I realized today what medical intervention would help her the most.
You know what prescription she needs?
Money. She needs money.
I'm an internal medicine doctor, which means I see adult patients in Baltimore. Today I saw one of my favorite patients. She has chronic pain and a particular gastrointestinal syndrome which leads to frequent hospitalizations. Both make it very difficult, and really -- in practicality -- impossible for her to work. Her disability is taking a while to come through, because "chronic pain" and "back pain" are too often not considered as "real disease" by the powers that be. She can't afford many of her prescriptions because she lacks an income. She might get evicted any day.
I realized today what medical intervention would help her the most.
You know what prescription she needs?
Money. She needs money.
This originally appeared in the Forward newspaper.
I stood, legs apart and face to the wall, in the Capitol Police Vehicle Maintenance Division. In other words, a garage. And I thought: I want to shake the hand of the person who invented plastic zip ties. They’re probably doing extremely well for themselves.
But let’s start from the beginning. How did I get here, hands cuffed behind my back, and why did I still feel, all in all, pretty good?
I’m a doctor who’s been in practice almost 10 years. During my training I wasn’t that involved in politics, and after 2009 even less involved. I was complacent after Obamacare passed.
In the following years it became evident that more and more patients were able to seek me out and start seeing me as their new doctor because of the insurance available through the Affordable Care Act. Sure the legislation wasn’t perfect. Everything can always be improved. I even rolled my eyes and acted supercilious at those who wouldn’t shut up about single payer. Why rock the boat? Then Trump happened. During the run-up to the election I understood the abstract possibility that he could win. Though I’m certainly no prophet and I didn’t come near to predicting what eventually happened, I was really worried that a President Trump would wipe out the progress of the past few years: the millions more Americans with insurance; the decrease in the rise of healthcare costs, the improvements in population health.
I was shocked in November, and after the inauguration it was as if I had woken up from a long nap. With mounting fear and panic I understood that the priorities of Trump and his Congress collaborators are different from mine, and those of my doctor and nurse colleagues — and certainly different than what my patients think is important. Many Republicans believe that government should not help the sick, because being ill is a moral failing. The sick need freedom to cure themselves.
As a response, I founded a social media group called Doctors Against Trump which later, with the help of expert friends, I converted to a political action committee to support candidates who believe in progressive health policies. I started calling my Congressmen and Senators regularly, and I made use of various on-line tools that connect blue-state voters with red-state constituents, urging them in their turn to call their elected officials.
This was something, but it didn’t feel like enough to me. I wanted to physically and concretely demonstrate support for my patients (sick, weak, old, marginalized), that I wasn’t sitting doing nothing while people were trying to take away their insurance. Once or twice I went and had a polite discussion with a senator’s health aide. That didn’t hit the spot either.
I saw that two separate groups were collaborating in a Senate protest action: those from various faith traditions (priests and ministers, rabbis, ordinary Jews and Christians; probably others too), on the one hand, joined also by health professionals: doctors, nurses, dentists; together with patients ready to tell moving stories for an audience and media. I joined them on a sunny morning in Washington, DC, at a Lutheran church not far from the Capitol and Union Station.
First we joined in prayer (as a Jew, I was happy that specific Christian expressions were deliberately avoided, and no one invoked Jesus’ name). I put on tefillin as a sign of serious piety in the public sphere defending the principle in the Biblical verse “you shall surely heal.” I was also thrilled to meet doctors and others who I had met before only on social media.
After a press conference at which we forcefully articulated our belief, as religious people and doctors, that health is a human right, we started off in a long, stately procession, slow and steady, to the Capitol building, two by two.
Good things come to those who wait, and protesting is no exception. They let the tourists up to the Senate galleries quite quickly, but apparently it was obvious to everyone that we were planning something different.
We finally got to the gallery, looking down at the Senate. It was like a Kabuki theater, Democratic and Republican statues frozen in their feigned gravity while true realities of life and death play out on the other side of the Capitol walls. When the number of the bill was called, we stood up and shouted, “Kill the Bill! Shame!”
Though we don’t yet know, while I write these words, if the terrible bill is truly dead, I am very happy with our work. We used our privilege as doctors and bearers of faith to march against the greed and cruelty of an unfeeling administration. As part of a group of activists I felt the collective frisson that many Jews have experienced in a minyan that davens with intention: the surety that all is not lost even when the hour is very dark. We are powerful precisely because we maintain, even under attack, our beliefs in healthcare and the needs of patients.
So maybe that’s why, when I stood feet apart in the police garage, the zip ties didn’t bite as much as I thought they would.
Read more: http://forward.com/writing-trumps-america/378864/faith-leaders-and-doctors-disrupt-the-senate-for-the-sake-of-health-insuran/
We're all sick of the health care debate. But those who are sick, trying not to get sick, or taking care of others who are sick don't have the luxury of absenting themselves from this debate.
They (we) are looking on in horrified fascination as the GOP makes its plan known: dismantling Obamacare and leaving millions without insurance -- replacing it with stopgap subpar underfunded skimpycare.
The so-called "skinny plan" is chockfull of real harm. 15 million more uninsured. 20% premium increases. And that's before the skinny bill is stuffed even more full with add-ons designed to pacify the elements in the GOP who take moral exception to Medicaid. (The poor should refrain from getting sick, you see. Government should not be involved in healthcare. We should go back to the good old days, whenever and wherever those were.)
It's as if the check-engine light was blinking on your dashboard, and in response your mechanic doused the car with gasoline and set it on fire.
If you have a Republican senator, call them and tell them your healthcare story. Ask them if they came to Washington to harm the sick. If you have a Democratic senator (or if your senator is Collins or Murkowski!) call and thank them for standing up for what's right. You can also go to the Indivisible website to be patched through to those in red states, whom you can connect directly with their senators. (I've done it. It's addictive.) https://www.indivisibleguide.com/hubdialer-signup/
Yes, life is full of complications. Things are hard. There's plenty to do besides this sort of advocacy. You have work to go to, kids to raise, doorknobs and toilets to fix. If you are involved in whatever else you have to do, no one should criticize. But if you can just take a moment to speak up, you'll feel good, and we'll all thank you.
This Is Just the AHCA
I have taken
you were probably
I think suffering
is so sweet
and so cold
Cada semana tutorizo (es decir, enseño y superviso) en la clínica de medicina interna a los residentes en las consultas externas del Hospital Johns Hopkins, en la calle Caroline en Baltimore. Los pacientes son en su mayoría de la ciudad Baltimore y afroamericanos, sin embargo recientemente empieza a acceder un número creciente de inmigrantes hispanohablantes.
He intentado algo nuevo estas dos últimas semanas. Cada vez que un residente me presenta un paciente (como nos exige la ley y la buena práctica), escucho la introducción, sonrío y luego me permito interrumpir con la siguiente petición:
-Por favor, dime algo no médico sobre el paciente.
En nuestra cultura médica, los residentes presentan al paciente de esta manera: "Sr. S. es un hombre de 69 años con enfermedad renal crónica, trastorno bipolar, enfermedad arterial coronaria, hipertensión e hiperlipidemia, acude para seguimiento." Pero a mí me interesa cada vez más saber algo sobre el paciente como una persona con tres dimensiones, cuando no está en la clínica.
Las respuestas de los residentes a esta solicitud mía parecían pertenecera una de estas categorías.
Hay algunos que obviamente no habían pensado en tal enfoque. Uno dijo: "El paciente es muy agradable. ¿Eso cuenta?". No, dije. Algunos residentes parecían reconocer que realmente podrían preguntar, por ejemplo, dónde vivía el paciente o qué hacía, pero les faltaba tiempo.
Otros habían preguntado sobre tales cosas, pero necesitaban permiso, por así decirlo, para mencionarlas desde el principio - para permitirse dar al amor por el paciente por los crucigramas, la devoción al coro de su iglesia y a la colección de figuras de jirafas, la misma importancia que la adherencia a la medicación y su nivel de creatina.
(Hubo incluso una residente que se rió, y siguió con su presentación - no estoy seguro si no lo entendió, o simplemente me ignoró).
Ninguno de los residentes dió dicha información personal sobre el paciente en la introducción de su presentación sin que yo lo hubiera pedido. Sólo se permiten ciertos tipos de conocimiento de los pacientes - sus datos biomédicos, sus disfunciones fisiológicas, y (algunos de) sus síntomas. Pero no su vida personal, no lo que hace que su vida - ellos mismos - les merezca la pena vivir. No ellos como personas.
Por supuesto, los criterios de conocimiento permisible se transmiten sólo implícitamente en la escuela de medicina y en la residencia. Pero son poderosos. Son una atmósfera que envuelve al médico en la clínica - tanto que incluso yo, varios peldaños por encima de los residentes en la jerarquía, me siento consciente pidiéndoles que me den una (¡sólo una!), "cosa no médica” como nombre justificativo, acerca de un paciente. E incluso entonces, debo justificarlo: "Se trata de ver al paciente como una persona completa".
¿Qué cosas no médicas le han preguntado a su paciente o compartido con su médico?
No soy hispanohablante nativo y le doy gracias a un colega generoso de Madrid que me ha editado este blog. Por supuesto llevo la responsabilidad para todas infelicidades de estilo y errores gramáticos.
Every week I precept (teach and supervise) in the residents' internal medicine clinic at the Outpatient Center of Johns Hopkins Hospital, on Caroline Street in Baltimore. The patients are mostly Baltimoreans, mostly African Americans, though an increasing number are Spanish-speaking immigrants.
I tried something new these past couple of weeks. Whenever a resident presented a patient to me (as is required), I listened to the introduction, smiled, and then let myself interrupt with the following request:
"Please tell me one non-medical thing about the patient."
You see, most often, the patient is presented this way: "Mr. S. is a 69 year old man with CKD [chronic kidney disease], bipolar [disorder], CAD [coronary artery disease], hypertension and hyperlipidemia, here for followup." But I was interested in knowing something about the patient as a person, when he's not in clinic.
The residents' responses to this request of mine seemed to fall into one of several categories.
There were those who had clearly never thought of such an approach; one said, "The patient is very pleasant. Does that count?" No, I said. A number of residents seemed to recognize that they might indeed ask about, for example, where the patient lives or what they do, but they hadn't had time.
Still others had asked about such things, but needed to be given permission, so to speak, to talk about such things right up front - to give the patient's love of crossword puzzles, devoted membership in her church choir, and collection of giraffe figurines the same pride of place as her creatinine and medication adherence.
(There was even one resident who gave a laugh and went right on with her presentation -- I'm not sure if she didn't understand, or was just ignoring me.)
None of the residents gave such personal information about the patient in the lead-in to their presentation before I asked for it. Only certain kinds of knowledge of patients are allowable - their biomedical data, their physiological malfunctions, and (some of) their symptoms. But not their personal lives, not what makes their lives -- to them -- worth living. Not them as people.
Of course, the criteria of allowable knowledge are transmitted only implicitly in medical school and residency. But they are powerful. They are an atmosphere all around a doctor in clinic - so much so that even I, several rungs above residents in the hierarchy, feel self-conscious asking them to give me one (just one!), apologetically named "non-medical thing," about a patient. And even then, I must justify it -- "It's about seeing the patient as a whole person."
What non-medical thing have you asked your patient about, or shared with your doctor?
Progressive care is in danger. Candidates to protect health for the vulnerable, evidence-based medicine, and access for all need your help. Please give today.
Also, please check out our new PAC, Clinicians for Progressive Care.
Like many of you, I have been thinking about normal-for-a-Republican and abnormal-for-anyone things that Donald Trump does. Let us bracket the obvious fact that these are on a spectrum; sometimes they overlap (the Iraq War was a huge, avoidable deception which was perpetrated by mainstream Republicans and many Democrats). I agree it is useful to keep the categories separate for the sake of argument. Further for that sake, let’s consider whether it is better to let our guard down so that some sane members of the Cabinet have the chance to do some good. James Mattis has already been confirmed as Secretary of Defense, and has been praised for some public remarks about the importance of international allilances. The name floated for the Secretary of the Veterans Administration, David Shulkin, is by all accounts a respected public servant.
But then there’s a question: given that run-of-the-mill Trumpism is racism and dismantling of the state (and we have no reason to believe the next 4 years will be any different), what does it mean to “do good” in that context? I think it depends on the extent to which different Cabinet departments are their own separate domains, or whether they are infiltrated and dismantled. I am no expert, but I assume that Defense is a much different place than State, which in turn is different from HHS or the EPA. Each could be ruined by Trump, or left untouched. Bannon could ride roughshod over any attempt by Mattis to retain the US’s place in the international order; the VA’s health care system could be crudely privatized even if Shulkin and his team are working on reform of an already well-performing system subject to unfair scrutiny.
Given what we have seen, I am afraid the expectation (in the economic sense) is a large negative: it seems very likely that Trumpism, and Bannonism, will affect the entirety of the Federal government, even if there are good actors here and there.
If I am right, and of course I welcome correction, it is our duty to oppose even the nomination of the relatively inoffensive nominees, and to try and gum up the works as much as possible. The good actors’ attempts will be thwarted by the incompetence and malevolence of the Administration as a whole, and any collaboration will sap strength from a growing movement whose aim should be the restoration of a liberal order.
Some thoughts, perhaps only to buoy myself, but also to consider when deciding who to call, with what demands, and why.
Primary care doctors ask the AMA: how could you endorse Price? The AMA says, "Mr. Trump gets to pick his team"
Doctors and other clinicians around the country reacted with dismay a few weeks ago when the American Medical Association, a generally right-wing group representing less than 15% of physicians, endorsed the fringe Rep. Tom Price as Trump's nominee for secretary of the Department of Health and Human Services. (The American Association of Medical Colleges did so as well - dealing academic medical centers a black mark.) His policies and his affiliation with the American Association of Physicians and Surgeons (like the John Birch Society, but for doctors, noted for anti-vax, racist, and conspiracist thinking) are both red flags.
Among the professional societies speaking out against the nomination is my own, the Society of General Internal Medicine. I am proud that, in separate letters, SGIM reacted with evidence-based, productive, but unstinting language, telling the AMA and AAMC in no uncertain terms why they should reconsider their endorsement.
Now comes the AMA's response to SGIM, which I paste in its entirety below. It is notable for several reasons: its deference to Trump ("America chose Mr. Trump, and he gets to pick his team"); its lack of specificity regarding those policies of Price's with which the AMA does not agree; and its disconcerting air of unreality regarding the contradiction between endorsing Price (or as the AMA distances themselves from it, "supporting the nomination") and a stated goal on the part of the AMA of not denying Americans coverage.
Thank you for your letter. I am on the AMA trail, so I will respond electronically rather than on letterhead.
I appreciate hearing your opinion about the AMA’s support for Dr. Tom Price, President-elect Trump’s nominee for Secretary of the Department of Health and Human Services. We take seriously the concerns expressed by those who do not support the nomination, and our support for it is not an endorsement of every policy position Dr. Price has advocated.
Here is a link to an article by our board chair, Patrice Harris, explaining our decision.
There is also an editorial in the Washington Post about why the Dems should not oppose the Price nomination. You might find that interesting as well. http://wpo.st/QWhI2
As a physician, Dr. Price has had a relationship with the AMA, and with organized medicine generally, for decades. Over these years, there have been important policy issues on which we agreed, and others on which we disagreed. One thing that has been consistent through the years is his understanding of the many challenges facing patients and physicians, and his willingness to listen directly to concerns expressed by the AMA and other physician organizations. I will paste below a summary of policies where we have found common ground.
If confirmed by the Senate, Dr. Price will be charged with pursuing the policy goals of the President he will serve. Similarly, as a non-partisan organization committed to improving the health of the nation, the AMA is charged with advancing a robust set of policies established by its House of Delegates, including the healthcare reform principles we circulated to our House following our recent Interim Meeting. I have attached that document to this email.
The AMA continues to be driven by our mission statement, which is “To preserve the art and science of medicine, and the betterment of public health. We remain committed to improving health insurance coverage so that patients receive timely, high quality care, preventive services and other necessary medical treatments. Moving forward, a core principle for the AMA is that any new reform proposal should not cause individuals currently covered to become uninsured.
Democracy is messy. America chose Mr. Trump, and he gets to pick his team. Our job is to work for the principles we believe in. We look forward to continuing dialogue with Dr. Price, and to our collaboration on health care priorities on which we share common ground.
The AMA has in no way abandoned its principles regarding patients, access, quality or equity. The AMA will continue to engage with the new administration on behalf of those principles. It was those principles, in fact, which led us to support the Affordable Care Act, which engendered equally critical emails from people whose world view is quite different from yours.
Thank you again for reaching out, and best wishes for the new year.
Andrew W. Gurman, MD
American Medical Association
Altoona Hand & Wrist Surgery, LLC
1701 12th Avenue, Suite C-2
Altoona, PA 16601
Dr. Tom Price efforts that align with AMA policy/advocacy
Leader on efforts to improve the Meaningful Use (MU) regulations:
Led the bipartisan effort to extend and expand the MU hardship exception for the 2015 reporting year. Introduced H.R. 3940, the “Meaningful Use Hardship Relief Act.” This was enacted as a part of S. 2425, the “Patient Access and Medicare Protection Act.”
Led an MU sign-on letter in the House (signed by 113 members) which was sent to the Office of Management and Budget (OMB) and the Department of Health and Human Services (HHS) (9/28/15).
Participated in an AMA/Medical Association of Georgia MU town hall in Atlanta, GA in July 2015.
Led efforts in 2015 and 2016 to have a 90-Day reporting period.
Leader on efforts to reverse Centers for Medicare and Medicaid Services (CMS) regulations to unwind global surgical codes (language was included in the Medicare Access and CHIP Reauthorization Act (MACRA) which accomplished this objective).
Leader on efforts to delay and improve the Comprehensive Joint Replacement (CJR) rule (led a House sign-on letter on the CJR Rule – 9/21/15).
Leader on House efforts to improve the proposed MACRA regulations. Led numerous stakeholder calls; led a House sign-on letter to CMS and OMB on improvements to the MACRA regulations (10/6/16).
Led House efforts to push back on the proposed Part B Drug Model; led House sign-on letter to CMS (5/2/16); co-introduced H.R. 5122, to prohibit further action on the proposed rule regarding testing of Medicare part B prescription drug models.
Introduced in multiple Congresses the “Medical Freedom of Practice Act” (H.R. 3100 in the 114thCongress) which would ensure that physicians are not required to participate in any health plan or comply with MU requirements for electronic health records (EHRs) as a condition of licensure in any state.
Led a House sign-on letter opposing a proposed demonstration on prior authorization for home health services (5/25/16).
This column was originally published in Yiddish at the Yiddish Forward, and is published here in translation by arrangement with them.
Dear Dr. Berger,
What is your medical opinion of cupping?
Yerachmiel Lopin, New York
Dear Mr. Lopin,
Though cupping is not a brand new cure, it got a new moment in the sun in 2016, when a picture of Olympic swimmer Michael Phelps went viral - featuring his back covered in black and blew circles, telltale signs of the practice. Presumably he didn’t do this out of nostalgia for the old country and its traditional healers or for the East Side’s “bankes” parlors frequented by immigrant Jews. Phelps used cupping because of its “alternative” cachet.
How does this so-called cure work and why is it more popular now (if that is the case)?
Cupping has arisen in parallel a number of times in different cultures. The Chinese, Greeks, and Arabs acknowledge the practice, and Jews too, under the name “bankes.” Each culture, or people, has a different explanation why it might work, relevant to its own health beliefs. Chinese explanations of cupping center on “qi,” the bodily energy which flows through the organism along various lines. The Arabs of the Middle Ages, on the other hand, emphasized the balance between liquids (probably under influence of the ancient Greeks’ humors). My favorite, “Dr. Maimonides,” in his Jewish-Arabic treatise on hemorrhoids, suggested cupping as a cure, though second-line.
The ancestors of today’s Ashkenazic Jews, for example, didn’t use cupping on the basis of any theory. They just used it as a treatment, sitting in the hot baths, applying a sort of jar (the meaning of the Yiddish word “bankes” is “jar,” from the Russian). The cup, or jar, creates negative pressure which tugs at the skin. Various kinds of cupping are possible - “hot,” “cold,” “wet,” “dry.” even (so says Dr. Wikipedia) “flaming.” (Don’t ask.) People say that cupping can help pains, heal certain illnesses -- all sorts of claims.
More important than claimed mechanisms are the reasons that people are attracted to a treatment like this. I think that it has to do with the “alternativeness” of it. It’s an old-wives’ treatment in the positive sense, something supposedly natural, from the home, and easily available, like in Grandma’s kitchen, without the costs, unfriendliness, and cold scientism of today’s medicine.
That brings us to the final question. Is cupping any good? In short, the answer is - probably not. Several systematic reviews of the scientific literature on cupping have been carried out in recent years (in particular, in China, where there is an incentive to carry out such studies, often of dubious quality), which show that it might be useful in some cases, but perhaps not (the evidence is weak), and probably no differently than placebo.
But if you’re looking for an alternative therapy, a placebo sort of thing, which can calm you and bring comfort, despite the ineffectiveness according to the dry facts, and something which has been popular throughout the generations….well, so what if it isn’t any good? Never mind that. You get bruised, the wallet gets lighter, and at the end of it all it’s unlikely to harm you very much.
The author of Talking To Your Doctor and Making Sense of Medicine blogs about the books, shared decision making, doctor-patient communication, and the redeemable imperfections of healthcare.