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‘Into the Covid ICU’: A New Doctor Bears Witness to the Isolation, Inequities of Pandemic


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This week marks a grim milestone: Half a million Americans have died of covid-19. KHN reporter Jenny Gold, in collaboration with Reveal from the Center for Investigative Reporting and PRX, spent eight months following one first-year medical resident working on the front lines of the pandemic.

Dr. Paloma Marin-Nevarez graduated from the Stanford University medical school in June, right before the virus began its second major surge. She’s one of more than 30,000 new doctors who started residencies in 2020. Just weeks after graduating, Marin-Nevarez began training as an ER doctor at Community Regional Medical Center in Fresno, one of the areas in California hardest hit by the pandemic.

Listeners follow Marin-Nevarez as she faces the loneliness and isolation of being a new doctor, working 80 hours a week in the era of masks and physical distancing. She also witnesses the inequality of the pandemic, with Latino, Black and Native American people dying of covid-19 at much higher rates than white people. Marin-Nevarez finds herself surrounded by death and having to counsel families about the loss of loved ones. We view the pandemic through the eyes of a rookie doctor, finding her footing on the front lines of the virus.

Learning to Listen to Patients’ Stories

Waclawa “Joanne” Zak, who now lives in Oxford, Wis., fought in the Polish resistance during World War II. As a teenager, she served as a scout, assessing German troop strength and positions. Later in the war she trained as a nurse and was liberated from a German P.O.W. camp. She told her story as part of the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.
Waclawa “Joanne” Zak, who now lives in Oxford, Wis., fought in the Polish resistance during World War II. As a teenager, she served as a scout, assessing German troop strength and positions. Later in the war she trained as a nurse and was liberated from a German P.O.W. camp. She told her story as part of the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.Credit…Andy Manis for The New York Times

Learning to Listen to Patients’ Stories

Narrative medicine programs teach doctors and other caregivers “sensitive interviewing skills” and the art of “radical listening” to improve patient care.

Waclawa “Joanne” Zak, who now lives in Oxford, Wis., fought in the Polish resistance during World War II. As a teenager, she served as a scout, assessing German troop strength and positions. Later in the war she trained as a nurse and was liberated from a German P.O.W. camp. She told her story as part of the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis.Credit…Andy Manis for The New York Times

  • Feb. 25, 2021, 5:00 a.m. ET

The pandemic has been a time of painful social isolation for many. Few places can be as isolating as hospitals, where patients are surrounded by strangers, subject to invasive tests and attached to an assortment of beeping and gurgling machines.

How can the experience of receiving medical care be made more welcoming? Some say that a sympathetic ear can go a long way in helping patients undergoing the stress of a hospital stay to heal.

“It is even more important now, when we can’t always see patients’ faces or touch them, to really hear their stories,” said Dr. Antoinette Rose, an urgent care physician in Mountain View, Calif., who is now working with many patients ill with Covid.

“This pandemic has forced many caregivers to embrace the human stories that are playing out. They have no choice. They become the ‘family’ at the bedside,” said Dr. Andre Lijoi, a medical director at York Hospital in Pennsylvania. Doctors, nurses and others assisting in the care of patients “need time to slow down, to take a breath, to listen.”

Both doctors find their inspiration in narrative medicine, a discipline that guides medical practitioners in the art of deeply listening to those who come to them for help. Narrative medicine is now taught in some form at roughly 80 percent of medical schools in the United States. Students are trained in “sensitive interviewing skills” and the art of “radical listening” as ways to enhance the interactions between doctors and their patients.

“As doctors, we need to ask those who come to us: ‘Tell me about yourself,’” explained Dr. Rita Charon, who founded Columbia University’s pioneering narrative medicine program in 2000. “We have fallen out of that habit because we think we know the questions to ask. We have a checklist of symptom questions. But there is an actual person in front of us who is not just a collection of symptoms.”

Columbia is currently offering training online for medical students like Fletcher Bell, who says the course is helping to transform the way he sees his future role as healer. As part of his narrative medicine training, Mr. Bell has kept in touch virtually with a woman who was being treated for ovarian cancer, an experience of sharing that he described as being both heartbreaking and also beautiful.

“Simply listening to people’s stories can be therapeutic,” Mr. Bell observed. “If there is fluid in the lungs, you drain it. If there is a story in the heart, it’s important to get that out too. It is also a medical intervention, just not one that can be easily quantified.”

This more personalized approach to medical care is not a new art. In the not-so-distant past, general practitioners often treated several generations of the same family, and they knew a lot about their lives. But as medicine became increasingly institutionalized, it became more rushed and impersonal, said Dr. Charon.

The typical doctor visit now lasts from 13 to 16 minutes, which is generally all that insurance companies will pay for. A 2018 study published in the Journal of General Internal Medicine found that the majority of doctors at the prestigious Mayo Clinic didn’t even ask people the purpose of their visit, and they frequently interrupted patients as they spoke about themselves.

But this fast-food approach to medicine sacrifices something essential, says Dr. Deepu Gowda, assistant dean of medical education at the Kaiser-Permanente School of Medicine in Pasadena, Calif., who was trained by Dr. Charon at Columbia.

Dr. Gowda recalls one elderly patient he saw during his residency who suffered from severe arthritis and whom he experienced as being angry and frustrated. He came to dread her office visits. Then he started asking the woman questions and listened with interest as her personal history unfolded. He became so intrigued by her life story that he asked her permission to take photographs of her outside the hospital, which she granted.

Dr. Gowda was particularly struck by one picture of his patient, cane in hand, clutching onto the banister of her walk-up apartment. “That image represented for me her daily struggles,” he said. “I gave her a copy. It was a physical representation of the fact that I cared for who she was as a person. Her pain didn’t go away, but there was a lightness and laughter in those later visits that wasn’t there before. There was a kind of healing that took place in that simple human recognition.”

While few working doctors have the leisure time to photograph their patients outside the clinic, or to probe deeply into their life history, “people pick up on it” when the doctor expresses genuine interest in them, Dr. Gowda said. They trust such a doctor more, becoming motivated to follow their instructions and to return for follow-up visits, he said.

Some hospitals have started conducting preliminary interviews with patients before the clinical work begins as a way to get to know them better.

Darrell Krenz of Madison, Wis., recounted his Army days as part of the V.A.’s “My Life, My Story” program.Credit…Andy Manis for The New York Times
Orlando Dowell, a 16-year Marine Corps veteran and “My Life, My Story” participant, at his home in Dakota, Ill.Credit…Andy Manis for The New York Times

Thor Ringler, a family therapist, started the “My Life, My Story” program at the William S. Middleton Memorial Veterans Hospital in Madison, Wis., in 2013. Professional writers are hired to interview veterans — by phone and video conference since the onset of the pandemic — and to draft a short biography that is added to their medical record and read by their attending physician.

“My goal was to provide vets with a way of being heard in a large bureaucratic system where they don’t always feel listened to,” Mr. Ringler said.

The program has spread to 60 V.A. hospitals, including in Boston, where more than 800 veteran stories have been compiled over the past three years. Jay Barrett, nurse manager at the VA Boston Healthcare System, said these biographies often provide critical information that can help guide the treatment.

“Unless they have access to the patient’s story,” Ms. Barrett said, “health care providers don’t understand that this is a mother who is taking care of six children, or who doesn’t have the resources to pay for medication, or this is a veteran that has severe trauma that needs to be addressed before even talking about how to manage the pain.”

Dr. Lewis Mehl-Madrona, a family doctor who teaches at the University of New England in Biddeford, Maine, has been studying veterans who were undergoing treatment for pain. Those who were asked to tell about their lives experienced less chronic pain and rated the relationship with their physician higher than those who had not. The doctors who solicited the stories also reported more job satisfaction and were subject to less emotional burnout, which has become an especially worrisome problem during the Covid pandemic.

Demands have never been greater on health care workers’ time. But narrative medicine advocates say that it only takes a few moments to forge an authentic human connection, even when the communication takes place online, as it often does now. Dr. Mehl-Madrona argues that remote videoconferencing platforms like Zoom can actually make it even easier to keep track of vulnerable people and to solicit their stories.

Derek McCracken, a lecturer at Columbia University who helped develop training protocols for using narrative techniques in telehealth, agrees. “Telehealth technology can be a bridge,” he said, “because it’s an equalizer, forcing both parties to slow the conversation down, be vulnerable and listen attentively.”

The critical point for Dr. Mehl-Madrona is that when people are asked to talk about themselves — whether that happens in person or onscreen — they are “not just delivering themselves to the doctor to be fixed. They become actively engaged in their own healing.”

“Doctors can be replaced by computers or by nurses if they think their only role is just to prescribe drugs,” he added. “If we want to avoid the fate of the Dodo bird, then we have to engage in dynamic relationships with patients, we have to put the symptoms in the context of people’s lives.”

Lost on the Frontline: Explore the Database

Journalists from KHN and The Guardian have identified 3,448 workers who reportedly died of complications from covid-19 after they contracted it on the job. Reporters are working to confirm the cause of death and workplace conditions in each case. They are also writing about the people behind the statistics — their personalities, passions and quirks — and telling the story of every life lost.

Explore the updated interactive tool tracking those health worker deaths.

(Note: The previous total announced by The Guardian and KHN was approximately 1,450 health care worker deaths. The new number reflects the inclusion of data reported by nursing homes and health facilities to the federal and state governments. These deaths include the facility names but not worker names. Reporters cross-checked each record to ensure fatalities did not appear in the database twice.)

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Doctors, Facing Burnout, Turn to Self-Care

Dr. Michelle Thompson, a family medicine physician in Ohio, had to convert to seeing her patients via telemedicine overnight.
Dr. Michelle Thompson, a family medicine physician in Ohio, had to convert to seeing her patients via telemedicine overnight.Credit…Dustin Franz for The New York Times

Doctors, Facing Burnout, Turn to Self-Care

A growing number of programs aim to help doctors, nurses and medical students who are struggling with mental health issues during the pandemic.

Dr. Michelle Thompson, a family medicine physician in Ohio, had to convert to seeing her patients via telemedicine overnight.Credit…Dustin Franz for The New York Times

  • Jan. 26, 2021, 5:00 a.m. ET

Dr. Michelle Thompson knows a lot about self-care. A family medicine physician in Vienna, Ohio, she specializes in lifestyle and integrative care, using both conventional and alternative therapies to help her patients heal. She also teaches medical personnel how to prevent and treat burnout.

But despite what she recommends to others, taking care of her own emotional well-being hasn’t been easy during the pandemic.

When the pandemic hit in March, Dr. Thompson, 46, who is also chair of medicine for the University of Pittsburgh Medical Center Horizon regional health service, was seeing about 25 patients a day in her office, whom she had to convert to seeing via telemedicine “overnight,” she said.

In April, she joined an eight-week online mind-body skills program run by Dr. James S. Gordon, founder and executive director of The Center for Mind-Body Medicine, which since its founding in 1991 has trained nearly a thousand health care professionals in various self-care measures that they can use in their practices. Dr. Gordon, a psychiatrist, started the skills group earlier this year to help doctors and other health care workers cope with the extra demands and psychological suffering the pandemic has brought. The program included weekly Zoom calls with others on the front lines, along with meditative exercises like drawing pictures, visualizations and guided imagery.

“It allowed me two hours a week to check in with myself and share my experience with other health care professionals who could relate to the overwhelm and intensity of the pandemic,” Dr. Thompson said. “I never realized the power of group support.”

Physician burnout has long been a serious concern in the medical community, with roughly 400 doctors dying by suicide each year in the United States. The issue of pandemic burnout among physicians came to the forefront in the early months of the pandemic following the death of Dr. Lorna M. Breen, who supervised the emergency department at New York-Presbyterian Allen Hospital in Manhattan. Dr. Breen, who had been sick with Covid but working remotely, was later admitted to a psychiatric ward for 10 days. Fearing the professional repercussions of her mental health treatment, she took her own life in April.

“She was overwhelmed with the volume of death and dying, and she could not keep up,” said her brother-in-law, Corey Feist, a lawyer in Charlottesville, Va. “The industry needs a big cultural change.”

Mr. Feist and his wife, Jennifer Feist, Dr. Breen’s sister, have since co-founded the Dr. Lorna Breen Heroes’ Foundation, a nonprofit dedicated to protecting the emotional well-being of health care workers. The Feists also worked with politicians and a cross section of health care industry experts to develop the Dr. Lorna Breen Health Care Provider Protection Act, which aims to reduce and prevent burnout, mental and behavioral health conditions and suicide among health care professionals.

Dr. Thompson teaches medical personnel how to prevent burnout, but learning how to take care of herself during the pandemic has been a challenge.
Dr. Thompson teaches medical personnel how to prevent burnout, but learning how to take care of herself during the pandemic has been a challenge.Credit…Dustin Franz for The New York Times

An October poll of 862 emergency physicians nationwide from the American College of Emergency Physicians and Morning Consult found that 87 percent felt more stressed since the onset of Covid-19, with 72 percent experiencing a greater degree of professional burnout. Concerns about family, friends and their own health were among their chief concerns, along with financial and job security and a lack of personal protective equipment. Yet consistent with a longstanding stigma surrounding physician mental health, 45 percent weren’t comfortable seeking mental health treatment, citing concerns about workplace stigma and fear of professional reprisal.

The American Psychiatric Association, the American Medical Association and other professional groups, have formal statements against punishing doctors who seek mental health treatment. The Americans With Disabilities Act, which prohibits discrimination based on disability, including psychiatric disability, applies to professional licensing bodies. Still, the stigma persists.

A growing number of organizations and programs have taken up the charge to help doctors, nurses, residents, interns and medical students who are struggling with mental health issues.

Columbia University, for example, created CopeColumbia for employees of Columbia University Irving Medical Center. Another program called #FirstRespondersFirst, from the Harvard T.H. Chan School of Public Health, Thrive Global, and the CAA Foundation, recently unveiled its new mental health initiative, designed to provide support to health care workers in the United States and abroad. The Frontline Workers Counseling Project includes some 500 volunteer therapists in the San Francisco Bay Area, while the Physician Support Line, started in late March, is a free, national support line of some 700 volunteer psychiatrists who provide peer support.

A Body Mind Skills group helped Dr. Thompson to take time out for her own needs.Credit…Dustin Franz for The New York Times

“Part of the healing for me is helping other people,” said Dr. Lois Kroplick, a psychiatrist in private practice in Pomona, N.Y., who co-ran a weekly support group for psychiatrists and psychologists at Garnet Health Medical Center, in Middletown, N.Y., and volunteered with the Physician Support Line. During this same period, Dr. Kroplick lost her first grandchild and mother-in-law. “The best way to cope with my own grief was to help others,” she said.

Doctors recognize the growing need for mental health help for others, and for themselves. And as the infection rate continues to climb, many health care workers feel torn between their duty to help patients while also caring for themselves.

Elizabeth M. Goldberg is an associate professor of emergency medicine at Brown University, in Providence, and an emergency room physician. “In March and April there was this sense that you choose either your patients or yourself and it was your expectation to be there,” said Dr. Goldberg, 38, who has three young children. “Many of us wanted to be there, but I did experience fear and anxiety about going to work.”

She attended a free support group for health care workers, which she had never done before. “It was great hearing other people share similar experiences I had of not sleeping well and worrying about our family’s health and talking openly about our anxiety and fear of contracting the illness,” she said.

Kathleen S. Isaac, 32, clinical assistant professor at NYU Langone Health who is also in private practice in New York, created a weekly support group in June for her residents. But not many doctors showed up. Part of that she attributes to time constraints and demanding schedules, but also that many were simply trying to be stoic and power through.

“Asking for help is less stigmatized in the psychological community, but sometimes I think there’s a sense of ‘I’m fine, I know what I’m doing,’” she said. “There’s such a culture of perfectionism, and it’s so competitive that people want to present their best self. It’s harder to admit they’re struggling.”

This applies in her own life, too. She talks to friends and colleagues, exercises, goes to therapy and admits to binge-watching the sitcom “That’s So Raven” to help her unwind.

As for Dr. Thompson, she credits the Body Mind Skills group with helping her change her own self-care routine, checking in with herself hourly. “I ask myself, ‘What do I need? How am I caring for myself in this moment? Do I need a cup of tea? Should I implement some mind-body medicine?’” she said.

This might include soft belly breathing, dancing, mindful eating or just heading outside to get a breath of fresh air. “Maybe I just need to use the restroom and need to make time for simple basic self-care needs,” she said.

“This has been the hardest time of my life, and I am super grounded and really well balanced,” she added. “I am doing OK, but it is constant work and making sure I’m staying aware of my own self.”

When the Cancer Doctor Leaves

Doctors

When the Cancer Doctor Leaves

I knew how difficult it would be to tell my colleagues I was leaving for a new job. I didn’t anticipate how hard it would be to tell my patients.

Credit…Aaron Josefczyk/Reuters

  • Jan. 14, 2021, 5:00 a.m. ET

“I’ve known you since 2003,” my patient reminded me, after I had entered the examination room and took my usual seat a few feet away from her. She was sitting next to her husband, just as she had been at her first visit 17 years earlier, and both wore winter jackets to withstand the sleet that Cleveland had decided to dump on us in late October. “That was when I first learned I had leukemia,” she added. He nodded dutifully, remembering the day.

I was freshly out of my fellowship training in hematology-oncology back then, and still nervous every time I wrote a prescription for chemotherapy on my own, without an attending’s co-signature. In her case, it was for the drug imatinib, which had been on the market only a couple of years.

At the time, a study had just reported that 95 percent of patients who had her type of leukemia and who were treated with the drug imatinib achieved a remission. But on average, patients in that study had been followed for just a year and a half, so I couldn’t predict for her how long the drug might work in her case.

Seventeen years later, she was still in a remission. During that time, she had retired from her job as a nurse, undergone a couple of knee replacements, and had a cardiac procedure to treat her atrial fibrillation.

“You had a toddler at home,” she reminded me. That son was now in college. “And then your daughter was born the next year. And you had another boy, right?”

I nodded, and in turn reminded her of the grandchildren she had welcomed into the world during the same time. We had grown older together. Then we sat quietly, staring at each other and enjoying the shared memories.

“I can’t believe you’re leaving me,” she said softly.

When I decided to take a new job in Miami, I knew how difficult it would be to tell the other doctors, nurses, pharmacists and social workers I work with, the team from whom I had learned so much and relied upon so heavily for years.

I didn’t anticipate how hard it would be to tell my patients.

For some with longstanding, chronic cancers, it was like saying goodbye to a beloved friend or a comrade-in-arms, as if we were reflecting on having faced down an unforgiving foe together, and had lived to tell about it.

For others, still receiving therapy for a leukemia that had not yet receded, I felt as if I were betraying them in medias res. I spent a lot of time reviewing their treatment plans and reinforcing how I would transition their care to another doctor, probably more to reassure myself than my patients, that they would be OK.

A few were angry. Unbeknownst to me, my hospital, ever efficient, had sent out a letter informing patients of my departure and offering the option to choose any one of eight other doctors who could assume their care — even before I had a chance to tell some of them in person. How were they expected to choose, and why hadn’t I told them I was leaving, they demanded indignantly.

I felt the same way as my patients, and quickly sent out my own follow-up letter offering to select a specialist for their specific types of cancer, and telling my patients I would miss them.

I then spent weeks apologizing, in person, for the first letter.

And though I always tell my patients the best gift I could ever hope for is their good health, many brought presents or cards.

One man in his 60s had just received another round of chemotherapy for a leukemia that kept coming back. I think we both knew that the next time the leukemia returned, it would be here to stay. When I entered his examination room, he greeted me where my other patient had left off.

“I can’t believe you’re leaving me.”

Before I could even take a seat, he handed me a plain brown bag with some white tissue paper poking out of the top and urged me to remove its contents.

Inside was a drawing of the steel truss arches of Cleveland’s I-90 Innerbelt bridge, with the city skyline rising above it.

“It’s beautiful,” I told him. “I don’t know what to say.”

“You can hang this on your office wall in Miami,” he suggested, starting to cry. “So you’ll always remember Cleveland.” And then, Covid-19 precautions be damned, he walked over and gave me a huge bear hug. After a few seconds we separated.

“No,” I said, tearing up. “I’ll hang up the picture and always remember you.”

Mikkael Sekeres (@mikkaelsekeres), formerly the director of the leukemia program at the Cleveland Clinic, is the chief of the Division of Hematology, Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine and author of When Blood Breaks Down: Life Lessons From Leukemia.”

The Covid Balancing Act for Doctors

Doctors

The Covid Balancing Act

At the start of the pandemic, I was “Dr. No” to my in-laws and cancer patients, but my conversations have become more nuanced.

Credit…Getty Images

  • Jan. 7, 2021, 5:00 a.m. ET

My wife’s parents have led a relatively monastic existence since about mid-March.

Both are in their 80s and live independently in rural Pennsylvania, maintaining a three-acre property by themselves. My father-in-law, the older of the two, has skirted major medical problems despite a decades-long indiscriminate diet, a testimony to the triumph of genetics over lifestyle choices. My mother-in-law, on the other hand, has been ravaged by lupus, which flares regularly and requires medications that suppress her immune system.

So when Covid-19 hit, we feared for their health, given their ages and her compromised immunity, and begged that they place themselves on lockdown, so we wouldn’t lose them to the pandemic.

And they did.

Where they used to buy groceries at their local Giant Eagle supermarket (which they call the “Big Bird,”) they turned instead to Instacart for home delivery, shrugging off the random items their shopper would get wrong with good humor.

Where they used to attend church in person every Sunday, they caught the video highlights online when they became available on Monday morning.

We arranged weekly Zoom calls with them, to replace our frequent visits.

We used to say that their social life rivaled ours, as they got together with friends they have known since kindergarten (kindergarten!) several times each week for dinner, drinks or shows. Instead, during the pandemic, they’ve replaced those social events with going cruising together in their blue ’55 Chevy Bel Air, satisfying themselves with the feel of a car they first drove in their teens, the beautiful countryside and a wave at their friends, who sat at a safe distance on their front porches.

Our whole family has been proud of them to the point of bursting. But in September, after six months of this, my father-in-law got antsy and did the unthinkable: He went to the hardware store, ostensibly for a tool, but really to see his friends who tend to congregate there.

He caught hell for his modest indiscretion, first from his wife, and then from mine. They explained to him that he could have ordered the piece online. They reminded him that his actions can affect my mother-in-law, and her frail health, too. Finally, he had enough.

“I’m 85 years old,” he said. “Eighty-five! I’m careful, I wore a mask. What do you expect me to do, spend the rest of my days here in prison?”

That gave me pause — my wife, too. At 85, he had done the math. Despite his lucky genetics, he probably didn’t have many years left on this earth, and he didn’t want to spend one or two of them in isolation.

Understanding the risks and consequences of his actions, shouldn’t he be allowed to see his buddies at the hardware store, and maybe buy a tool while he’s there?

I thought about it from the perspective of my patients, many of whom also don’t have much time left on this earth, and the conversations we had been having in clinic.

At the beginning of the pandemic, I was “Dr. No,” prohibiting my patients, most of whom have devastated immune systems, from engaging in their usual social activities. Where much of what we had all been hearing from government authorities about Covid-19 transmission had often been contradictory, I wanted to give concrete advice.

Attending a family gathering to celebrate a birthday? No.

How about a high school graduation party for a granddaughter? No.

Visiting elderly parents in another state? Not safe for you or them.

A road trip to Montana with a friend (this from a man in his 80s with leukemia): Are you kidding me?

At the risk of sounding paternalistic, I feared for my patients’ health, as I did for my in-laws’ health, and wanted to protect them.

But perhaps because our understanding of Covid-19’s epidemiology has gotten better over time; or with our recognition that we may have to live with the pandemic for many months more; or given my father-in-law’s perspective that people at the end of life should make their own risk-benefit calculations, my conversations have now become more nuanced.

I’m more open to my patients not missing important life events, when there may not be much life for them left, provided they take precautions to avoid endangering themselves or those around them, particularly amid the most recent surge in Covid-19 cases.

One woman with leukemia was receiving chemotherapy early in 2020 when her daughter had a miscarriage. Now that her daughter is eight months pregnant again, can she hold the baby when it is born? Absolutely, let’s talk about how to do it safely.

Another patient’s mother died. Can she attend the funeral? Yes, with appropriate distancing, limited numbers, and personal protective equipment. But skip the reception.

The road trip to Montana? I still wasn’t comfortable with that, but my patient and his friend went anyway, took their own food, slept in their truck, and he returned without Covid-19.

And my father-in-law? He gets out of the house a little bit more than he used to, but not as much as he’d like. The rare times that he does nowadays, he is always masked and stays outdoors, and both he and my mother-in-law remain Covid-19-free.

Which strikes me as about the right balance.

Mikkael Sekeres (@mikkaelsekeres) is the chief of the Division of Hematology, Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine and author of When Blood Breaks Down: Life Lessons from Leukemia.”

A Night in the Hospital, From Both Ends of the Stethoscope

Doctors

A Night in the Hospital, From Both Ends of the Stethoscope

As a doctor writing about medical errors, I saw potential risks lurking everywhere when my daughter was hospitalized with appendicitis.

Credit…Xiao Hua Yang

  • Jan. 5, 2021, 5:00 a.m. ET

Just as the first coronavirus reports were emerging from China in late 2019, the medical world was observing the 20th anniversary of “To Err is Human,” the seminal report from the Institute of Medicine that opened our eyes to the extent of medical error. The news media jumped on the popular aviation metaphor, that the number of Americans dying each year as a result of medical error was the equivalent of a jumbo jet crashing every day. Those numbers remain difficult to accurately quantitate, but we know that they are not small.

The conversation has now been broadened to include all preventable harms to patients, even ones that are not errors per se. As I set about writing a book on medical error, I wanted to see both sides of the story. I drew upon my own experiences as a physician but also interviewed patients and families to get the view from the other side. But I soon realized that the distinction between those two “sides” was rather fluid.

Midway through writing the book, my teenage daughter experienced a stomachache. My kids know that fevers, colds, coughs and sprained ankles do not get my pulse up, and that “if you’re not bleeding out or in cardiac arrest” they should seek medical sympathy from their computer programmer father. They often accuse me of ignoring their medical complaints altogether, but as a primary care doctor I know that most aches and pains of daily life get better on their own and are best left unobsessed about.

But this time I became suspicious of my daughter’s inability to find a comfortable position and so pulled out my stethoscope. When I heard complete silence instead of gurgling bowel sounds, I shuttled us straight to my hospital’s E.R. My correct diagnosis of appendicitis modestly redeemed me in my daughter’s eyes, though she was mortified that I chatted it up with colleagues.

Surgery was planned for the next morning, so I stayed in her hospital room overnight, reading the stack of journal articles I’d been reviewing for my book. Hospitals have always been a comfortable setting for me, but the familiar ward suddenly felt apocalyptic, with medical errors and harms lurking everywhere. The population of a midsize city traipsed in and out of my daughter’s room that night, each armed with potentially dangerous things to administer or extricate. And even if they were all batting 99 percent, the denominator of “things” was so enormous that some amount of error was all but guaranteed.

When the pediatric resident arrived at 3 a.m. to assess my daughter — after she’d been evaluated by the triage nurse, the E.R. resident, the E.R. attending, the surgery resident, the surgery chief, and then the surgery attending — I put my foot down.

“She’s on pain meds now,” I hissed, “so you won’t find any abdominal tenderness. And the ultrasound already showed an inflamed appendix.” The resident eyed me warily, clearly calculating the risk/benefit ratio of pressing her case with an ornery, sleep-deprived parent.

“But if you are going to wake her up, jab on her belly, and then come to the grand conclusion that she has appendicitis and needs surgery, forget about it,” I snapped. The resident backed off, and I flopped back into my chair to read yet another cheery article about medical calamities.

The surgery team came by with another option: giving just IV antibiotics, with no operation. With antibiotics alone, they said, there was a 50 percent chance of appendicitis recurring. Which meant that for half the patients, surgery could be avoided altogether. But we had to decide right away so they could know whether to book the O.R.

I asked the surgery resident how strong the data were. I wasn’t going to make a half-baked decision just because he was time-pressed to set the O.R. schedule. He groaned mightily but stood by while I searched up some studies. The data were preliminary but seemed encouraging.

Just getting a flu shot reduces my daughter to a sobbing mess huddled in my lap even though she’s a head taller than me. So I was sure she’d jump at the chance to avoid surgery.

It turned out that she had an utterly different take. The experience of getting an IV in the E.R. was so miserable that she never wanted to repeat it. The definitiveness of surgery was much more appealing than the possibility — however small — of going through this again in the future.

The next morning, that dangly tail of residual colon was successfully snipped. When my daughter was coming out of anesthesia, I asked her if she’d like some Toradol, the pain medication that the nurse was offering. “Tortellini?” she mumbled foggily. “Are we having tortellini?”

I was impressed, yet again, by the marvels of modern medicine, knowing full well that had this taken place a century earlier I might have been digging a grave for my child that evening instead of digging through the freezer for tortellini.

As a physician, I’m stunningly proud of the medical care our hospitals can provide. But during our stay as civilians, every aspect felt like harm waiting to happen. I’m sure I ruffled a few feathers with all of my questions, but addressing family members’ worries is part of the job — even if the family member isn’t a physician, and isn’t on the faculty of that institution, and doesn’t coincidentally happen to be writing a book about medical error while sitting at the bedside.

It’s not comfortable being the squeaky wheel. Being on guard for my daughter 24/7 was frankly exhausting. But once you are on the patient side of the stethoscope, everything looks like a minefield.

Of course, the burden should not have to be on the patient or family for ensuring safe medical care. That is the job of the health care system. But as we well know, the system has not yet achieved pristine perfection, so it behooves patients and families to stay engaged as much as possible.

The Covid-19 pandemic has surely demonstrated the professionalism of health care workers. But even the most dedicated staff need extra sets of eyes on the ground.

My advice to patients is to be polite but persistent. Don’t let unspoken annoyance deter you. Offer appreciation for the things that are going well — and acknowledge that everyone is working hard! — but plow forward. At the very least, ask what each medication is and why you are getting it.

And if you are too nauseated or too sleepy or too feverish, don’t rack yourself with guilt because you are not interrogating every staff member. Get the rest you need. Before you doze off, though, use some leftover surgical tape to affix a sign across your chest that says “Wash your hands!”

The onus is on the medical system to make health care as safe as possible. But patients and families shouldn’t feel shy about taking a forthright role. Keeping those jumbo jets from falling out of the sky is a team effort, and the team includes the folks on both ends of the stethoscope.

Dr. Danielle Ofri practices at Bellevue Hospital in New York City and is a clinical professor of medicine at New York University. Her newest book is “When We Do Harm: A Doctor Confronts Medical Error.”

After a Covid-19 Semester, College Doctors Reflect on Sports

The Checkup

After a Covid-19 Semester, College Doctors Reflect on Sports

Weighing the risks and benefits of participating in sports against the larger public health factors.

Members of the University of Southern California Trojans college basketball team during a game against the California Baptist Lancers last month.
Members of the University of Southern California Trojans college basketball team during a game against the California Baptist Lancers last month.Credit…Brian Rothmuller/Icon Sportswire via Getty Images

  • Dec. 14, 2020, 4:18 p.m. ET

My latest column, about the American Academy of Pediatrics’ new guidance on youth sports in the time of Covid, drew two very different sets of parental responses. The guidance emphasizes the importance of wearing face coverings, and also the importance of making sure that any young athletes who have had Covid infections — even asymptomatic infections — are checked out medically before they return, gradually, to full activity.

Some readers were shocked and horrified that youth sports and college sports are going on at all, even with face coverings; to some parents, that is the very definition of unnecessary risk, with players, coaching staff, perhaps parents and even spectators congregating, with the possibility of close physical contact and heavy breathing. Others were shocked and horrified at the idea of asking athletes to wear face coverings during exercise.

Those are not equivalent reactions, or at least not from my point of view. To weigh and measure the risks of participating in athletics, or to think about how to modify the normal athletic schedule to reduce infections are aspects of thinking sensibly around public health risks and benefits. That’s very different from refusing to acknowledge the increasing body of evidence that face coverings protect everyone — the wearer and the wearer’s contacts, and are safe during exercise.

It’s been a semester like no other, and I asked some people who have been taking care of the health of college athletes what they’ve learned and what they’ll be taking forward into the unknown territory of the winter and the spring.

A New York Times analysis released Friday found that more than 6,600 college athletes, coaches and staff members had tested positive for the coronavirus, and there have been reports of spectators behaving in risky ways.

To many people, intercollegiate competition, with attendant travel risks, by definition brings up highly problematic issues of university priorities, and the risks that students are asked to take.

“It’s not reasonable to ask adolescents and young adults to take on additional risks for the enjoyment of spectators and the financial gain of their universities,” said Dr. Adam Ratner, the director of pediatric infectious diseases at New York University School of Medicine and Hassenfeld Children’s Hospital at N.Y.U. Langone Health.

There are places where athletes have been exempt from campus shutdowns, he said: “Everyone is used to there being a different set of rules for athletic programs at universities,” and it’s particularly troubling to see that playing out in a pandemic.

What happens with a college’s sports program has to be seen as part of the larger question of what happens with campus life — whether the dorms are open, whether classes are happening, and whether there is an effective plan in place for limiting exposures and testing for infections.

While some conferences — the Ivy League, for example — have canceled their seasons, there are places that have kept their sports programs going even though they decided it was too dangerous to teach in the classroom, said Marc Edelman, a professor of law at Baruch College who consults on sports-related legal issues, and was the lead author on an article on college sports in the time of Covid in the Michigan State Law Review.

Basketball season, which will be indoors, will be even more dangerous than football season from the point of view of infections, he said.

“These schools have reached the conclusion, right or wrong, that because of the risks of the virus, students should be at home with their families, studying on Zoom,” Mr. Edelman said. “But they’re willing to take a small number of students, who are disproportionately minorities, and fly them back and forth across the country to compete in sporting events indoors because it’s revenue-generating. Ethically, that’s appalling, and logically it doesn’t make sense.”

Other colleges and universities, which do have students on campus and in the classroom, have modified their athletic seasons and the rules they expect their athletes to follow, amid changing information about the virus and its effects, different sports with different degrees of potential exposure, and a changing social landscape.

Dr. Peter Dean, a pediatric cardiologist who is the team cardiologist for University of Virginia athletes, noted, for example, that at the beginning of the epidemic, as it became clear that Covid infection could cause inflammation of the heart in adults, no one in pediatric cardiology knew what the implications were for children and adolescents. Now, cardiologists are much more focused on checking out those athletes who have had moderate or severe Covid infection, or who have persistent symptoms such as chest pain, fatigue or palpitations. “What we’re doing now seems to be working to protect athletes’ hearts,” said Dr. Dean, who sits on the American College of Cardiology sports and exercise leadership committee; so far, there have not been reports of unexpected cardiac events on the athletic field.

Dr. Dean said that in his experience, the students involved in fall sports had been particularly careful to follow the rules about reducing possible Covid exposure. “The fall sport athletes have something to lose, they’re being safe, not going to parties,” he said. “They want to play,” and they know that if they test positive, they can’t.

His colleague Dr. James Nataro, the chairman of pediatrics at the University of Virginia, who is a pediatric infectious diseases expert who studies emerging infections, said that the university, which had students on campus and held in-person classes in the fall, generally did well. “Against almost every prediction, the students complied, the students were just wonderful,” he said.

The school is part of the Atlantic Coast Conference, which modified its schedule to include more in-conference games, Dr. Nataro said, and spectators were kept to a minimum. Still, he said, it was clear, watching football games, that “there were lots of opportunities for transmission,” and some of the good results may have been a matter of luck. And though he himself loves football, he said, he worries about “the lesson it sends if people turn on the TV and watch all these guys without masks standing next to each other — that image isn’t lost.”

Some of the schools that canceled or curtailed their sports seasons were those that do not generate significant revenue from televised games.

Dr. Thomas McLarney, the medical director of Davison Health Center at Wesleyan University, which is a Division III school, said that for fall sports that involve close contact — football, lacrosse, soccer — the teams practiced and worked on their skills, but they did not play against other teams and “did not scrimmage even with themselves.”

In sports like tennis, where strict distancing is possible, he said, there was some opportunity for Wesleyan’s athletes to play — sometimes wearing masks while playing outside. For swimmers, the locker room was taken out of the equation; students changed in their dorm rooms, and then dried off as best they could when they got out of the pool, before going back to their rooms to change back (it helped that it was a relatively warm fall).

“I thought our plan was very good,” Dr. McLarney said, but of course, the plan was only good if the students followed it. “Our students were extremely compliant, I give these folks so much credit,” he said, adding that he was annoyed to come home and turn on the evening news, only to see stories about students taking risks.

Student athletes, Dr. McLarney said, “were hungry for being with other athletes, and we felt we could provide that to some extent — they would rather be out mixing with other teams, but they understood, it’s a pandemic.” Wesleyan is a member of the New England Small College Athletic Coalition, which made the decision in October to cancel winter sports as well, because of pandemic concerns.

“It’s hard,” Dr. Dean said. “We didn’t learn about this in medical school.”

Doctors and Nurses Are Running on Empty

About 2 a.m. on a sweltering summer night, Dr. Orlando Garner awoke to the sound of a thud next to his baby daughter’s crib. He leapt out of bed to find his wife, Gabriela, passed out, her forehead hot with the same fever that had stricken him and his son, Orlando Jr., then 3, just hours before. Two days later, it would hit their infant daughter, Veronica.

Nearly five months later, Dr. Garner, a critical care physician at the Baylor College of Medicine in Houston, is haunted by what befell his family last summer: He had inadvertently shuttled the coronavirus home, and sickened them all.

“I felt so guilty,” he said. “This is my job, what I wanted to do for a living. And it could have killed my children, could have killed my wife — all this, because of me.”

With the case count climbing again in Texas, Dr. Garner has recurring nightmares that one of his children has died from Covid. He’s returned to 80-hour weeks in the intensive care unit, donning layers of pandemic garb including goggles, an N95 respirator, a protective body suit and a helmet-like face shield that forces him to yell to be heard.

As he treats one patient after another, he can’t shake the fear that his first bout with the coronavirus won’t be his last, even though reinfection is rare: “Is this going to be the one who gives me Covid again?”

Frontline health care workers have been the one constant, the medical soldiers forming row after row in the ground war against the raging spread of the coronavirus. But as cases and deaths shatter daily records, foreshadowing one of the deadliest years in American history, the very people whose life mission is caring for others are on the verge of collective collapse.

In interviews, more than two dozen frontline medical workers described the unrelenting stress that has become an endemic part of the health care crisis nationwide. Many related spikes in anxiety and depressive thoughts, as well as a chronic sense of hopelessness and deepening fatigue, spurred in part by the cavalier attitudes of many Americans who seem to have lost patience with the pandemic.

“This is my job, what I wanted to do for a living. And it could have killed my children, could have killed my wife — all this, because of me,” said Dr. Orlando Garner, a critical care physician in Houston.
“This is my job, what I wanted to do for a living. And it could have killed my children, could have killed my wife — all this, because of me,” said Dr. Orlando Garner, a critical care physician in Houston.Credit…Michael Starghill Jr. for The New York Times

Surveys from around the globe have recorded rising rates of depression, trauma and burnout among a group of professionals already known for high rates of suicide. And while some have sought therapy or medications to cope, others fear that engaging in these support systems could blemish their records and dissuade future employers from hiring them.

“We’re sacrificing so much as health care providers — our health, our family’s health,” said Dr. Cleavon Gilman, an emergency medicine physician in Yuma, Ariz. “You would think that the country would have learned its lesson” after the spring, he said. “But I feel like the 20,000 people that died in New York died for nothing.”

Many have reached the bottom of their reservoir, with little left to give, especially without sufficient tools to defend themselves against a disease that has killed more than 1,000 of them.

“I haven’t even thought about how I am today,” said Dr. Susannah Hills, a pediatric head and neck surgeon at Columbia University. “I can’t think of the last time somebody asked me that question.”

Dreading the darkness of winter

For Dr. Shannon Tapia, a geriatrician in Colorado, April was bad. So was May. At one long-term care facility she staffed, 22 people died in 10 days. “After that number, I stopped counting,” she said.

A bit of a lull coasted in on a wave of summer heat. But in recent weeks, Dr. Tapia has watched the virus resurge, sparking sudden outbreaks and felling nursing home residents — one of the pandemic’s most hard-hit populations — in droves.

“This is much, much worse than the spring,” Dr. Tapia said. “Covid is going crazy in Colorado right now.”

Dr. Tapia bore witness as long-term care facilities struggled to keep adequate protective equipment in stock, and decried their lack of adequate tests. As recently as early November, diagnostic tests at one home Dr. Tapia regularly visits took more than a week to deliver results, hastening the spread of the virus among unwitting residents.

Some nursing home residents in the Denver area are getting bounced out of full hospitals because their symptoms aren’t severe, only to rapidly deteriorate and die in their care facilities. “It just happens so fast,” Dr. Tapia said. “There’s no time to send them back.”

The evening of Nov. 17, Dr. Tapia fielded phone call after phone call from nursing homes brimming with the sick and the scared. Four patients died between 5 p.m. and 8 a.m. “It was the most death pronouncements I’ve ever had to do in one night,” she said.

Before the pandemic, nursing home residents were already considered a medically neglected population. But the coronavirus has only exacerbated a worrisome chasm of care for older patients. Dr. Tapia is beleaguered by the helplessness she feels at every turn. “Systematically, it makes me feel like I’m failing,” she said. “The last eight months almost broke me.”

At the end of the summer, Dr. Tapia briefly considered leaving medicine — but she is a single parent to an 11-year-old son, Liam. “I need my M.D. to support my kid,” she said.

Dr. Shannon Tapia, a geriatrician based in Denver, mourns the nursing home residents she cares for. “It just happens so fast,” Dr. Tapia said of patients whose conditions deteriorated after being discharged from hospitals. “There’s no time to send them back.”Credit…Daniel Brenner for The New York Times

It goes on and on and on

For others, the slog has been relentless.

Dr. Gilman, the emergency medicine physician in Yuma, braced himself at the beginning of the pandemic, relying on his stint as a hospital corpsman in Iraq in 2004.

“In the military, they train you to do sleep deprivation, hikes, marches,” he said. “You train your body, you fight an enemy. I began running every day, getting my lungs strong in case I got the virus. I put a box by the door to put my clothes in, so I wouldn’t spread it to my family.”

The current crisis turned out to be an unfamiliar and formidable foe that would follow him from place to place.

Dr. Gilman’s first coronavirus tour began as a resident at New York-Presbyterian at the height of last spring. He came to dread the phone calls to families unable to be near their ailing relatives, hearing “the same shrill cry, two or three times per shift,” he said. Months of chaos, suffering and pain, he said, left him “just down and depressed and exhausted.”

“I would come home with tears in my eyes, and just pass out,” he said.

The professional fallout of his Covid experience then turned personal.

Dr. Gilman canceled his wedding in May. His June graduation commenced on Zoom. He celebrated the end of his residency in his empty apartment next to a pile of boxes.

“It was the saddest moment ever,” he said.

Within weeks, he, his fiancée, Maribel, their two daughters and his mother-in-law had relocated to Arizona, where caseloads had just begun to swell. Dr. Gilman hunkered down anew.

They have weathered the months since in seclusion, keeping the children out of school and declining invitations to mingle, even as their neighbors begin to flock back together and buzz about their holiday plans.

There are bright spots, he said. The family’s home, which they moved into this summer, is large, and came with a pool. They recently adopted a puppy. Out in the remoteness of small-town Arizona, the desert has delighted them with the occasional roadrunner sighting.

Since the spring, Dr. Gilman has become a social media tour de force. To document the ongoing crisis, he began publishing journal entries on his website. His Twitter wall teems with posts commemorating people who lost their lives to Covid-19, and the health workers who have dedicated the past nine months to stemming the tide.

It’s how he has made sense of the chaos, Dr. Gilman said. What he’s fighting isn’t just the virus itself — but a contagion of disillusionment and misinformation, amid which mask-wearing and distancing continue to flag. “It’s a constant battle, it’s a never-ending war,” he said.

Reaching the breaking point

Nurses and doctors in New York became all too familiar with the rationing of care last spring. No training prepared them for the wrath of the virus, and its aftermath. The month-to-month, day-to-day flailing about as they tried to cope. For some, the weight of the pandemic will have lingering effects.

Shikha Dass, an emergency room nurse at Mount Sinai Queens, recalled nights in mid-March when her team of eight nurses had to wrangle some 15 patients each — double or triple a typical workload. “We kept getting code after code, and patients were just dying,” Ms. Dass said. The patients quickly outnumbered the available breathing support machines, she said, forcing doctors and nurses to apportion care in a rapid-fire fashion.

“We didn’t have enough ventilators,” Ms. Dass said. “I remember doing C.P.R. and cracking ribs. These were people from our community — it was so painful.”

“We’re there to save a person, save a life, stabilize a person so they can get further management,” said Shikha Dass, an emergency room nurse at Mount Sinai Queens. “And here I am, not able to do that.”Credit…Kholood Eid for The New York Times

Ms. Dass wrestled with sleeplessness and irritability, sniping at her husband and children. Visions of the dead, strewn across emergency room cots by the dozens, swam through her head at odd hours of the night. Medical TV dramas like Grey’s Anatomy, full of the triggering sounds of codes and beeping machines, became unbearable to watch. She couldn’t erase the memory of the neat row of three refrigerated trailers in her hospital parking lot, each packed with bodies that the morgue was too full to take.

One morning, after a night shift, Ms. Dass climbed into her red Mini Cooper to start her 20-minute drive home. Her car chugged onto its familiar route; a song from the 2017 film “The Greatest Showman” trickled out. For the first time since the pandemic began, Ms. Dass broke down and began to cry. She called her husband, who was on his way to work; he didn’t pick up. Finally, she reached her best friend.

“I told her, ‘These people are not going to make it, these people are not going to survive this,’” she said. “We’re there to save a person, save a life, stabilize a person so they can get further management. And here I am, not able to do that.”

Shortly after, she phoned a longtime friend, Andi Lyn Kornfeld, a psychotherapist who said Ms. Dass was in the throes of “absolute and utter acute PTSD.”

“I have known Shikha for 13 years,” Ms. Kornfeld said. “She is one of the strongest women I have ever met. And I had never heard her like this.”

The sounds of silence

Long gone are the raucous nightly cheers, loud applause and clanging that bounced off buildings and hospital windows in the United States and abroad — the sounds of public appreciation at 7 each night for those on the pandemic’s front line.

“Nobody’s clapping anymore,” said Dr. Jessica Gold, a psychiatrist at Washington University in St. Louis. “They’re over it.”

Health workers, once a central part of the coronavirus conversation, have in many ways faded into the background. Some, like Dr. Gilman, in Arizona, have had their salaries slashed as hospitals weigh how to cover costs.

Many have guiltily recoiled from the “hero” label emblazoned in commercials or ad campaigns, burdened by the death march of the people they could not save and the indiscriminate path of the coronavirus.

The word “hero” evokes bravery and superhuman strength but leaves little room for empathy, said Dr. Nicole Washington, a psychiatrist in Oklahoma. When portrayed as stalwart saviors, health workers “don’t have the room or right to be vulnerable.”

But the trope of invincibility has long been ingrained into the culture of medicine.

Dr. Tapia, the Colorado geriatrician, began taking an antidepressant in September after months of feeling “everything from angry to anxious to furious to just numb and hopeless.” The medication has improved her outlook. But she also worries that these decisions could jeopardize future employment.

Many state medical boards still ask intrusive questions about physicians’ history of mental health diagnoses or treatments in applications to renew a license — a disincentive to many doctors who might otherwise seek professional help.

“I don’t want to be a hero,” said Dr. Cleavon Gilman, an emergency medicine physician in Yuma, Ariz. “I want to be alive.”Credit…Caitlin O’Hara for The New York Times

Being on the front lines doesn’t make health workers stronger or safer than anyone else. “I’m not trying to be a hero. I don’t want to be a hero,” Dr. Gilman said. “I want to be alive.”

As social bubbles balloon nationwide in advance of the chilly holiday months, health care workers fret on the edges of their communities, worried they are the carriers of contagion.

Dr. Marshall Fleurant, an internal medicine physician at Emory University, has the sense that his young children, 3 and 4 years old, have grown oddly accustomed to the ritual of his disrobing out of work clothes, from his scrubs to his sneakers, before entering his home.

“I do not touch or speak to my children before I have taken a shower,” Dr. Fleurant said. “This is just how it is. You do not touch Daddy when he walks in the door.”

A week of vacation with his family startled him, when he could scoop the little ones up in his arms without fear. “I think they must have thought that was weird,” he said.

Bracing for the next wave

Trapped in a holding pattern as the coronavirus continues to burn across the nation, doctors and nurses have been taking stock of the damage done so far, and trying to sketch out the horizon beyond. On the nation’s current trajectory, they say, the forecast is bleak.

Jina Saltzman, a physician assistant in Chicago, said she was growing increasingly disillusioned with the nation’s lax approach to penning in the virus.

While Illinois rapidly reimposed restrictions on restaurants and businesses when cases began to rise, Indiana, where Ms. Saltzman lives, was slower to respond. In mid-November, she was astounded to see crowds of unmasked people in a restaurant as she picked up a pizza. “It’s so disheartening. We’re coming here to work every day to keep the public safe,” she said. “But the public isn’t trying to keep the public safe.”

Since the spring, Dr. Gilman has watched three co-workers and a cousin die from the virus. Ms. Dass lost a close family friend, who spent three weeks at Mount Sinai Queen’s under her care. When Dr. Fleurant’s aunt died of Covid, “We never got to bury her, never got to pay respects. It was a crushing loss.”

In state after state, people continue to flood hospital wards, where hallways often provide makeshift beds for the overflow. More than 12 million cases have been recorded since the pandemic took hold in the United States, with the pace of infection accelerating in the last couple months.

Jill Naiberk, a nurse at the University of Nebraska Medical Center, has spent more of 2020 in full protective gear than out of it. About twice a day, when Ms. Naiberk needs a sip of water, she must completely de-gown, then suit up again.

Otherwise, “you’re hot and sweaty and stinky,” she said. “It’s not uncommon to come out of rooms with sweat running down your face, and you need to change your mask because it’s wet.”

It’s her ninth straight month of Covid duty. “My unit is 16 beds. Rarely do we have an open one,” she said. “And when we do have an open bed, it’s usually because somebody has passed away.”

Many of her I.C.U. patients are young, in their 40s or 50s. “They’re looking at us and saying things like, ‘Don’t let me die’ and ‘I guess I should have worn that mask,’” she said.

Sometimes she cries on her way home, where she lives alone with her two dogs. Her 79-year-old mother resides just a couple houses away.

They have not hugged since March.

“I keep telling everybody the minute I can safely hug you again, get ready,” she said. “Because I’m never letting go.”

Think Like a Doctor: The Boy With Nighttime Fevers Solved!

Photo

Credit Andreas Samuelsson

On Thursday we asked Well readers to take on the case of a 7-year-old boy who’d been having fevers and drenching sweats nightly for over a month. More than 300 of you wrote in, and although 20 of you came up with the right diagnosis, only three of you figured out both the diagnosis and the test needed to confirm it.

The correct diagnosis is…

Coccidioidomycosis, or valley fever.

The diagnosis was made based on a lymph node biopsy.

The first reader to suggest this diagnosis and the test was Dr. Malkhaz Jalagonia, an internist from Zugdidi, in the Republic of Georgia. He says he’s never seen a case like this, but he’s fascinated by zebras and so recognized the disease immediately. Well done, Dr. Jalagonia!

One of the reasons I chose this case was that, although this diagnosis is rare in life, it was the most frequently suggested diagnosis in my last column – the one about the middle-aged man with a cough for over a year. I thought it would be fun to show what valley fever really looks like. Hope you did too.

The Diagnosis

Coccidioidomycosis is a lung infection usually caused by inhaling the spores of a tiny fungus called coccidioides. This organism grows as a mold, a few inches below the surface of the soil in deserts in parts of the southwestern United States, Mexico and other countries of Central America.

In dry conditions, the fungus becomes fragile and is easily broken up into tiny single-celled spores that can be sent airborne with even the slightest disturbance. And once these single cells are aloft they can remain suspended there for prolonged periods of time.

Infection is usually acquired by inhaling the spores. Once lodged in the lung, the organism begins to reproduce almost immediately. The time course between exposure and disease depends on the inhaled dose and the patient’s immune system.

Symptoms, or No Symptoms

Disease severity varies considerably. Nearly half of those who breathe in these spores have no symptoms, or symptoms are so mild they never visit the doctor’s office.

More severe infection usually takes the form of a slowly progressive pneumonia known as coccidioidomycosis, or valley fever. This illness is characterized by a cough, fevers, chest pain, fatigue and sometimes joint pain. Indeed, because of the prominent joint pain, in some cases — though not this one — the disease is also known as desert rheumatism.

Rashes are also seen in many patients. Those who get a rash seem to have a more benign course of illness. The thinking is that the skin symptoms are the result of an aggressive immune response in the host to the pathogen.

Symptoms can last for months, and in many cases they resolve without treatment. But in some cases they get worse.

Hard to Diagnose

Those who seek medical attention are often not diagnosed — or not diagnosed quickly — because the symptoms of valley fever are not very specific, and few of the tests that doctors usually order have features that are unusual enough to suggest the diagnosis.

Chest X-rays are often normal. Blood tests may be normal as well, though some patients, like this child, have an unusually high number of a type of white blood cell known as eosinophils. These cells are usually seen in allergic responses or with infections due to parasites.

The most important clue to the possibility of this infection is travel to one of the areas where the fungus lives. In the United States, valley fever is endemic primarily in Arizona and southern California, as well as parts of southern New Mexico and West Texas. Indeed, the name valley fever is a shorter and more general term for an earlier name, San Joaquin Valley fever, because it was so common in that part of California.

A Dramatic Rise

There has been a significant increase in the number of cases of coccidioidomycosis in the past 15 years, with nearly 10 times as many in areas where the fungus is found. Development in areas where the fungus is endemic is thought to be the primary cause. Better diagnostic testing may also play a role.

While this infection may cause only a minor illness in many, there are some – like this child – for whom the disease can spread beyond the lungs into the rest of the body. Disseminated coccidioidomycosis is usually seen in those with some problem with the immune system – an underlying disorder such as H.I.V., for example, or because someone is taking immune suppressing medications such as prednisone.

Once out of the lungs, the bugs can go anywhere in the body, though they seem to prefer joints, skin or bones. Those with disseminated disease have to be treated for a long time – often up to a year, or occasionally for life.

How the Diagnosis Was Made

The little boy had been sick for nearly a month, and his parents were getting quite worried. He was pale, thin and really, really tired.

With their pediatrician’s encouragement, they had gone on a long planned, much anticipated vacation to the mountains of Colorado. But the child wasn’t getting better, and so his mother took him to yet another doctor – this one in a walk-in clinic.

The results of some simple blood tests done at that visit worried the doctor, who suggested that the boy be taken to a hematologist, a specialist in diseases and cancers of the blood.

Now the parents were terrified. The mother faxed copies of the lab results to her brother, a researcher in immunology. He wasn’t a physician but showed the results to friends who were. They agreed with the doctor at the walk-in clinic: The boy needed to be seen by a hematologist.

A Series of Specialists

The next morning the family headed home to Minneapolis. They took the boy to his regular pediatrician, who sent them to a hematologist. It wasn’t cancer, that specialist told them. Maybe some kind of severe food allergy, he suggested, and referred them to a gastroenterologist.

Not a GI thing, that specialist told them, and he referred the now nearly frantic family to an infectious disease specialist and a rheumatologist.

Nearly 10 days after getting the alarming blood test results, the couple and their child found themselves in the office of Dr. Bazak Sharon, a specialist in infectious diseases in adults and children at the University of Minnesota Masonic Children’s Hospital. After introducing himself, Dr. Sharon settled down to get a detailed history of the boy and the family.

A Desert Visit, but Other Possibilities

When Dr. Sharon heard that the family had spent a week at a ranch in the desert of Arizona, he immediately thought of coccidioidomycosis. The fungus isn’t found in Minnesota or Colorado – which is probably why other doctors hadn’t considered it. But it is all over the part of Arizona where they’d visited.

Still, there were other possibilities that had to be ruled out, including some types of cancer. After Dr. Sharon examined the boy, he sent the family to the lab for a chest X-ray and some blood tests.

The results of those tests were concerning. The child was getting worse. Dr. Sharon wasn’t going to be back in clinic for a week, and he was certain the child needed to be seen and diagnosed well before then. He called a friend and colleague who was taking care of patients in the hospital, Dr. Abraham Jacob, and asked if he would admit the child and coordinate the needed diagnostic workup for the boy.

First Some Answers, Then More Questions

Once in the hospital, the child had a chest CT scan. The results were frightening. The lymph nodes that surround the trachea, the tube that carries inspired air to the lungs, were hugely enlarged. They were so big that the trachea was almost completely blocked. The opening at one point was just two millimeters wide – basically the dimensions of a cocktail straw. Any worsening of his disease might cause the tube to close completely, making breathing impossible.

A pediatric surgeon was brought in immediately. The enlarged lymph nodes had to be removed. First in order to protect the child’s airways. And second because those nodes would reveal what the little boy had.

But trying to do surgery on a 7-year-old boy’s neck was complicated. Although the surgeon could easily feel the enlarged gland in his neck, it was close to many vital blood vessels, nerves and organs. The child had to lie perfectly still, and with most children that could only be guaranteed if they were under anesthesia.

Risky Surgery

When the anesthesiologist saw the CT scan, the doctors’ concern grew. They could put the child to sleep, but if anything went wrong during surgery and they had to put a tube down his throat into his lungs, they weren’t sure it would be able to fit.

The trachea was so small, there was no guarantee they could get the tube into place. In order to do this safely, they said they needed to use a technique known as ECMO, or extracorporeal membrane oxygenation – basically a machine that allows them to oxygenate blood without sending it to the lungs.

Rather than subject the child to this risky procedure, Dr. Jacob and the surgeon decided to just take a piece of the lymph node out in order to make the diagnosis. Treatment of whatever the boy had would bring the size of the lymph node down.

Don’t Make a Move

When the boy was brought to the procedure room, the surgeon explained that he was going to put numbing medicine all around the bump in the boy’s neck and take out a piece of it. The child listened calmly and agreed.

He wasn’t to move at all, the surgeon explained. The child nodded solemnly. He understood. The boy was remarkably mature and so brave throughout the entire process of anesthetizing the region that the surgeon thought he might be able to continue and get the entire node out.

He paused in his surgery and consulted the parents. Would they allow him to try this? Their son was doing so well he was sure he could get it. They agreed, and the surgeon returned to his task. The lymph node came out without difficulty.

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Credit

It was sent to the lab and the answer came back almost immediately. The swollen tissue was filled with the tiny coccidioides. You can see a picture of these little critters here.

A Year of Medicine

The boy was started on an intravenous medicine for fungal infections. Then after a week it was changed to one he could take by mouth.

Because the infection had spread beyond the lungs, the child will have to take this medication for a year. After starting the medication, the child began to look a little better. Slowly he was less tired. Slowly he started to eat the way he used to.

It was a long road to the diagnosis, and an even longer road to cure, but at least they were on the right one.

A Perfect Storm?

The mother called the ranch in Arizona where they stayed to let them know what had happened.
The owner told them that their son was not the only person visiting then who got sick. At least one other guest, there at the same time, had come down with the disease.

Apparently the conditions for spread were perfect. Their stay had started off with some rain, followed by heat and some brisk wind. The moisture helped the fungus grow; the heat dried it out so that it could become easily airborne and inhaled when lifted by the wind.

Although the family has loved their visits to this ranch – this was their second year – the child’s mother tells me that she’s not sure she’ll be going back, at least for a couple of years. Most people exposed to valley fever become immune forever, but because her little boy was so very sick, she’s planning to wait a while before they return.

Think Like a Doctor: The Boy With Nighttime Fevers

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Credit

The challenge: A healthy 7-year-old boy suddenly starts having fevers and night sweats. Can you figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult medical case and solve a diagnostic riddle. This month we present the case of a boy who has fevers topping 102 degrees every night for over a month. His parents sought help from nearly a dozen doctors in two states before a diagnosis was made.

Below I’ve given you the information that was available to the doctors who figured out the cause of the boy’s fevers. It’s up to you to use this information to put his story together for yourself.

As usual, the first person to crack the case gets a copy of my book, “Every Patient Tells a Story,” and, of course, that fabulous feeling you get when you solve a really tough puzzle.

The Patient’s Story

“I think you need to take him back home.” Her brother’s voice was calm, but she could hear an undertone of anxiety even over the poor cellphone reception that was all she could get from rural Colorado. “He needs to see a hematologist. It could be a virus, but it could also be something else.” He didn’t say it, but she knew what he was thinking: cancer.

Her son, just 7 years old and always a little delicate, had been sick for nearly a month. He was fine during the day, but every night he’d spike a fever of 102 or 103.

Even before they’d come to the mountains for a much needed vacation, she’d taken him to see his pediatrician at home in Minneapolis several times. At each visit, the doctor or one of his partners had looked the boy over closely, and each time he’d seemed fine.

It was probably viral, she was told, time after time. But he seemed to be having one viral infection after another.

A Vacation Cut Short

The day before they left for Colorado, the boy’s father took him to the doctor’s office one more time.

Maybe it wasn’t viral, the pediatrician acknowledged, and prescribed a “Z-pak” — a five-day course of azithromycin. Don’t cancel the trip, the doctor reassured him. He’ll get better.

But he hadn’t. While on vacation, his mother took him to a walk-in clinic, where they’d checked his blood. A worried looking doctor told her that he didn’t know what was wrong with her boy. He should probably see a cancer specialist.

Now she was really worried. There weren’t any specialists anywhere near the bucolic town where they were staying. That’s when she’d sent the test results to her brother, a researcher in immunology. He wasn’t a doctor, but he passed the results to friends who were, and they were worried, too.

Thin and Pale

The family headed home right away, but the 4th of July was coming. They couldn’t get in to see a hematologist until Tuesday.

By now the boy was starting to look sick. He was pale and had dark circles under his eyes. Small for his age — consistently in the fifth percentile for height and weight — he now looked even smaller, thinner. He was a quiet child, always had been. Thoughtful and comfortable in the company of adults, as so many only children are. Even now he never complained.

Nothing hurt. He was simply tired. His fevers started coming a little earlier, peaking a little higher. His mother noticed a cough and wheezing sometimes. Always a picky eater, with these intermittent fevers, very few foods seemed appealing. She tried to hide the terror she felt when he seemed to be fading as she watched.

A Long Line of Specialists

The hematologist examined the boy and sent off more blood. Definitely not cancer, he said. He suggested seeing a gastroenterologist.

The gastroenterologist got an M.R.I. of the child’s digestive system. Nothing there. He noticed the boy’s wheezing and gave him an inhaler, then referred mother and child to a rheumatologist and an infectious disease specialist.

It seemed to the parents that this had to be an infection, but the earliest they could get in to see the infectious disease doctor was the following week. For the boy’s mother, the delay now seemed intolerable.

It had been five weeks since the fevers first started. In that time, the boy had lost nearly 10 pounds. They’d seen eight doctors in two states. They’d all been very nice, thorough, thoughtful, but had no answers.

By the weekend she was desperate. The boy needed to be in the hospital. Couldn’t they see how sick he was? She couldn’t wait for the specialist. She took him to the emergency room of the big university hospital.

The E.R. doctors, like all the doctors they’d seen so far, were kind and thoughtful, and so gentle with her delicate son. But like all the other doctors, they had no answers. They prescribed another inhaler for the boy’s wheezing, since the first hadn’t helped. They also urged her to see the infectious disease specialist. His appointment was just a couple of days away.

TB or not TB?

The boy was sitting quietly between his parents watching a video on his tablet when Dr. Bazak Sharon and the infectious disease fellow he was training entered the exam room. Dr. Sharon’s first thought was that the child looked as if he had tuberculosis.

He’d seen a lot of TB in this clinic, but it was usually among immigrant families who had traveled to Minneapolis from countries where the disease was common. Like this boy, kids with TB were usually thin, sickly looking, pale and quiet. But based on what his fellow told him, the child had no exposures that would put him at risk for this disease. He’d only been out of the country once – to Canada. He’d visited the beaches of South Carolina and the deserts of Arizona, and most recently the mountains of Colorado. But TB was rare in all these locales.

Dr. Sharon introduced himself to the child, who looked up immediately and smiled. How do you feel, he asked the boy? His temperature had been recorded at 103 degrees. I feel good, he’d answered pleasantly. Does anything hurt? No.

His heart was beating rapidly – nearly 140 beats per minute, but that was probably due to the fever. There were several enlarged lymph nodes in the child’s neck and his groin, though none under his arms. Otherwise his exam was unremarkable.

Getting Worse

Dr. Sharon had reviewed the blood tests that had already been done but wanted to see if anything had changed. And given that the only localized complaint was cough and wheezing, he wanted to get another chest X-ray.

Reviewing those studies that night, Dr. Sharon saw that the boy was slowly getting worse. He saw patients at that clinic only once a week and was reluctant to wait that long before having him seen again. He thought they needed an answer much sooner than that.

You can see the note from Dr. Sharon and his fellow here.

Dr. Sharon’s Note

The note from the patient’s visit to the hospital.

To the Hospital

Dr. Sharon called the family the next morning. He’d reached out to one of his friends and colleagues, Dr. Abraham Jacob, who could see them. They should go to the University of Minnesota Medical Center Fairview, where Dr. Jacob would orchestrate a thorough workup. That would be the fastest way to get an answer.

Based on the assessment by Dr. Jacob and his resident and the recommendations from Dr. Sharon, the team reached out to specialists in hematology-oncology and in rheumatology. And since his chest X-ray was abnormal and he had enlarged lymph nodes, they wanted to get a CT scan as well.

You can see the note from Dr. Jacob and his resident here.

Dr. Jacob’s Notes

Here are the notes from the pediatrics department.

Breathing Through a Straw

It was the results of the CT scan that really got things moving. It was the middle of the day when the resident was paged by the radiologist. The pictures showed that the lymph nodes in the boy’s chest were so swollen that they were pressing on the trachea – the breathing tube – so that it was almost completely cut off. Essentially he was breathing through the equivalent of a cocktail straw.

Any additional swelling could cut off the boy’s breath completely. You can see an image from the CT scan here.

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This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.

This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.Credit

A normal trachea in a child this age is four to six times the size seen in the scan. The image added even more pressure to make a diagnosis and treat the child before he got sicker.

Solving the Mystery

A diagnosis was made within the next 24 hours. Can you figure out what the boy had, and how the diagnosis was made?

The first person to offer the correct answers to these two questions will get a copy of my book and that sense of triumph that comes from nailing the right diagnosis when it really matters.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Just a Regular Doctor

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Credit iStock

“What’s your specialty?” That’s the question people always ask, as soon as they learn that you are a doctor.

My specialty? This question continually flummoxes me. This is the moment that I experience a brief surge of envy toward my cardiology and dermatology colleagues who have simple one-word answers to this question that any lay person can understand.

But what do internists say? What is our specialty?

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Danielle Ofri, M.D.

Danielle Ofri, M.D.Credit Joon Park

I sometimes say, “general internal medicine.” But that’s a mouthful. Plus many people have no idea what general internal medicine actually means.

I usually end up saying that I’m just a regular doctor, but it always feels deflating to have to add that “just.”

The American College of Physicians, the professional group for internal medicine, started an ad campaign several years ago to address the confusion. They came up with the slogan of internists as “doctors for adults,” wanting us to credibly sound like specialists, people with more training than the old-fashioned G.P.s. But it just didn’t catch on. I don’t fault the A.C.P. or its Madison Avenue colleagues who came up with this lusterless campaign; there’s just not a lot of pithy material to work with.

Internists, along with the others in the primary care field — family physicians, pediatricians, gynecologists — make up the bulwark of the medical system, though nothing we do or say or represent is especially snappy. No one is rushing to make an edgy cable TV series about adjusting blood pressure medications or treating constipation.

But the need is surely there. Anyone who’s tried to get an appointment with his or her doctor already knows about the primary-care crunch. The Affordable Care Act has highlighted the need for more primary care doctors, with the shortage only likely to grow more acute with a growing and aging population.

In most other countries, the vast majority of physicians are primary care doctors, in recognition that they deliver the vast majority of health care. It is only in the United States that the free market for higher-paid fields results in the number of specialists actually surpassing that of primary care doctors.

We all know the stats — primary care doctors get paid less than specialists, have more administrative headaches, more paperwork, and are generally viewed as lower on the totem pole. Reputation always has it that the smartest medical students go into the specialties; the generalist fields get everyone else who couldn’t make up their mind or who didn’t want to compete in the big leagues.

Dr. Wayne Riley, the president of the American College of Physicians, strongly disputes this characterization. He notes the wisdom acquired by physicians who are required to take both the long view and the wider view of medicine. “I proudly tell people that my specialty is internal medicine.” And if people are still confused, he humorously describes an internist as, “Like television’s Dr. House, but without the bad manners or ethical issues.”

The stereotype of specialists handling the more complex and intellectually challenging cases makes many generalists fume. Generalists observe that specialists get the “simplicity” of handling very narrow slivers of medicine. It’s much easier to be an expert when you only have a handful of diseases to worry about. And any issue that a specialist doesn’t want to deal with can be permissibly kicked back to the generalist.

The generalist, however, gets no dispensation. Every issue that the patient raises must be addressed. Every symptom from any organ has to be acknowledged. Plus, every medication prescribed by every specialist must be accounted for. Every competing interest between the many medical cooks in today’s fragmented health care environment must be integrated.

A recent study regarding patients with diabetes illustrates this reality. In a review of more than 4,500 patients with diabetes, 80 percent of visits to specialists involved only one diagnosis. However, only 45 percent of visits to generalists involved a single diagnosis. Of patients with four or more diagnoses, 90 percent fell to the generalists.

Specialists also get the added ease of pre-screening. A patient referred to a gastroenterologist is generally known to have a GI issue. A patient sent to a cardiologist has some type of heart condition. But the patient who walks into a generalist’s office will often just report pain somewhere in the middle of the body. The generalist has to figure out if the source of the pain is cardiac or pulmonary or gastric or muscular or inflammatory or infectious or hematologic or autoimmune or psychosomatic — a tall order that is somehow considered less intellectually rigorous, and less worthy of reimbursement, than specialty care.

To me, primary care and specialty care are equally demanding. They perhaps represent different types of intellectual challenges, but there’s no reason for one to be thought of as more worthy of respect (or pay).

Primary care doctors, the generalists, won’t be likely to achieve parity in pay or respect until the economics of American medicine changes drastically to reflect more realistically the needs of our patients. Right now, the system values procedures far more than talking to the patient, and so generalists — who do far fewer procedures — continue to rank at the bottom.

But generalists can take heart in the fact that they are what people usually have in mind when they say that they need a doctor. So now when people ask what my specialty is, I say that I’m just a regular doctor. Though I try to remember to leave out the “just.”


Danielle Ofri’s newest book is What Doctors Feel: How Emotions Affect the Practice of Medicine. She is a physician at Bellevue Hospital and an associate professor of medicine at the New York University School of Medicine, as well as editor in chief of the Bellevue Literary Review. She spoke on Deconstructing Our Perception of Perfection at TEDMED.

Food, a Place to Sleep and Other Basic Patient Needs

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Credit Earl Wilson/The New York Times

“Doc,” my patient said, his voice a mix of amusement and irritation. “I ain’t got food to eat or a place to sleep. Took me two hours and three buses to get here. And you’re tellin’ me about some numbers?”

He had a point. Though, in my defense, these numbers — his cholesterol and blood pressure — were important ones.

As I tried to persuade him of their relevance, I thought of another number, his ZIP code — or lack of one, since he lived on the street — and how that was a far more important factor for how long he might live than his cholesterol.

What’s remarkable about our conversation isn’t that it happened, but that it doesn’t happen enough. Many of my patients are not forthcoming about their challenges, and when I probe, I’m often surprised by how many struggle with basic needs like housing, food and transportation.

I recently discussed starting insulin with a patient to control his diabetes. He hesitated — his concern not the syringes needed to inject it, but rather not having a refrigerator to store it. Another patient recently called to cancel her appointment. She was moving into a new apartment — again. Her son’s asthma had flared up, and she thought the mold and cockroaches in their current home were making it worse.

These situations highlight what we’ve known for decades: that patients’ social and economic circumstances powerfully influence their health and well-being. But until recently there’s been relatively little effort to systematically address these factors.

The Center for Medicare and Medicaid Innovation, a government organization established by the Affordable Care Act to test new ways to deliver and pay for health care, is trying to change that. It recently announced a pilot program to help health systems close gaps between medical care and social services in their communities. The program, known as Accountable Health Communities, will invest $157 million over five years to study whether helping patients with social needs in five key areas — housing, food, utilities, transportation and interpersonal safety — can improve health and reduce medical costs.

“Clearly we’re not the first to understand that social factors are important,” said Dr. Darshak Sanghavi, the innovation center’s director of preventive and population health care models. “But these efforts have been fragmented. They haven’t been studied in a way that can be nationally scaled.” As the world’s largest purchaser of health care services, the Centers for Medicare and Medicaid Services can help address that, he said.

The Accountable Health Communities program will award grants to 44 organizations around the country to build partnerships among state Medicaid agencies, health systems and community service providers to identify which strategies are most effective for linking patients to the services they need.

There’s good evidence that dedicated attention to social support can improve health and cut costs. Research suggests nutrition assistance for low-income women and children reduces the risk of low birth weight, infant mortality and developmental problems — at a cost that’s more than fully offset by lower Medicaid spending. Other work suggests providing elderly patients with home-delivered meals can help them live independently and prevent expensive nursing home stays. Research also shows that providing housing for low-income and homeless people can substantially reduce medical costs. A housing initiative in Oregon, for example, decreased Medicaid spending by 55 percent for the newly housed; a study of a similar program in Los Angeles found that every $1 spent on housing led to $6 saved on medical costs.

And local efforts around the country can serve as models for change.

Hennepin Health in Minnesota, for example, is an organization that serves low-income patients, and emerged as a partnership between local social service, public health and medical leaders. These groups share data and funding to ensure patients have access to services like housing, utilities, job training and behavioral and substance abuse counseling. The program’s efforts have lowered emergency department use, reduced the need for hospitalizations, improved chronic disease care — and saved money. Other innovative organizations, like the Camden Coalition in New Jersey and Health Leads in several metropolitan areas, have likewise recognized the challenges vulnerable patients face outside the hospital, and tackled them in inspiring ways.

But we haven’t yet done enough to collect, examine and scale these insights. There’s been no concerted national effort to ease the social problems that drive poor health, and consequently, little financial incentive for medical practitioners to collaborate with social service providers. Until now.

“I think what’s most important is the signal we’re sending,” Dr. Sanghavi said of the Accountable Health Communities initiative. “We recognize that hundreds, potentially thousands, of communities have these needs. We can’t meet them all right now. But this sends a broader signal to other innovators out there — be they private, public or philanthropic: Social determinants are important. We want to learn from their efforts. We want to spark that flame.”

Dhruv Khullar, M.D., M.P.P., is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.

Doctors Should Listen to Patient Instincts

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When a patient complains that he or she doesn’t feel well, doctors should pay attention.

That’s the finding of a new study that suggests that how patients say they feel may be a better predictor of health than objective measures like a blood test. The study, published in Psychoneuroendocrinology, used data from 1,500 people who took part in the Texas City Stress and Health Study, which tracked the stress and health levels of people living near Houston.

The survey included self-assessments from a 36-item questionnaire as well as blood samples, which were analyzed for markers of inflammation and the activity of latent herpes viruses. (The viruses were benign and not the type associated with sexually transmitted disease or cold sores.) Inflammation and viral activity are general markers of immune system health, but they don’t typically cause any obvious symptoms or show up in traditional blood tests.

The study found that when people said they felt poorly, they had high virus and inflammation levels. People who reported feeling well had low virus and inflammation levels.

“I think the take-home message is that self-reported health matters,” said Christopher P. Fagundes, an assistant psychology professor at Rice University and a co-author of the study. “Physicians should pay close to attention to their patients. There are likely biological mechanisms underlying why they feel their health is poor.”

The Doctor-Patient Relationship Is Alive and Well

It’s 2:20 p.m. and Ms. M. is precisely on time for her appointment. She’s brought her hand-printed list of questions, her sack of medications that need renewal, her mordant observations about her newest home attendant, and a box of chocolates that she will press upon me no matter how hard I protest. At 89, her medical conditions don’t have easy cures and the setbacks from aging are often implacable. Yet we always manage to find something optimistic to work on, even if modest in scope.

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Danielle Ofri, M.D.

Danielle Ofri, M.D.Credit Joon Park

Ms. M. requires the assistance of her daughter to make the hour-plus trip by public transportation. Over the 10 years we’ve worked together, I’ve periodically suggested she might consider a clinic closer to home to avoid the arduous travel. She sniffs sharply at the affront and then barrels into the meat of our visit.

It’s been a rocky decade for medicine — the Affordable Care Act, the migration to electronic medical records, record-breaking medication prices, and the shift from traditional doctor-run practices to mammoth corporate-run organizations have left us all reeling. Physician anger at overwhelming administrative demands and patient frustration at the impossibility of navigating the system have frayed the fortitude of everyone.

Medicine is unquestionably harder than it was 10 years ago. Many more doctors I know talk about quitting (an option that is not equally available to patients). However, there’s been no mass exodus of doctors. We doctors grumble loudly — often with good cause — but we aren’t quitting in droves, mainly because of patients like Ms. M.

A new study by the Physicians Foundation of more than 1,500 patients found that more than 90 percent of patients were satisfied with their relationship with their primary care doctor. They felt that their doctors were respectful of them, listened well, explained well, and had a good understanding of their medical history.

On the surface, this seems to contradict the dyspeptic view of medicine we hear about in the media. But it actually reflects the larger truth that most patient rancor is directed not toward the doctor but to the bureaucratic aspects of medicine — the cost, the hassle, the opaqueness. On the whole, patients are happy with the medical care they receive from their primary care doctors — once they’ve slogged through the seven circles of pre-authorization purgatory to get there.

The same is true for doctors. What doctors hate most is everything that surrounds medicine, but not medicine itself. Peel away the administrative migraines and most doctors relish the practice of medicine.

It’s heartening to see that the doctor-patient relationship is surviving this latest round of upheaval. For primary care doctors in particular, whose daily work life has been pummeled with exceptional relentlessness, this latest survey is immensely validating.

So maybe it’s not surprising that it can feel as if morale is both exceptionally high and exceptionally low at the same time. Just this month, a new set of requirements was piled on to our clinic’s electronic medical record system, and a dreary sigh of resignation echoed from one doctor to the next. With all the computerized busywork that a medical visit requires these days, there’s hardly time to call in our patients from the waiting room.

On the other hand, when we welcome our new students and interns — July is the starting month of the medical calendar — the enthusiasm for primary care is fervent. We all have patients, like Ms. M., who bring joy and fulfillment no matter how much inanity we have to lumber though in the electronic medical records system.

Nothing comes close to the experience of making another human being feel better, even a tiny bit. After months of trial and error, Ms. M. and I finally worked out a schedule of her diuretic pill such that she could go for a midday stroll without having to scramble for a nonexistent public bathroom. This isn’t the sort of high-tech medical wizardry that grabs headlines or stock prices, but it allows a formerly housebound patient to now keep tabs on her Brooklyn neighborhood.

The awe of discovering the human body, the honor of being trusted to give advice, the gratification of helping someone through a difficult illness, the intellectual stimulation of continually learning — these things never grow old.

And word seems to be getting out — applications to medical school are at an all-time high, and new medical schools are opening to meet the demand. (By comparison, law school applications continue to decline and business school applications remain flat.)

When I close the door to the exam room and it’s just the patient and me, with all the bureaucracy safely barricaded outside, the power of human connection becomes palpable. I can’t always solve my patients’ issues, but the opportunity to try cannot be underestimated.

We doctors shouldn’t be afraid to speak up about what’s wrong with medicine — and there is plenty that is wrong. But we also shouldn’t be afraid to speak up about what’s right. While the logistics of practicing medicine may feel like an ever-tightening thumbscrew, the doctor-patient relationship is alive and well, and the prognosis is excellent.

Danielle Ofri’s newest book is “What Doctors Feel: How Emotions Affect the Practice of Medicine.” She is a physician at Bellevue Hospital and an associate professor of medicine at N.Y.U. School of Medicine, as well as editor in chief of the Bellevue Literary Review. She spoke on Deconstructing Perfection at TEDMED.

Think Like a Doctor: A Cough That Won’t Stop

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Credit Andreas Samuelsson

The Challenge: A 43-year-old man starts to cough every time he takes a deep breath. Can you help him figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a healthy middle-aged man who starts coughing and just can’t stop. He can’t exercise. He can’t laugh. Sometimes he can’t even talk without interrupting himself with deep, awful-sounding hacks.

Below I provide much of the information available to the doctors who examined him. It took 18 months before a doctor figured out what was wrong. Can you do it any faster? The first reader to offer the correct diagnosis will receive a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a real-life case.

An Emergency 18 Months in the Making

“You should probably have that checked out in the E.R.,” the nurse suggested to the middle-aged man on the other end of the phone. “And sooner rather than later.” In the next few days? he asked. In the next few hours, the nurse replied.

The 43-year-old man hung up the phone more surprised than worried. He had been dealing with an annoying and persistent cough for a year and a half and none of the doctors or nurses he’d seen in that time seemed to think it was a big deal. Until now – since he started coughing up blood.

He called his wife to tell her what the nurse suggested. After work he was going to drive himself to the emergency room at the veterans’ hospital in downtown Denver. He could hear the relief in her voice when she asked if he wanted her to come with him. No, she had enough on her hands looking after their four children. He’d let her know what they said.

An Abnormal X-ray

In the E.R., the man’s complaint got him seen right away. His chest X-ray was normal, they told him. (The X-ray is shown here)

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Credit

But when they came back into his cubby wearing masks over their noses and mouths he suspected that the CT scan was not. The scan had shown some kind of hole in his lungs, the E.R. doctor told him. That’s why he was coughing up blood. One of the diseases that can cause those kinds of cavities was tuberculosis. Had he ever been exposed to TB? Not that he knew of. (The CT scan images are shown here.)

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Credit

Because TB was such a dangerous disease – and extremely contagious — they would have to find out if he had it. If he did, he would certainly need to be treated. And to make sure he didn’t infect anyone while he was being tested, he needed to be in a specialized room – a room where the air he breathed wouldn’t be breathed by anyone else. None of the hospital’s negative pressure rooms were available so they were going to transfer him to Presbyterian/St. Luke’s Medical Center, the big regional hospital just a couple of miles away. They had an available room and would be able to care for him.

You can read the patient’s history and physical from the E.R. here:

Admission Notes

The patient’s notes from the hospital.

The Patient’s Long Story

Dr. Karen Schmitz was the second-year resident assigned to care for the new guy sent over to be tested for TB. She could see the patient sitting up in bed talking on the phone as she secured the mask over her nose and mouth and entered the double-door room that would prevent any air-borne infectives from spreading. As she entered, the patient looked at her, smiled a warm smile, and held up a finger as if to say, “I’ll be with you in a minute.” As he finished up his phone call, the doctor looked at him carefully. He was a robust guy – youthful and healthy looking. He certainly didn’t look like any of the people she’d cared for with active TB. When he hung up, he apologized and the doctor introduced herself. She pulled up a chair and settled in. She knew from what she’d read in the chart that it was going to be a long story.

The bloody cough was pretty new, he told her. It started two weeks earlier. But the cough itself had been around for 18 months. He’d caught it a couple of summers ago, and it just never went away. At first he thought it was bronchitis – he’d had that a lot when he was a kid — but when it lasted for more than a couple of weeks, he went to see his primary care doctor. He’d never had a fever or any other sign of being sick. He had some runny nose and itchy eye symptoms that started weeks before the cough and so he and his doctors thought it was allergies. Or asthma. His doctor prescribed an antihistamine and later an inhaler. They fixed his runny nose, and eased up the chest tightness, but the hacking never slowed down.

He went to an ear, nose and throat specialist who scoped his nose and throat. Completely normal. He had a chest X-ray – also normal.

He saw a pulmonologist who, hearing that he had a little heartburn, started him on a powerful antacid medication. That pill completely fixed the heartburn but didn’t touch the cough.

That first year he’d seen three doctors in a half-dozen appointments, and had a scope, a chest X-ray and a slew of blood tests and still no one could tell him why he was coughing or how to make it stop. So he figured he’d just have to learn to live with it.

Not that he wanted that. Every time he took a deep breath he would cough. In the middle of telling a good story he’d have to stop to cough. Whenever he laughed, he coughed. Dozens of times a day, he coughed. He even had to give up exercising. Any time he exerted himself, even just a little, the cough would kick in with a shocking fierceness. Recently he’d tried riding his bike and just 15 minutes in he had to stop. Even though he was taking it easy, as soon as he started to breathe just a little harder than usual, he nearly keeled over. He had to get off his bike. He was doubled over with the ferocious hacking. Sweat and tears poured down his cheeks. He could hear the rasping sound of his breath between the deep jagged coughs. He wondered if he could even make it home. That was the last time he tried to exert himself. And that had been weeks earlier.

You can see the pulmonologist’s notes here:

Pulmonary Consult Note

The notes from the lung specialist.

The Doctor’s Visit

But eventually, he started to cough up blood. That happened the morning after he’d had another terrible blast of coughing. He’d gone with his wife and four children to Vail for Thanksgiving. As he was packing the car to come home he started coughing and felt as if it would never stop, as if he’d never be able to breathe again. But he recovered, until the next morning when he started to cough up blood. It scared him. And terrified his wife. When it didn’t get better after a couple of weeks, he’d decided to call the hospital, and the nurse on the phone sent him to the E.R.

Now, talking to Dr. Schmitz, he told her he never smoked and rarely drank. And even though it was legal, he never smoked pot either. He had been an officer in the Air Force and now was a real estate agent. He had spent a few months in Kuwait and another few in Saudi Arabia, but that was in the 1990s. He’d traveled a bit – mostly out west, but nothing recent. He took medicine for high cholesterol, the antihistamine and the antacid medicine, but that was it. His exam was unremarkable. Dr. Schmitz listened hard through her stethoscope as she placed it on his chest where she knew the hole in his lung was, but heard nothing abnormal.

She didn’t start him on antibiotics, because she didn’t yet know what she was treating, she told him. Tuberculosis seemed unlikely so she was going to test him for other infections as well. To make sure the team didn’t miss anything, they consulted an infectious diseases specialist and a pulmonologist.

You can see their notes here.

Infectious Disease Consult

Notes from the infectious disease specialist.

Dr. Schmitz checked on her patient throughout the day. He was always on the phone, his computer open, hard at work. So far they were doing nothing for the guy – just watching and waiting for answers. When the TB test came back negative, Dr. Schmitz thought he might very well be the healthiest patient in the entire hospital. Was she right? The patient got his diagnosis the very next day.

Solve the Mystery

What do you think is making this patient cough?

Post your answers in the comment section. I’ll tell you the answer tomorrow.

At the End of Life, What Would Doctors Do?

Photo

Credit Stuart Bradford

Americans have long been chided as the only people on earth who believe death is optional. But the quip is losing its premise. A recent profusion of personal narratives, best-selling books and social entrepreneurs’ projects suggest that, as a culture, we are finally starting to come to terms with our mortality. Nationally, the Conversation Project is engaging people to discuss their wishes for end-of-life care. Death Cafes and Death Over Dinner events are popping up across the country, reflecting an appetite for exploring these matters. So too, the Dinner Party and the Kitchen Widow are using meals as a communal space to explore life after loss.

Admittedly, contemplating mortality is not (yet) a national strong suit. That’s why these cultural stirrings are so significant. At a minimum, our heightened awareness and willingness to talk about illness, dying, caregiving and grieving will lead to much better end-of-life care. However, the impact on American culture needn’t stop there. Like individuals who grow wiser with age, collectively, in turning toward death, we stand to learn a lot about living.

Doctors can be valuable guides in this process. In matters of illness, people are fascinated by the question, what would doctors do? Consider the social phenomenon of Dr. Ken Murray’s online essay, “How Doctors Die.” Dr. Murray wrote that doctors he knew tended to die differently than most people, often eschewing the same late-stage treatments they prescribed for patients. The article went viral, being read by millions, and reprinted in multiple languages in magazines, newspapers and websites across the globe.

Dr. Murray’s observation even engendered studies of doctors’ preferences for care near the end of life. So far, results are mixed. In a Stanford study, 88 percent of responding physicians said they would avoid invasive procedures and life-prolonging machines. But a newly released comparative study of Medicare recipients, as well as a longitudinal study and separate analysis of Medicare data published in January, suggest that the actual differences between end-of-life treatments that doctors and nondoctors receive are slight. Perhaps like nearly everyone else, when life is fleeting, physicians find it difficult to follow their previous wishes to avoid aggressive life-prolonging treatments.

For what it’s worth, the terminally ill colleagues I’ve known, including those I’ve been privileged to care for, have usually been willing to use medical treatments aplenty as long as life was worth living, and took great pains to avoid medicalizing their waning days. In any event, the public’s interest in the medical treatments that doctors choose must not be allowed to reinforce our culture’s tendency to see dying solely through medical lenses. More to the point is the question, how do dying doctors live?

What dying doctors do with their time and limited energy, and what they say, are deeply personal, sometimes raw and often tender. Like everyone else, doctors experience pain and suffering – yet many speak of a deepening moment-to-moment sense of life and connection to the people who matter most.

Listen to a few.

Dr. Jane Poulson lost her sight to diabetes while still in medical school. After years of successful internal medicine practice, Dr. Poulson developed inflammatory breast cancer and knew it would claim her life. Writing in the Canadian Medical Journal she said:

In a paradoxical way, I think I can say that I feel more alive now than ever before in my life … When you presume to have infinity before you the value of each person, each relationship, all knowledge you possess is diluted.

I have found my Holy Grail: it is surrounding myself with my dear friends and family and enjoying sharing my fragile and precious time with them as I have never done before. I wonder wistfully why it took a disaster of such proportions before I could see so clearly what was truly important and uniquely mine.

About a year after being given a diagnosis of incurable esophageal cancer, Dr. Bill Bartholome, a pediatrician and ethicist at the University of Kansas, wrote:

I like the person I am now more than I have ever liked myself before. There is a kind of spontaneity and joyfulness in my life that I had rarely known before. I am free of the tyranny of all the things that need to get done. I realize now more than ever before that I exist in a ‘web’ of relationships that support and nourish me, that clinging to each other here ‘against the dark beyond’ is what makes us human … I have come to know more about what it means to receive and give love unconditionally.

Dr. Bartholome referred to this period before his death as “a gift.”

It has given me the opportunity of tying up the ‘loose ends’ that all our lives have. I have been provided the opportunity of reconnecting with those who have taught me, who have shared their lives with me, who have ‘touched’ my life. I have been able … to apologize for past wrongs, to seek forgiveness for past failings.

A healthy defiance is often palpable within the personal decisions of doctors who are living in the growing shadow of death. My friends Herbert Mauer and Lisa Mills, long-married oncologists, boldly renewed their vows before a crowd of family and friends during the months Herb was dying of cancer. In “When Breath Becomes Air,” the neurosurgeon Dr. Paul Kalanithi relates the decision he and his wife, the internist Dr. Lucy Kalanithi, made to have a child, while knowing full well that he was unlikely to see their daughter grow up. Such affirmations of couplehood in the face of death are not denial; but rather insubordination, eyes-wide-open commitments to living fully despite the force majeure.

Gratitude also commonly emerges in the experiences of dying clinicians. In one of our last email exchanges, my friend, the clinical psychologist Peter Rodis, wrote:

The shock of knowing I’ll die has passed. And the sorrow of it comes only at moments. Mostly, deep underneath, there is quiet, joyous anticipation and curiosity; gratitude for the days that remain; love all around. I am fortunate.

The neurologist Dr. Oliver Sacks concluded his essay “My Own Life” in exaltation.

Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.

These experiences are like dabs of paint on an Impressionist’s canvas. Taking in this contemporary ars morendi we can appreciate how dying and well-being can coexist. For all the sadness and suffering that dying entails, our human potential for love, gratitude and joy persists.

How fitting would it be for a corrective to the medicalization of dying to come from the medical profession itself? The general public’s interest in what doctors do can teach all of us about living fully for whatever time we each have.

Ira Byock, a palliative care physician, is founder and chief medical officer of the Providence Institute for Human Caring in Torrance, Calif. His books include “Dying Well” and “The Best Care Possible.”

When Doctors Have Conflicts of Interest

My mother-in-law is an impressive woman.

At the age of 77, she still maintains a garden the size of my entire backyard, on the three acres of land she and my father-in-law, now 81, share in rural western Pennsylvania.

She does not tolerate stasis, and anytime my father-in-law collapses into his plaid armchair in front of the television, she appears on the scene within a minute or two, barks at him that there will be plenty of time to rest when they’re in the old age home, grabs the remote control, and turns the television off while simultaneously giving him another task to perform.

Photo

Mikkael Sekeres, M.D.

Mikkael Sekeres, M.D.Credit

She has kept old age at bay through constant activity, sheer strength of will, and a splash of denial.

Her hip must have been bothering her for some time, then, before she let me and my wife in on her problem. At our insistence, she told one of her doctors, who sent her for X-rays and reviewed them with her, in his office, with my wife at her side.

“Ouch,” her doctor said, pointing at the image of her hip where her femur was scraping against the acetabulum of her pelvis, bone-on-bone. “That looks like it hurts.”

“Well, I do a few chores around the house in the morning and rest on the couch with a heating pad, and then I’m all right,” she told him.

My wife interjected. “Just so you understand, by ‘a few chores,’ she means that she plants five flats of flowers.”

Her doctor’s eyes widened. Recognizing that she is the type of person who would have to decide for herself when she was ready for surgery, he recommended she let the rest of us know when that time occurred. Earlier this summer, she decided it was time.

She met with the orthopedist who would perform her surgery, and the two quickly bonded. As it turned out, his wife is also a gardener, and like my father-in-law, he collects classic cars. He discussed the surgery he intended to perform, her likely recovery period, and then paused.

“Now, I have to tell you that the artificial hip I’m going to use is one that I had a hand in inventing, and although I will receive no royalties for implanting this hip in you, I do have a conflict of interest, and want to make sure you’re O.K. with that.”

I sit on our institution’s conflict of interest committee and this scenario, while not falling into the majority of doctor-patient interactions, is becoming increasingly common.

There are a number of different types of potential conflicts that can arise.

Like my mother-in-law’s surgeon, a doctor may invent a technology, or develop a drug, and receive payments every time that technology or drug is used – though, as my mother-in-law’s doctor told her, no royalties are received if the device is used at our institution. Still, you might wonder if his using that artificial hip influences other doctors who want to emulate him to use the same device, from which he would receive royalties.

Or, a doctor may provide advice to a company, for which she receives an honorarium, and conducts research (such as being an investigator on a clinical trial) using that company’s product. Will the payment she received influence her interpretation of the clinical trial results, in favor of the investigational drug? Or did she make the trial better because of the advice she provided?

What if, instead, the drug for which she provided advice is already commercially available. How much is her likelihood of prescribing this medication – what we call a conflict of commitment – influenced by her having been given an honorarium by the manufacturer for her advice about this or another drug made by the same company?

We know already that doctors are influenced in their prescribing patterns even by tchotchkes like pens or free lunches. One recent study of almost 280,000 physicians who received over 63,000 payments, most of which were in the form of free meals worth under $20, showed that these doctors were more likely to prescribe the blood pressure, cholesterol or antidepressant medication promoted as part of that meal than other medications in the same class of drugs. Are these incentives really enough to encroach on our sworn obligation to do what’s best for our patients, irrespective of outside influences? Perhaps, and that’s the reason many hospitals ban them.

In both scenarios the doctor should, at the very least, have to disclose the conflict to patients, either on a website, where patients could easily view it, or by informing them directly, as my mother-in-law’s doctor did to her.

More importantly, what do patients think of these conflicts? Back in the comfort of our family room, following her appointment, I asked my mother-in-law that very question.

“Oh, I was glad he told me.” I prodded her to go on, as she shifted in her chair, trying to get comfortable. “It made me trust him more. He must be an expert if he helped invent the hip. And of course I want him using the one he invented, he knows it better than anyone!”

It turns out, she’s not alone. In a study of over 600 surgical patients, about 80 percent felt it was both ethical and either did not influence, or actually benefited their health care, if their surgeons were consultants for surgical device companies.

It’s complicated. Certainly, the relationships doctors have with drug or device manufacturers drive innovation, and help make those products better for patients. But can we ever be sure these relationships aren’t influencing the purity of our practice of medicine, even a little?

Dr. Mikkael Sekeres is director of the leukemia program at the Cleveland Clinic. Follow him on Twitter @MikkaelSekeres.

Pelvic Exams May Not Prolong Life, a Task Force Says

Photo

Credit Stuart Bradford

Many women dread the indignity of the annual pelvic exam, in which they are poked and prodded with their feet in stirrups.

Now an influential government task force says there isn’t evidence that routine pelvic exams are necessary or prolong a woman’s life. Some experts think they may even do more harm than good.

And although some 60 million pelvic exams are done each year, the practice hasn’t been studied much. The United States Preventive Services Task Force, a panel of experts in preventative and primary care, declared today that the current evidence is “insufficient” to assess the balance of benefits and harms of the pelvic exam. The task force performed an exhaustive search of the medical literature published over the past 60 years and located only eight studies looking at the diagnostic accuracy of pelvic exams for just four medical conditions.

“We can’t make a recommendation one way or the other at this time,” said Dr. Maureen Phipps, the chairwoman of obstetrics and gynecology at Brown University’s Warren Alpert Medical School and a member of the task force. “We need more evidence.”

The finding refers only to the practice of routine pelvic exams for healthy women, and does not apply to women who are pregnant or those with existing conditions or symptoms that need to be evaluated.

“This is not a recommendation against doing the exam,” Dr. Phipps emphasized. “This is a recommendation to call for more research to figure out the benefits and harms associated with screening pelvic exams. That’s the big message here.”

This is the first time the Preventive Services Task Force has turned its attention to pelvic examinations, which can include a visual exam of external genitalia, an internal exam using a speculum, manual palpation to check the shape and size of the uterus, ovaries and fallopian tubes, and the simultaneous palpation of the rectum and vagina using lubricated gloves.

The recommendations about pelvic exams do not change current guidelines for cervical cancer screening, in which cells are collected from the surface of the cervix and vagina. The screening test is recommended every three years for women ages 21 to 29 and every five years for ages 30 to 65.

Pelvic exams have been subjected to quite a bit of scrutiny in recent years, possibly because of turf battles between physicians and reimbursement battles with insurers. The exams can be both time-consuming and expensive, in part because doctors are advised to have a chaperone present during the exam.

In 2014, the American College of Physicians told doctors to stop performing routine pelvic exams as part of a physical, saying there is no evidence they are useful and much evidence to suggest they can provoke fear, anxiety and pain in women, especially those who have suffered sexual abuse or other trauma.

The American Academy of Family Physicians endorsed that recommendation. But the American College of Obstetricians and Gynecologists (ACOG) continues to recommend an annual pelvic examination for women 21 and older, while acknowledging a dearth of data. Its Well-Woman Task Force, which was convened in 2015, recommended annual external exams but said internal speculum and bimanual exams for women without specific complaints or symptoms should be “a shared, informed decision between the patient and provider.”

“No woman should ever be coerced into having an exam, and that discussion should take place in a nonexam room environment, while the woman is fully dressed and sitting at equal level with the provider at a round table, without a desk between them,” said Dr. Barbara S. Levy, vice president for health policy at ACOG.

But Dr. Levy says that the exams should not be scrapped because trials – which would be difficult to design and fund — have not been carried out.

“I think there’s tremendous value in the laying on of hands,” Dr. Levy said. “Touch has a lot to do with establishing trust, and there are many things I can pick up on during a pelvic exam because I’m skilled and trained.”

She may pick up on the fact that a woman is experiencing abuse or domestic violence, or discover that a woman may benefit from interventions to strengthen muscles to prevent urinary incontinence down the line, she said, adding, “This is the art of medicine.”

Most obstetrician-gynecologists do routine pelvic exams, as do many other physicians, and the majority of preventive care visits between 2008 and 2010 included one, according to the task force’s report.

Health care providers say they can pick up on myriad gynecologic conditions during a pelvic exam, including cancers of the cervix, vagina, vulva, ovaries and endometrium, sexually transmitted diseases, genital warts and genital herpes, uterine fibroids, ovarian cysts and more.

But the task force found no studies that assessed how effective the exams are for reducing death and disease. So for example, although a pelvic exam might be useful in detecting ovarian cancer, the disease is relatively rare, so exams often result in false-positives that can lead to unnecessary surgery, the report said.

In four ovarian cancer screening studies with over 26,000 screened patients, more than 96 percent of the positive test results were false positives, meaning there was no real disease and many patients had unnecessary follow-up procedures.

But Dr. Levy said the call for more research is impractical. Exams are part of preventive care that is tricky to evaluate or assess, she said, and such studies are unlikely to get funded. “Looking for evidence-based answers to centuries-old processes and procedures doesn’t always make sense,” she said.

Reading Novels at Medical School

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Credit Getty Images

Sitting in a classroom at Georgetown Medical School usually reserved for committee meetings, we begin by reading an Emily Dickinson poem about the isolating power of sadness:

I measure every Grief I meet
With narrow, probing, eyes –
I wonder if It weighs like Mine –
Or has an Easier size.

It’s a strange sight: me, a surgical resident, reading poetry to 30 medical students late on a Tuesday night. Some of us are in scrubs, others in jeans; there are no white coats. Over the past four years, as the leader of the group, this has become my routine.

The students are here after long days in class and on the wards because they have discovered that medical education is changing them in ways that are unsettling. I remember that uneasiness well. My own medical education began with anatomy lab. The first day with the cadaver was unnerving, but after the first week the radio was blaring as we methodically dissected the anonymous body before us.

Two years later, on my first clinical rotation, I discovered that it does not take long to acclimate to the cries of patients as I hurried past their rooms, eager not to fall behind in a setting where work must be done quickly and efficiently. This practiced detachment feels necessary, a form of emotional and physical self-preservation. But with little time to slow down, ignoring our own thoughts and feelings quickly hardens into a habit.

During my first year in medical school, I found myself gravitating toward my old comfort zone — literature. As an English major, I had grown accustomed to the company of books and was feeling their absence now that “Don Quixote” had been displaced by Netter’s “Atlas of Human Anatomy.” I could look to Netter for concrete answers, but I needed Cervantes to help me formulate questions I had trouble pinning down, like why it was so easy to ignore the dead (and later, living) bodies around me? Illustrated cross-sections of the brain did little to illuminate the workings of my own mind. I needed time and space for introspection. The solution came in the form of a book club that later became an official course.

At Georgetown, the goal of our new literature and medicine track is to foster habits of reflection over four years of medical school. On the surface, the assigned books have nothing to do with medicine. We read no patient narratives, doctors’ memoirs or stories about disease.

Today’s topic is Haruki Murakami’s novel “Colorless Tsukuru Tazaki and His Years of Pilgrimage,” which tells the story of a depressed middle-aged Tokyoite’s attempt to retrace his past in order to understand how his life became so empty. We talk about the main character’s colorless perception of the world, and why his mind feels so inaccessible to us.

I receive an email from a student later that evening. He, an aspiring psychiatrist, tells me the story of a much-admired college mentor. “I heard last week that he committed suicide. I am still crushed,” he writes. “He was diagnosed with depression but seemed to be doing great.” If he so misjudged his teacher’s state of mind, he worries, how will he make it as a psychiatrist?

Earlier this year, we placed the ethics of animal testing under the magnifying glass of Karen Joy Fowler’s “We Are All Completely Beside Ourselves.” The novel is narrated by a woman whose “sibling,” we later discover, is a chimpanzee who was raised with her as part of a human-chimp experiment. We used the book to think through real-life examples like the Silver Spring Monkeys — a series of gruesome primate experiments that both galvanized American animal-rights groups and led to breakthrough scientific discoveries.

A third-year student talked about the three years he spent working with rhesus macaques. Research from his lab led to breakthrough discoveries about memory and behavior and contributed to therapies such as deep brain stimulation. “Doesn’t that answer the ethical questions?” he asked.

Another student talked about studies that she worked on for several years before starting medical school. “Have you heard of professional testers?” she asked the room. “People whose only source of income is volunteering for different studies, mostly college kids and immigrants? Shouldn’t we be talking about human research also?” For me, the discussion proved transformative. I walked into that class firmly supporting animal research and walked away still supporting research but no longer eating meat.

Our busy jobs on the hospital wards require precision and efficiency, but in literature class we can slow down and explore human lives and thoughts in a different, more complex way. The class is an anatomy lab of the mind. We examine cultural conventions and conflicting perspectives, and reflect on our own preconceived notions about life and work. Reading attentively and well, we hope, will become a sustaining part of our daily lives and practice.

As I’m walking out of the classroom at the end of the evening, a third-year student approaches me to tell me he’s been thinking more deeply about his experience of being an unrelated organ donor to his step-uncle, a man he barely knew. “It’s been on my mind since we read Ishiguro’s ‘Never Let Me Go’ last month,” he says. “I want to write about it. I don’t even know how I feel about it, and I need to figure it out.”

Daniel Marchalik, M.D., is a urologist in Washington and heads the literature and medicine track at the Georgetown University School of Medicine.

Leaving the Pediatrician? Not at 26

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Lule Rault, 26, talks with her doctor, pediatrician Ramon Murphy, who she’s visited since childhood at Uptown Pediatrics in Manhattan.

Lule Rault, 26, talks with her doctor, pediatrician Ramon Murphy, who she’s visited since childhood at Uptown Pediatrics in Manhattan.Credit Yana Paskova for The New York Times

Lule Rault took a seat in the waiting room of Uptown Pediatrics on Park Avenue, across from several young mothers with babies in tow. A toddler played with the toys on the waiting-room floor.

“I felt like they might think I’m just another young mom or something,” she said, “since I am so close to their age.” But Ms. Rault, a 26-year-old medical student, was there this month for her own annual checkup. She has been a patient at Uptown Pediatrics since her own infancy. And she plans to remain so until she finishes her M.D. at Tulane University. At that point she will be 29.

She is not looking forward to the transition.

“I don’t have to leave Dr. Murphy, do I?” she said in an interview by email. “I’m only 26!” And she is not Dr. Ramon Murphy’s only patient long out of high school. “The last time I was there, he told me there was one patient older than me — a boy.”

A poll from the Pew Research Center last month found that for the first time in more than a century, young adults are more likely to live with their parents than with a partner or a spouse. So it should come as no surprise that many are perfectly happy to remain with their childhood physicians. The age at which patients leave the pediatric nest varies, depending on whether their doctors are trained to treat adolescents and young adult patients. Historically, that age has been 18 to 22. It seems to be moving up.

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Lule Rault, 26, left, emerges from an appointment at Uptown Pediatrics in Manhattan. The waiting room there caters both to young children and to patients in their twenties.

Lule Rault, 26, left, emerges from an appointment at Uptown Pediatrics in Manhattan. The waiting room there caters both to young children and to patients in their twenties.Credit Yana Paskova for The New York Times

Under the Affordable Care Act, children can remain under their parents’ insurance plan until they are 26, which since 2010 has added three million young people to the insurance rolls, according to the Department of Health and Human Services. But that doesn’t mean healthy young adults are regularly visiting any doctors.

“Young adults on the whole are not very connected to the health care system,” said Dr. Patience White, a director at the Center for Health Care Transition Improvement, a group that studies the transition from pediatric to adult health care. “They often turn to the emergency room when they get sick.”

In New York City, many pediatricians are willing to keep their older patients so that they won’t stray from the system. Dr. Murphy and other pediatricians also said many young adults have found it impossible to find an internist who will accept insurance from new patients. Some require an initial concierge fee that runs as much as $3,000; those who do take insurance often don’t have appointments available for four to six months.

“The patient, or parent, reasons that it makes more sense to just stay with the pediatrician,” Dr. Murphy said.

Furthermore, a growing number of pediatricians are trained to treat adolescents and young adults. Dr. Murphy’s practice reflects his 19 years at the Adolescent Health Center at Mount Sinai Hospital in Manhattan. It’s a different kind of rapport from the one he has with his grade-school patients.

“I ask them about friends, school, career choices,” he said. “I wasn’t cut out to wear clown noses and funny ties.”

His waiting room at Uptown Pediatrics even has two sides — one furnished with the familiar trappings of the Sesame-Street-and-K.C.- Undercover set, the other with seating and reading material for adult-size patients.

“I think it’s a New York City phenomenon,” said Dr. Ralph Lopez, whose Upper East Side practice focuses primarily on teenage boys and young men. “Your mom and dad may pick out an internist for you, but you don’t like the doctor, so you stay with someone like me.” He added, “I’m seeing two 25-year-olds later today.”

Andrew Ruvkun, 20, who runs varsity track at Carleton College in Minnesota, plans to stay with his Manhattan pediatrician, Dr. Sol Zimmerman, at least until he finishes college.

“He’s a nice guy, so for now this is it for me,” Mr. Ruvkun said. “He signs off on my N.C.A.A. forms, and he’s the only doctor I’ve ever known.”

Suzy Storr, 25, an artist who a year ago moved back to her Park Slope home after finishing her studies in England, would have liked to keep her old pediatrician, Dr. Sylvain Weinberger, but was told she had aged out of his practice.

“It was kind of sad to me,” she said. “I’d always had a fear of needles, and while I’m better about it now, he always knew how to comfort me.”

Dr. Weinberger suggests his patients find another physician when they leave for college. Up to age 19, “they can always call me,” he said.

As a practical matter, he noted, any patient 18 or older who needs to be hospitalized will go on an adult floor, where a pediatrician may not have admitting privileges.

Ms. Storr tried an internist, but she felt that she was“kind of rushed” and that the visit was about “doing a checkup and kicking you out.”

In New York City, several private practices devoted to adolescent medicine have sprung up to fill the gap for young adults whose needs have outgrown the so-called baby doctor.

“Many pediatricians are uncomfortable with talking about birth control, condom use,” said Dr. Karen Soren, director of adolescent health care at the NewYork-Presbyterian Morgan Stanley Children’s Hospital. “This is part of why adolescent medicine came into being.”

“Traditionally,” she added, “adolescent medicine was intended to deal with kids 12 to 18 years old. It became pretty clear kids didn’t suddenly change into adults at 18, so a lot of us kept them until 21 and beyond.”

Dr. Cynthia Pegler, whose private patients on the Upper East Side primarily are young women, will continue to treat patients until they are ready to be parents themselves.

“My official rule is it is really time to go when you yourself are ready to have a baby,” Dr. Pegler said.

Dr. Soren recalled one patient who returned to her adolescent clinic after a year at an adult internist.

“I tried to prepare her as best I could,” Dr. Soren said. “I printed out her vaccines, her medical records. I made an appointment for her with the new doctor. She went once, but said she went into the waiting room and there were all these ‘old people.’ A year later she came back to refill her birth control pills, so I began seeing her again.”

Dr. David Bell, medical director of the Young Men’s Clinic and the Family Planning program at NewYork-Presbyterian, said that when he started at the clinic 16 years ago, the age cutoff was 24. Now it’s 35.

“I pushed it up to 27, then 30, and now 35,” Dr. Bell said. “I’m kind of sticking to 35.”

Drug Company Lunches Have Big Payoffs

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A free lunch may be all it takes to persuade a doctor to prescribe a brand-name drug instead of a cheaper generic, a new study suggests.

Using Medicare’s Open Payments data, researchers collected information on 279,669 doctors who received 63,524 payments reported by drug companies. They concentrated on specific drugs in four categories: cholesterol lowering statins, two types of blood pressure drugs and antidepressants.

The study, in JAMA Internal Medicine, found that 95 percent of the payments were for meals sponsored by drug companies, worth about $12 to $18 each.

Doctors who were treated to a single meal, where drug companies present information about their medications, were 18 percent more likely to prescribe Crestor, a brand-name cholesterol-lowering medicine. They were 70 percent more likely to prescribe Bystolic, a brand-name beta blocker for high blood pressure, and 52 percent more likely to prescribe Benicar, also for hypertension.

The more meals doctors had, the more likely they were to prescribe the promoted drug.

The Doctor’s Ties

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Credit Getty Images

I carefully unwrapped the lilac-colored tissue paper as my patient watched, expectantly. Given its size and shape, I was pretty sure I knew what was in this package.

He was in his late 60s and had been coming to our cancer center for years – first for chemotherapy to treat his lymphoma, then for a bone marrow transplant when the chemotherapy didn’t work. Now, cured of his lymphoma, he was in our clinic for the myelodysplastic syndrome that our treatments had caused. His bruised fingers, a consequence of the low platelets resulting from his failed bone marrow, tapped his knees impatiently until I uncovered his present.

“A tie! I love it! What a beautiful pattern!” I exclaimed, holding it up against my shirt.

He beamed at me. “See? I know you, I know what you like!” he almost shouted.

“I’m touched. Thank you,” I told him. He was still grinning. He had just retired as a tailor, and this was his business – knowing men’s styles, and making them feel comfortable in their clothes. He had done well and it gave him pleasure, I suspect, to be able to help me.

Perhaps I’m in the minority of men, but I appreciate being given ties.

My kids get me ties for Father’s Day, clichéd as that may be. Their taste tends toward bright colors and animals, and I dutifully wear them to work, proudly displaying them to colleagues and patients alike, despite my wife’s entreaties to keep an extra, more subdued tie at the office that I could change into.

My dad, on the other hand, hated ties. He even declared, on the few occasions I ever actually saw him wear one, that he hoped the man who invented these objects of asphyxiation suffered mightily during his own lifetime.

Yet, when my dad died, it was his ties I turned to. After his funeral, I sat on the floor of his closet and sorted through his collection, some decades old, of varied patterns and widths, some still bearing the stains from hurried pasta dinners or cups of coffee. And during the weeks that followed, when I felt as if I roamed the earth unmoored in his absence, I wore his ties to give me strength, and bring me peace.

I still do.

My patients often comment on my ties. I have one, I think intended for a lawyer, subtly patterned with tiny wolves in sheep’s clothing. When a patient notices the gag, I joke that it’s probably not what they were hoping for in an oncologist, and they laugh, breaking the tension in the room.

Ties can be conversation starters, allowing me and my patients to talk about mundanities, before we launch into the seriousness of cancer. Most patients compliment me on my ties. A few of my patients, all older and more formal in how they approach their doctors’ appointments, come dressed to the nines to my clinic, and I make sure to compliment them, too, as they clearly value appearances. But occasionally, someone will make a comment that is vituperative. One patient blurted, as soon as I walked into the clinic room:

“Whoa, doc, that tie is awful! Did you get dressed this morning with the lights off in your bedroom?”

I didn’t get upset. I’m not exactly considered a fashion maven, and style is subjective. I also knew, as did he, that his leukemia had returned, and suspected he was taking out his anger about the return of his cancer on the fabric of my tie.

Ties in medicine can be controversial. There is even a growing movement to ban ties, as they may be vehicles for transmission of germs in their casual draping across hospital beds and exam tables as we move from one patient to the next. Many pediatricians eschew ties for this reason – as well as to prevent themselves from choking, as infants and toddlers are prone to grab them during a clinic visit. This is less likely to occur with adult patients, although it did to me recently.

I was examining a woman in her 30s with leukemia who had suffered mightily at the hands of our chemotherapy, but had emerged in a remission and was feeling better. As I stood before her and reached to feel for lymph nodes in her neck, she similarly reached up to straighten my tie and tighten the knot. Our eyes met, and we both laughed, embarrassed.

“I’m sorry,” she said. “Your tie was off to the side. I need you looking right for me.”

Many patients have expectations of how professional their doctors should appear. If a tie helps build confidence as they face the uncertainty of cancer treatment, as wearing my dad’s ties helped me build confidence as I faced life without a father, then I’m happy to wear one.

Dr. Mikkael Sekeres is director of the leukemia program at the Cleveland Clinic. Follow him on Twitter @MikkaelSekeres.

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Finding Ways to Keep Patients at Home

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Credit Getty Images

My patient was a proudly elegant woman in her 70s who lived alone. Her Parkinson’s disease had so severely restricted her ability to move that it would take her hours to get dressed in the morning. And leaving the house was virtually impossible, so she had to rely on neighbors and friends from her church community for help with shopping.

She was adamant that she wouldn’t want aggressive treatment to keep her alive. She’d been hospitalized many times, and she told me she wouldn’t want to take a hospital bed that would be better used for someone else. So she dutifully completed an advance directive that made her wishes clear. It said that she would not want to be kept alive on a breathing machine, and that she wouldn’t want cardiopulmonary resuscitation if her heart stopped. She also wouldn’t want to be fed through a tube if she was no longer able to eat. What was most important to her, though, was staying at home and avoiding a nursing home.

As a palliative care physician, I always urge my patients to complete advance directives. These are legal documents that tell doctors and family members what treatment they do and don’t want if they’re ever unable to make decisions for themselves. That’s important, because if I don’t know what my patients want, the default is to do everything to keep them alive, which typically results in unnecessary and costly treatment. Indeed, one of the most often-cited arguments for advance directives is the fact that 25 percent of Medicare spending is for people in the last year of life.

When my patient developed a cough and a fever, likely a result of pneumonia, she became too confused to make decisions for herself. Thanks to her advance directive, her family knew that she didn’t want aggressive treatment, and we knew that she wanted to stay home. So we arranged for short-term daily nursing visits and enough support so that, with additional help from her family, she was able to remain at home as she wanted.

I thought that she would get worse without aggressive treatment in the hospital, and that we would enroll her in hospice, so I was surprised when she began to improve. Soon she was able to make decisions for herself and even returned to the same level of independence that she’d had before she became sick. That’s when it became obvious to me that advance directives have their limits.

My patient lived, as many people with chronic, serious illnesses do, on a thin ledge of independence. The smallest nudge — a few missed medication doses, the loss of just a little support — left her entirely vulnerable. In my patient’s case, that nudge came two months later, when her neighbors ran into financial problems and their daughter, who had been doing the grocery shopping for my patient, had to take an after-school job. My patient valued her independence more than anything, so whenever her neighbors and her out-of-state family checked on her, or when we called her, she told us all that she was fine.

For three weeks, my patient subsisted on nothing but white rice, because that was all she had in the house. When her grand niece called us and asked us to check on her, we sent a social worker and a nurse to visit her. We found her housebound, surrounded by garbage, with no clean laundry and no toilet paper.

Despite our best efforts, we couldn’t do enough to keep her safe at home, so she went to live in a nursing home, where she spent the last two months of her life. An advance directive had helped her stay out of the hospital, as she had wanted. And perhaps it even made a bed available for someone who needed it more, as she’d hoped. But that piece of paper didn’t help her to live out her final months with the sort of comfort and dignity that she deserved.

When we talk about advance directives and reducing costly and unnecessary treatment at the end of life, we should also be talking about ways we can provide more support. We need to make sure that people like my patient have access to the kinds of care that can help them remain safely and comfortably at home.

Now when I help my patients complete an advance directive that defines the treatment they don’t want, we also discuss what support they’ll need in the future. I talk with my patients and their families about what’s going to be necessary to keep them safe and comfortable in their homes today, and next month and — if they’re lucky — for the next few years.

Those sorts of discussions are essential, but they’re not enough. We also need to revise the way we think about advance directives. Advance directives help reduce health care costs at the end of life by avoiding aggressive treatment, but that’s not the most compelling argument for them. It’s not enough to reduce what we spend on aggressive treatment at the end of life; we also need to spend those resources in better ways.

For someone around my patient’s age, the average cost of a hospitalization is about $13,000. So Medicare should have been willing to spend $13,000 to keep her safe and comfortable at home. That sum would have been more than enough to pay for a visiting nurse to continue to check on her after she recovered from pneumonia and a home health aide to help her with bathing and dressing. And it could have paid the girl next door to do her grocery shopping so a frail elderly woman didn’t need to subsist on white rice because it was the only food she had.

We should have been able to provide all of that help. My patient was adamant that she didn’t want to spend her last days of life in a hospital, taking up a bed that someone else could use. Let’s make sure that when people like her forgo costly treatment at the end of life, they get something in return.

Dr. David Casarett is a professor at the University of Pennsylvania Perelman School of Medicine and the author of “Stoned: A Doctor’s Case for Medical Marijuana.”

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