Tag Archives: Public Health

Remarkable People

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Movement at the periphery of my vision caught my attention as I sat at a stop light on my way to work. The movement was a person standing on the sidewalk. Perhaps they were dancing in their mind. Their movements were rhythmic but not in the way most people move to a beat. Something was wrong. Then I realized they were foaming at the mouth and a string of drool hung from their chin. Their eyes were open, but I wasn’t sure they saw the world around them. The explanation didn’t take a medical degree to deduce: Drugs. Likely cocaine or another stimulant. Opiates make people sleepy, not interested in dancing on a street corner.

That day in clinic I had a new patient scheduled who hadn’t been seen by a doctor in several years. The patient was young. They had a history of substance use disorder. The last notes in our system, from several years prior, said they’d stopped using drugs. Previously, they’d used almost every class of drug: alcohol, tobacco, cocaine, benzos, and opiates. As I waited for their appointment to start, I wondered how they were doing, now years later.

The patient entered my clinic calm, clean, and collected. They were articulate and respectful. They had cool hobbies including gardening and beekeeping. “Last time you saw us, you hadn’t used drugs for a few years. Is that still the case?” I asked.

“Yeah, I don’t use drugs anymore. Haven’t for years. I still smoke cigarettes though,” the patient said.

The conversation about their health unfolded. I looked at my computer to go through the never-ending reminders the healthcare system required me to complete with my patients. The reminders for the current appointment included cancer screening and offering nasal naloxone (maybe better known by its brand name “NARCAN.” It’s a nasal spray that reverses the effects of opiates and, if given soon enough after an overdose, saves lives).

“I know you said you don’t use drugs, but I have a reminder here for naloxone. Would you like free naloxone just in case?” I asked.

“No. I’m good. I used to have it. It saved my life twice…and I saved the lives of two other people. I had a friend that said over his time, he saved 60 people with NARCAN,” the patient said.

“I’m glad you were able to do that. I’m glad you’re still with us,” I said.

I finished going through the reminders. We finished our appointment. The patient was healthy and didn’t even need any blood tests.

I thought about the patient as I walked to my car. Beekeeping is awesome. I hoped I’d get back to gardening someday too. As I put my car in reverse, I remembered the person I saw foaming at the mouth on my drive to work. The contrast between the person I saw on the street corner and my patient that day was stark. The contrast reminded me how life is nonlinear. I thought about how the patient had saved their own life and the lives of two others. The patient I’d seen was a remarkable person. The phrase popular for healthcare workers during the COVID pandemic came to mind, “Not all heroes wear capes.” I decided the phrase was accurate but needed modification. Perhaps a better phrase for remarkable people in the world is, “Not all heroes wear capes, but they have baggage and have learned to carry it with grace.”

I hoped the person I saw dancing to drugs and foaming at the mouth would turn down a different road in life. Maybe that person on the street corner would someday tend their own flowers and suck honey from honeycombs too. Maybe the person I saw on the street corner had saved a life right before I saw them. Maybe their life had been saved by an unknown remarkable person. Afterall, the only thing that makes people remarkable is what they’ve done. Every day each of us can decide to do something new. Every day we can evolve and refresh. That’s the most exciting thing about life: The only constant is change.

Positive Transformation

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The first time I saw the patient, they weren’t sure if they wanted to take the medications I recommended for lowering their cholesterol and blood pressure. Primary care appointments are conversations. My assessment of their health after reviewing their labs, vital signs, and story suggested that making lifestyle changes (like more exercise and diet adjustments) and starting a few medications would help the patient be healthier and reach their goal of living a long, healthy life. I explained the reasoning behind my recommendations and the patient agreed to think about them. We planned to continue our discussion of possible medications and lifestyle changes at future appointments. As I like to remind my patients, it doesn’t help anyone if I prescribe them medications they won’t take. I’d rather have an honest conversation about the medications I think would help them but only prescribe the medications the patient would like to try.

Primary care is proactive. In other words, the goal of primary care is to prevent the development of disease in the first place or, if a disease is present, to prevent its progression. Contrast primary care with the reactive approach of hospital medicine. The goal of hospital medicine is to treat disease that is unstable or so far along in its course that it can’t be safely managed outside of a hospital. We know we can help people live longer, healthier lives when they have good access to primary care. However, the challenge with primary care is that often the interventions it promotes don’t create visible changes in the present.

For example, people generally don’t feel any different if their cholesterol is high or low. However, we know that high cholesterol over time can lead to clogging of arteries which, in turn, can lead to heart attacks, strokes, and blockages in arteries that feed the legs (causing pain, poor healing, and tissue death). If a patient has high cholesterol and chooses to lower their cholesterol through diet, exercise, and (possibly) medications they are taking important action to prevent heart attack, stroke, and the other complications of clogged arteries. Yet, it can be hard for people to find the motivation to change their lifestyle and (possibly) take medications every day when those changes don’t change how they feel, and the health benefits are intangible (though very real).

I saw the patient who agreed to think about my medication recommendations many months later. They had lost weight and looked more muscular. They’d revamped their lifestyle – they started a balanced exercise program at least 3 days a week and minimized sugars and carbohydrates in their diet in favor of lean meats and vegetables.

“I’m ready to try the cholesterol-lowering medication,” the patient said, bringing up the topic before I did.

It was a complete transformation. “What motivated you to make all these changes?” I asked.

“I decided I want to live a long time still. I have things I want to do,” the patient said.

I found myself smiling long after the patient left. Many people struggle to make all the changes that this patient had to support their health. Yet, this patient had taken their health into their own hands. And, while I’ll never be able to say exactly how their actions changed the course of their life, every bit of research suggests these choices would shape the patient’s future. They’d lowered their probability of dying from heart disease or stroke. They’d lowered their risk of developing heart failure and diabetes. And such a positive transformation, though rare, is the dream of primary care.

The Floors Don’t Shine Like They Used To

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I walked into the Veterans Affairs (VA) hospital where I have primary care clinic. I hadn’t been there for a few weeks between vacation and working in the ICU (critical care unit) at a different hospital. Yet, I’d heard about the budget cuts and other residents had shared murmurs of uncertainty related to what was to come for our patients. Entering the VA hospital for the first time since the budget cuts started to take effect, I was immediately struck by how gross the floors looked. And, as I was processing the dullness of the floors and their peeling finish, I heard a woman next to me comment on the floors too.

I used to joke to my spouse about how frequently they refinished the floors at the VA hospital. Over the past 2 years it seemed that every time I worked nights or left late, they were refinishing the floors. These efforts resulted in a floor as shiny as the shoes of the sentinels at the Tomb of the Unknown Soldier in Arlington Cemetery. And, until the floors looked dull, I’d never thought about their symbolism.

Every patient seen at the VA hospital is a veteran. Some of them wouldn’t have access to healthcare if it weren’t for the VA. Most of them wouldn’t have access to some of the most critical medical resources that our veterans need for good health without the VA. Mental health care is one example of such a resource.

I settled into my day at the clinic. A patient I hadn’t seen before was among my first patients. “I’d like to be screened for PTSD,” he said.

“Okay, why?” I asked. PTSD stands for “post-traumatic stress disorder.” It’s a condition that can occur when people experience things that are mentally traumatic. It can include flashbacks to the event(s) that disrupt life, nightmares that prevent sleep, and mood challenges that make it difficult to function in daily life.

“My daughter thinks I have it,” he said.

“Do you have nightmares?” I asked.

“No. But I think about things that happened. I just push the thoughts out of my head though. You know, I saw people die in Vietnam,” he said.

“How often do you have those thoughts?” I asked.

“Multiple times a day,” he said.

“How long has that been going on?” I asked.

“Years. I also get angry really easily,” he said.

“Do you get angry over things that other people don’t?” I asked.

“Yeah, all the time. I just get angry fast,” he said.

“Any thoughts of hurting yourself?” I asked.

“Hasn’t come to that,” he said.

“What about thoughts of hurting others?” I asked.

“All the time, but I don’t act on it,” he said.

The conversation unfolded. From my assessment he easily met criteria for PTSD. “Well, I think your daughter’s right that you have PTSD. Do you want treatment for it?” I said.

“Yes,” he said.

We discussed our options for treatment. I was grateful that we had options. How awful it was to think he’d potentially lived for 50 years with thoughts of the people he saw die in Vietnam haunting him multiple times daily.

Mental health is a huge part of health for all people and an especially common challenge for veterans. It has taken years of population education and eradication of misinformation to create an environment where veterans feel comfortable asking medical providers for help with their mental health. In my experience younger veterans are more comfortable discussing things like depression and PTSD than older veterans. But it’s an important issue for all veterans. To put it in perspective, about 18 veterans across the US die by suicide daily.

The VA offers more mental health services than any other healthcare system I have encountered. People using civilian healthcare often wait months to be seen by a therapist and longer to see a psychiatrist. When working at the VA, I can ensure my patients’ mental health is supported as soon as I learn it is a challenge for them thanks to the VA’s dedication to the mental health of our veterans. The VA’s effort to help manage mental health challenges among veterans matters. For example, suicides among veterans diagnosed with PTSD decreased by 32% been 2001 and 2022.

What makes medicine different from most other industries is that we don’t deal in money, property, or things. We deal in lives saved, lives lost, and human suffering. What does the shine of the VA hospital floor say about the future of our veterans’ healthcare? Time will tell. Yet, looking at the landscape of US federal budget cuts and executive mandates, people’s access to healthcare in this country is declining. I suspect that it’s only a matter of time before the health effects are felt broadly. Of course, these federal healthcare budget cuts and restrictions are concurrent with cuts in federal funding for research. As a result, we probably won’t be able to quantify the impact politics today had in terms of lives lost and population health deterioration. Perhaps the symbolism of a floor, which one walks all over for their personal benefit, is fitting symbolism for the value current political figures place on the health of others.

References:

  1. VA releases 2024 National Veteran Suicide Prevention Annual Report: https://news.va.gov/137221/va-2024-suicide-prevention-annual-report/

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.

Lost in Delirium

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The patient was sick. On death’s door kind of sick. They were a nice person – treating all the hospital staff with respect. Saying “please” and “thank you.” Cracking jokes even though they were ill. They were articulate. Earlier in their hospital stay we’d discussed God. They believed strongly in the power of God. The patient explained that they were at peace with their life and were ready to join God whenever he called.

Then one night the nurse found the patient completely naked in their room. At that time, the patient couldn’t remember their name. The nurse was able to redirect them, remind them of their name, and put them back to bed. They were embarrassed by the events the next morning. In the morning, they seemed to still understand what was happening around them.

The next night they became confused again. But, this time, they weren’t better by morning. As the days unfolded, they were usually able to tell me their name. They’d lost track of why they were in the hospital or what the plan for the day was. They didn’t know the month or the year. At times they seemed more lucid and at other times they were so confused that they believed they were on a business trip. Occasionally they were angry. But, more often, they looked scared. They were easily frightened because they didn’t know where they were or what was happening to them.

This patient was a classic example of delirium. Delirium is a state of confusion that waxes and wanes. It occurs because of the unfamiliarity of the hospital setting, the disruptive nature of hospital activity, and the stress of being ill.  Every patient in the hospital is at risk of developing delirium during their stay. Some people are at greater risk of delirium – elderly people, severely ill people, and people with underlying brain illness.

Delirium is complex from a medical standpoint. We try to prevent it but everything about the hospital promotes delirium – from frequent sleep disruptions to the unfamiliar setting and faces of the hospital. Preventing delirium involves encouraging family members to visit, minimizing overnight wake ups for medical care (vitals, blood draws, meds, etc.), and frequently reminding patients of where they are and the date. We try hard to ensure lights are off at night and lights are on during the day (and window shades open). Despite precautions, delirium can still develop. The challenge is that we have no good treatment for it. Overcoming delirium involves the same strategies as preventing it and treating the illness that brought patients to the hospital in the first place. Another difficult aspect of delirium is managing it when it causes patients to become agitated.

When patients are lost in delirium they don’t act as they normally would. They are in a state of confusion. They may scream and cry not because they are in physical distress but because they don’t understand what is happening. They might fight hospital staff or try to run away. They might become dangerous to staff or other patients. They might refuse the medical care they need to get better. Sometimes to keep a delirious patient and staff safe we need to use sedating medications. But sedating medications can prolong delirium. It’s a tricky situation.

Delirium is one of those conditions that takes up a lot of my time as a physician and consumes nursing time but is little-known among people who don’t work in healthcare. In the short term, it can negatively impact patients by making it difficult to care for them. In the long term, it may impact patients’ cognition.  

Everyone should know about delirium because the best way to prevent delirium has nothing to do with medicine. Delirium is most successfully prevented by having family/friends at bedside. Patients who have frequent family/friend visits (ideally daily for multiple hours) while in the hospital are less likely to develop delirium. The reason family/friends are so important is that they are familiar faces. They can help patients keep track of night and day. Family/friends help keep patients’ minds engaged in conversation, games, and other shared activities. Engaging the mind helps keep it from getting lost in delirium.

In the US, it is fascinating how many patients don’t have family members or friends visit while they’re in the hospital. There are many reasons for this, but two important ones are the American focus on independence and our geographic distance from relatives. Many Americans can’t help that they live hours from their family (and even their friends). But, in an era of electronic connectivity, don’t forget that your loved ones need you. Try a voice or video call. Call or visit even if your loved one says they’re fine. Your support might be the reason your loved one remembers their name the entire time they’re in the hospital. And that, though seemingly small, might make a world of difference in their recovery.

Meeting in a Common Place

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Over dinner with a non-medical friend they said, “Even though I will inevitably have a heart attack [in relation to their love of ice cream], I’d rather enjoy a short life than live a long miserable life.” They brought this up even though I hadn’t made any comments about health during our meal. I’ve noticed that since becoming a physician family and friends make comments like this about their lifestyle with a frequency that surprises me. It seems that they feel guilty or defensive because they think I might be judging or evaluating the healthfulness of the life they lead. 

Perhaps more important than highlighting that I don’t judge my friends’ lifestyles just because I’m a physician is pointing out that in my role as a physician, I also do not judge my patients’ lifestyles. Society likes to use guilt to control people and create hierarchies of worse and better. Many health and physical attributes have been used to define people as better and worse. The list of such attributes is long; several common examples are weight, cholesterol level, blood sugar level, and brain functioning. Despite this societal tendency, guilt and creating arbitrary lists of good and bad don’t help achieve health, so they are not part of my practice as a physician.  

My job, especially as a primary care physician, is not to make my patients feel guilty or inferior. My job is to help my patients increase their chance of living a long, healthy life. Health is defined, in my mind, as a physical and mental state where a person can do the things they want to do with as little suffering as possible. My goal is to help my patients avoid suffering, illness, and pain from medical conditions and physical injury. Especially in the primary care setting, I provide my patients with recommendations to optimize their health. But my recommendations are recommendations – they are not law, and they are nonbinding.

Science continues to investigate what the optimal lifestyle is to ensure that one avoids illness and lives a long time. Yet, while we know many things, we don’t know what the perfect lifestyle is. Further, research can not account for the complexity of human experience. It is absurd to think that all people can live the same lifestyle. Individuals have different access to resources, different preferences, different priorities, and different realities. There is simply no universal fit for lifestyle.

When I discuss lifestyle with my patients my goal is not to make them start a different life. My goal is to identify reasonable adjustments that have a high chance of improving their health. For example, I might ask a patient about their typical diet. As I learn about their diet, I might offer education tailored to specific goals – such as reducing salt to help control blood pressure, strategies to ensure a stable weight or weight loss, or adjustments to prevent diabetes. I try to identify realistic adjustments because unrealistic suggestions are not likely to happen (by definition). For example, some of my patients only eat out. In those cases, rather than telling them they need to start cooking, I ask about the menus at the restaurants where they frequently eat and offer suggestions to optimize their health based on the menu choices they have. I might ask patients about exercise, tobacco, alcohol, drugs, sleep, stress, and any number of other things. The process remains the same for each: 1) Where is the patient now? 2) Is there some optimization that can be done? 3) What are the small steps and adjustments that can help my patient reach that optimization?

As a physician I meet my patients where they are in terms of their health goals and health situation. I see our relationship as a partnership where I’m an expert and they are advice seekers. Just as people hire financial advisors as experts and planners for their personal finance, physicians are experts and planners for lifelong health. As a physician I relay what research has shown is important for health; help my patients make decisions about specific medications, procedures, and tests; and form a plan for how my patients might optimize their health.

To my friend who thinks everyone who eats ice cream will have a heart attack – that simply isn’t the case. To my friend who thinks a heart attack is trivial – I’ve met hundreds of people who have had heart attacks and even those who survived were changed forever. So, in a general sense my response is, why not consider a middle ground where one can have ice cream and not have a heart attack? Curious how to do that? Consult your primary care doctor; she’s an expert in health and you hired her to help you reach your health goals.

Heat Wave and Other Environmental Concerns

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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.

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/