad turtles when I see balloons. I don’t expect you to have the same reaction, but paper streamers are just as cool as balloons and better for the environment.

Want more ideas about what you can do to help slow global climate change? Check out the United Nations’ page on “Actions for a Healthy Plant” at https://www.un.org/en/actnow/ten-actions. Another good page with ideas for individuals can be found at the Milken Institute School of Public Health at the George Washington University: https://onlinepublichealth.gwu.edu/how-to-reduce-climate-change.

Listening to the Birds

Posted on by

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

Posted on by

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

Posted on by

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

Posted on by

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?

Posted on by

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/

She Must Be Just a Number to You

Posted on by

“You see so many patients, she must be just a number to you,” the patient’s son said as he watched me perform the official exam declaring his mother dead.

“We care about all our patients and take the best care of them we can. Of course, I haven’t known your mother for as long as you have. You’ve known her your whole life,” I said. I finished my exam. I stated the time of death, gave my condolences, and left the room.

I had pronounced a patient dead almost daily that week. During this patient’s exam my emotions were not the emotions of a son who had just lost his mother without much warning. My emotions as the patient’s physician could not be the same as her son’s. I was sad, of course, but I also knew we had done everything we could for her. As a physician I must balance being emotional and being clear-headed so that I can make objective decisions about how to help patients with their medical challenges.

In medicine we push to the edge of current scientific knowledge, yet we are not capable of magic or miracles. We cannot predict the future and we cannot stop the inevitable. Death is part of life. Since medicine in the science of life it inherently involves death.

As a physician my mission is to prevent and cure disease and reduce suffering. A lot of suffering can happen when a person is gravely ill. Part of my job is to recognize when the fight for life is futile. Once the fight becomes futile, anything we do to prolong life also prolongs suffering. It is at the time of futility that I can offer a path that leads to greater comfort and death with dignity. This path requires a shift from a goal of prolonging life to one of promoting comfort. To stop fighting death is not a decision to take lightly. Further, the decision must be made by the patient or their appointed decision-maker (when the patient is too sick to decide). I can only offer guidance as part of the patient’s care team.

This patient, the mother of this son, had fought for her life. She had maxed out every treatment we could offer. She had failed other treatments. When she was worsening, we called the family to come into the hospital. When everyone who needed to be there was at her side, we turned off the medications and interventions that were keeping her alive. We did this because to keep those medications and interventions going would not save her. She would die regardless. She was suffering. Most importantly, she had made it clear when she was well that she would not have wanted to keep going in these circumstances.

When we turned off the medications and interventions keeping her alive, we gave the patient medications to treat her discomfort. She had pain, shortness of breath, and anxiety. She died shortly after we changed our approach from treatment to comfort. She died peacefully and surrounded by the people most important to her. None of this struggle made her a number. She was a person who had fought bravely and died with dignity. And, sometimes, that is all we can offer in medicine – a place that illuminates a person’s intrinsic bravery and permission to stop struggling.   

I have seen and will see many people die. My role in these circumstances is not a counting role. As a physician I ensure my patients get the best treatment available when there is a fight to have and the most comfort possible when there is no fight left. My role is to adhere to their wishes regarding their life and death as best as I can within the constraints of medicine. These are serious responsibilities that are both rewarding and harrowing. Rewarding because I know my patients receive the best care we can offer and a death as close as possible to what they would want if they had a choice. Harrowing because it is hard to lose someone I cared for and because I feel each patient’s loss, not as a friend or family member, but as a partner in the patient’s battle against death.

Being a physician has made me realize exactly how people aren’t numbers. It is my job to learn my patients’ stories and to partner with my patients to tackle their health goals. What happens to my patients is partially a reflection of how well I did my job and partially a reflection of the complexity of being human. The depth of the patient-physician relationship is part of the reason I chose medicine. My patients’ stories are sometimes tragedies and my relationship with my patients is sometimes difficult, but the opportunity to heal, cure, and reduce suffering is enough to make those challenges worth it. I am grateful for the opportunity to take part in my patients’ lives. Grateful even if we meet under extremely unfortunate circumstances. Grateful even if we meet at the end of their life.