A Question that Will define Your Life


The patient presented for depression, an unexplainable feeling that things weren't as they should be. He came to me for help, unsure of what he could do to improve his situation. He had achieved every goal he had set for his in life but something was missing. He had a beautiful wife and well-behaved children, a good paying job, a nice car, and a comfortable home. He had arrived at the destination he had been working toward since he graduated high school, he had checked off every box on his list, but he wasn’t happy.

He came to see me wondering if he was depressed. He wasn’t. It took only a few minutes of conversation to identify the problem. He was unfulfilled. He had met his goals but failed to find his purpose. He had not addressed life’s most important question. He had not asked himself, “What happens next?”

He had fallen into the trap that has ensnared so many. He had lived his life thinking that once he checked off all of the items  on the list of attributes of a successful life that he would be happy. He believed the lie that if he could simply achieve his life’s goals that he would then be content. When he had achieved those goals and not found happiness he did not know what to do with himself.

His fate is the fate that awaits all who believe that earthly success can bring happiness. It is a pursuit that ends in despair. News reports and reality TV provide overwhelming evidence of the fact that the rich and famous are not fulfilled and happy people, yet our pursuit of wealth and fame continue unabated. For life to have meaning, more is required. For life to have meaning, there must be more to life than this life offers.

The question for our lives is “What happens next?” for it is eternity that matters. Living for eternity, with the awareness of what happens when this live is over, can keep us from empty pursuits.  When we die it will be the only question that matters. The most fulfilling and truly successful lives are lived by those for who the answer to the question is “I will spend eternity with God.”

-          Bart

Thanks for reading and sharing. The greatest reminder of why this question is significant is just a week away, when Christians all over the world celebrate the enduring evidence for life after this one, the resurrection of Jesus Christ.

A Death Defining Conversation

The visit was supposed to be brief, a quick assessment of a minor complaint. One look at the patient as he sat to have his blood pressure taken told me that his minor complaint was not the major issue of the day. The patient, a man in his early 70’s, was a shadow of his former self. Once heavy set and strong, he now seemed gaunt and frail. Once vibrant, he now had the look of a man fighting for his life. And losing.

His appearance should not have surprised me. He had been diagnosed with metastatic cancer a few months earlier and in that short time had undergone two surgeries and 3 courses of chemo therapy. 70 pounds had come off of his 250 pound frame in just a matter of months. He was a very sick man.

It took less than a minute to diagnose the cause of the man’s immediate complaint (swollen feet due to poor circulation) and plan a course of treatment. Thinking I had dealt with that issue I decided to address the greater concern, his cancer therapy. "How is the chemo going," I asked.

“It is going well,” he told me, “the blood tests show that the tumor markers are decreasing.” He spoke with hope, as if this was a sign of cure. I knew in my heart and head that it wasn’t. The tumor marker levels had dropped from incredibly terrible to really bad. He wasn’t being cured, he was postponing his death. It bothered me that he did not seem to understand this. I wondered if he knew the grimness of his prognosis, if the cancer doctor had told him that this was the illness that would eventually take his life. I had little confidence that he had, as in my experience oncologists are often the worst bearers of bad news.

I decided to take some extra time with him to see if I could help him understand the reality of his circumstances. As a way of introducing the topic I talked in general terms about the difficulty some doctors have discussing bad outcomes. I supported my contention by taking about previous patients who did not know they were dying until their last days of life and by pointing out doctors wait so long to talk about dying that the on average, patients die within 2 weeks of being placed on hospice. I expressed my belief that it was not fair to keep patients in the dark about the seriousness of their illness, that people deserved to have clear explanations so they could make appropriate plans.

With that said, I asked what his doctor had told him about his treatments and the likelihood of success. Not unexpectedly, the oncologist had said nearly nothing. The patient did not have any idea as to what the likelihood of success or failure was with the current treatments. I told the patient I would call the doctor and get the information on his behalf. The visit ended with me making a promise to call back later in the day.

The oncologist returned my call within the hour. After the usual exchange of pleasantries I asked the question. “If you had 100 people like Joe in front of you today, how many would you expect to still be around 6 months from now?”

“Five,” was his surprising reply.

“Five with treatment, or without treatment?” I asked.

“Without treatment,” he answered, “With treatment I would expect 50.”

“How many after 12 months?” I pressed, wanting to know how serious my patient’s prognosis really was.

“25,” he said, confirming my fears. I thanked him for his time and hung up the phone, shaken by the news. Knowing the tendency of many oncologists to overestimate survival rates, and factoring in Joe’s weakened condition, I concluded that the 25% survival rate at one year was the best case scenario. It was highly unlikely he would make it to Christmas.

I paused and pondered how to communicate this information to my patient. As I did I opened the chart and saw that I had a phone message from Joe’s son. I was caught off guard by the words on the screen. “Please call daughter, Joe was very depressed and angry when he left the office.”

I called Joe instead. Joe was indeed angry with me. He told me that he did not want to hear bad news and that I should not have said the things that I did. He told me that I had not been kind, and that he liked his cancer doctor. “He gives me hope,” he said, “It may be false hope, but I like it.” I apologized for the hurt, telling him that determining the best moment to address life and death issues is difficult, and that I am often left dealing with the issue the only time I can, which is when the patient is in the office. As the conversation ended he pointedly instructed me to be more sensitive in the future.

His words stung. My desire to educate and enlighten, to allow him to make informed decisions about his care and to intelligently plan for his limited future had instead offended and shaken him. While I was correct in my assessment that he had not been well-informed by his oncologist and was in the dark about the gravity of his situation I had been seemingly equally ignorant in where he was emotionally.

I ruminated on our conversation for the next 24 hours, internally debating on how I could have done better. My thoughts went back and forth. I found myself arguing that patients cannot make informed decisions about their health care without accurate information, and then countering that patients should be able to choose when and how to receive that information. Hours of thought and prayer did not resolve the dilemma. The only certain conclusion I reached was that I wanted to do better.

I ultimately decided that I would be more cautious in the future. I would still ask people if they knew their prognosis but when they didn’t know ask, “Do you want to know?” before going further. It is not a perfect approach, but it may be better than how I approached Joe.

A few day’s later a patient who is a friend of Joe’s came in to see me. The first thing he said to me was, “I heard you saw Joe a few days ago. He wasn’t happy,”

“So I heard,” I sheepishly replied.

“Don’t worry about it,” said Joe’s friend, “everyone knows Joe is dying. He just doesn’t want to admit it.”

I held back a smile, grateful for the comforting information that Joe’s anger was at least in part due to the fact that he wanted to deny the seriousness of his disease. I may have messed up, but I hadn’t totally messed up.

In the aftermath of the difficult discussion, I am left pondering the challenges faces by doctors who find themselves having to discuss end of life issues with their patients. There is so much emotion, fear, and denial involved that effective communication is incredibly difficult and perilous. Doctors and patients need to realize this and extend grace, kindness and understanding to one another. As difficult as these discussions are we cannot fail to have them.

- Bart

Update- 2 weeks after my visit with Joe he was hospitalized with severe pain. His oncologist finally admitted the truth, that there was nothing further he could do. Joe went home on hospice.

Thanks for reading and sharing posts with others. You can subscribe to the blog to receive posts via email. I can be followed on twitter @bartbarrettmd. I am beginning to video blog as well, and my vlog posts will be available here and on my vimeo page www.vimeo.com/bartbarrett

Free Markets Won't Save Health Care

I hate to be the one to break it to conservatives, but there are no free market solutions to America’s healthcare problems. Free markets exist when purchasers have the ability to make informed choices. If widget maker A makes a better widget then widget maker B and sells it for the same price, consumers will eventually choose widget A. Widget maker B will have to lower its prices, improve its quality or go out of business.

Patient care is not like widgets.

Purchasers of health care services have no accurate way to compare health care providers. The most commonly used measures of quality are dependent more on the provider's ability to convince patients to do what they should than they are on the actual care provided. An example of this is colon cancer screening. There is no effective way to measure the skill of physicians providing colonoscopies, so insurers instead measure screening rates. I know of a physician who screens for blood in the stool based on office exams, in direct conflict with the recommended testing protocol. He knows this is not as accurate, but he doesn’t care. He has the highest rate of colon cancer screening in his medical group, and gets a large bonus as a result. His quality is low, but his quality ratings are high.

Hospitals are similarly motivated to meet inaccurate metrics. One of the most important complications on which hospitals are measured is ventilator associated pneumonias. Patients on breathing machines are already seriously ill. If they get pneumonia while on a ventilator mortality rates increase dramatically. It makes sense that hospitals be given incentives to develop policies to improve outcomes by preventing these infections. As a significant amount of money is tied to this quality measure hospitals have aggressively searched for ways to lower the complication rate. Many hospitals have found an easy way to improve their scores. When ventilator patients get pneumonia, they call it something else. Voila! No more pneumonia. Patients still get sick, but hey, the hospital numbers look great.

Inaccurate quality measurements are a major problem that has not been addressed by Obamacare or any of the other proposals currently put forth. We live in a world where looking good at times pays better than doing good. Insurers, hospitals, medical groups and physicians are all looking for ways to improve their bottom line. Most are trying to do a good job taking care of patients but good care is not a guarantee of financial success and institutions that don't succeed financially can't help anyone.

If we are ever going to reach a solution for our healthcare problems we will need to begin by making sure that incentives are aligned with patient outcomes. The best way to do this is by establishing systems where keeping patients healthy leads to the highest profits. There is no perfect system, but any good solution will need to make patient health the key to success.

- Bart

The Doctor will see You... For $3500

My grandmother went to the doctor this week with a sore on her leg. She came home with a bill for $3500. The bill had nothing to do with the treatment of her leg wound. The bill was to cover the doctor’s new annual membership fee. If she does not pay it she will be forced to seek care elsewhere. She is 95 years old and on a fixed income and will need to either pay up or move on.

Her doctor left me a lengthy voice mail explaining his fee, informing me that it will allow him to spend more time with each patient and provide high quality care. What it won’t do is cover any of her visits for the year. Those are extra and will be billed to her insurance. The $3500 is for access alone.

The fee seems exorbitant and it is. A typical senior citizen goes to the doctor 6 times a year. The fee works out to a payment of an additional $600 per visit, an astronomical sum.

While the charges are insanely high they are becoming increasingly common. Doctors who cannot make ends meet on what insurance companies pay are looking to their patients to pick up the slack. Especially for older and sicker patients, insurances don’t pay enough to cover the time needed, typically only about $120 for a 30 minute visit. This may seem like a lot, but after factoring in overhead ($160 an hour) and unpaid time spend on refills, phone calls and emails, the end result for the doctor paid this fees could be a salary of about $120,000 a year. While this is a good wage for many people it isn’t enough for a doctor with student loan debt to live in Southern California, where mortgages for a modest home can exceed $4000 a month. Many doctors are desperate to find a way to increase their income.

While this is understandable, the $3500 fee seems excessive. It seems that a doctor with 2000 patients in his practice could make ends meet by charging much less. $100 a year would result in a $200,000 a year increase in salary and make up for what insurance pays. Why charge $3500.

My recent experience answers the question. The majority of patients won’t pay the smaller amount either. My office provides a wide array of services, from guaranteed same day access and short wait times to digital visits and email communications, that are not covered by insurance plans. To cover the cost of these services, on January 1 of this year we started charging an annual access fee of $120. While we thought this was reasonable and affordable we have lost over half of the 1000 patients to whom we billed the fee. In their minds the additional access and services just aren’t worth it. It is apparently easier to find 200 patients willing and able to pay $3500 a year than it is to find 1000 patients willing and able to pay $120. My grandmother’s physician has figured this out.

This does not bode well for the future of medicine. None of the current health care plans being discussed in Washington D.C. or Sacramento address the reality that good medical care costs a lot of money and that quality doctors require competitive salaries. Patients unwilling or unable to pay extra for services will find it increasingly difficult to find a primary care doctor willing to see them and will be increasingly unhappy with the options available. It seems we are headed for a crisis of inaccessibility.

The solutions to this problem are too complex for a blog post but there is one thing of which I am certain. These solutions will not be easy and will be expensive.

-          Bart