Specialties & Topics
- Arthritis/Rheumatic Disease
- Breast Cancer
- GERD/Peptic Ulcers
November 4th, 2016
A harsh reality I am coming to terms with, as a newly minted “pre-tending,” is that we don’t know the cost of the care we provide. There are recommendations for things like High Value Care, from organizations like the ACP. But how much do things actually cost? Certain apps and websites, like the Healthcare Bluebook, give you an idea of the cost of tests, procedures, and medications that you are ordering for your patients. But often, especially at hospitals like mine, public hospitals that serve many uninsured, under-insured, and Medicare/Medicaid patients, we encounter situations where patients can’t afford the services and medications that they need. I often find myself turning to sites like Good Rx to get coupons for patients, but, beyond this, the reality is that I don’t know where they can get affordable care.
I live in North Carolina, and I recently had a patient with presumed Rickettsial illness who was unable to afford doxycycline. I assumed this antibiotic was so basic and simple and been marketed for such a long time that surely it had to be accessible. But he wasn’t able to afford it. So how can we help? What tools are at our disposal?
Good Rx is one. If you type in a drug name, it will show you the pharmacies near the patient’s home that have that medication; the patient can compare prices at different pharmacies in the area. You can get printable coupons; you can print a voucher for the medication. We use the old standbys of the WalMart $4 list and the Target $4 list, and many medications are on those. Other resources exist, like Formulary Search, to tell you what is preapproved by a patient’s insurance. Remember all that prior auth paperwork? There are budding apps to help you with that.
But this is one of the things that we just don’t receive any training on during medical school and residency. I wish that it doesn’t matter — that “I’ll just prescribe the Best Therapy for my patient.” But I’m realizing that is a real struggle. In real life, if the benefit of the Best Therapy is something like 0.05%, but that Best Therapy is 10 times more expensive than the next best drug, sometimes it makes sense to recommend the one that is technically inferior but affordable. Because my patient will then actually be getting treatment.
It’s hard when your best intentions are met with a roll of red tape. It’s a real issue for all of our graduates fresh from residency. We are still shiny and hopeful. We haven’t become so jaded that we don’t want to Do Good. But we could use the tools to help us accomplish that.
Post your favorite resources that help you Do Good! Help others to stop grasping in the darkness!
October 7th, 2016
As physicians, we generally attempt to separate our personal lives from our work. Some of this comes from modeling behavior of others during training, some comes with further experiences in coping with the patients we encounter.
I recently had the pleasure of caring for an elderly gentleman who was brought into the hospital by his loving wife and son. He had Parkinson disease, as well as dementia, and his family reported that his memory had declined considerably over the past several months.
I could not help but to be reminded of my own grandma — a fiercely independent and hard-working woman who had suffered her own declining health and memory recently — also as a result of Parkinson disease.
The family of my patient mentioned that, over the past 3 days, he had declined to the point of sleeping all day. When I first saw him, he was fairly somnolent but roused to voice, and he was not oriented to place or time. He referred to the nurse in the Emergency Department as his girlfriend, which his somewhat-embarrassed family members immediately apologized for. I stated that it wasn’t unusual for patients with memory problems to experience further confusion in a new setting.
I thought of my own grandmother, who had been unable to respond to questions without significant delay and effort, who at times could not remember all the names of her children who she dearly loved.
As we interviewed the patient further, he coughed on his own secretions; several minutes passed before he was able to breathe comfortably again. His wife noted that he had been doing that a lot during the past week. He needed oxygen now, although he never had before. I broached the subject of goals of care, knowing from chart review that the patient’s primary doctor had discussed this before. The grave expressions on the family’s faces conveyed their understanding of the severity of the situation. They looked at me expectantly. “Doctor, please tell us the truth about what’s happening.” The reality of the story — what his family members shared — was that he was in a stage of dying. Over the past several weeks, he had not been getting out of bed. He had not been eating or drinking, and he was losing weight. He could no longer safely swallow and was aspirating his own saliva.
I had recently watched my grandmother in these same stages. First, she could no longer eat bread, because she could not do so without risk of choking. Later, she could not go long without coughing on her own saliva.
The patient’s wife understood clearly when I conveyed his poor prognosis. She and her son did not hesitate when I discussed care options for their loved one; they immediately stated that they wished for him to be comfortable and not to undergo aggressive measures such as a feeding tube. His wife commented that “his life has not been living.”
Again, I thought of my grandmother. The gardening and quilting that she enjoyed so much during her life had become a distant memory by the end. My grandfather lovingly had visited her every day in the facility where she received hospice care.
Our patient passed away only a few days after I had met him. My grandmother had also passed away comfortably after receiving hospice care, only a few weeks prior. When I saw him, I saw my grandmother. When I saw his grieving family, my eyes filled with tears.
September 27th, 2016
It’s that time again — time to dust off your nicest suit and prepare for either residency or fellowship interviews. Being knee-deep in interview season for Infectious Diseases fellowships, my interview days bear some resemblance to my residency interviews, yet also are quite different. I have a unique opportunity this year to be a part of the recruitment and decision process for our internal medicine residency program, in addition to being a fellowship applicant.
I was visiting my cousins this past week, and they were baffled about my latest job search. “Matching” is a foreign concept to my cousins and to almost everyone else not in medicine. They asked, “So how was your interview? Did you get the job?” I started to describe the ERAS and NRMP match system: Filling out a centralized application (through ERAS), picking certain programs, accepting invitations for interviews, submitting a “rank list,” then having an algorithm determine where I will be working (while I wait with bated breath). I explained that I am interviewing at program XYZ now, and my cousins asked: “So, when does the position start?” The conversation that ensued was abruptly cut off by a crying baby in the next room. Probably for the best — it would have been a long conversation for the uninitiated. It is unique and unlike any traditional job application process. But, to be honest, it is an exciting and unforgettable time in the life of any medical student or resident.
Sure, last-minute plane tickets must be booked at an exorbitant cost, long drives in the rain on the morning of an interview are common, and pleading with your colleagues or program director to leave work a few hours early to make a pre-interview dinner is stressful. But all the students and residents who are going through this process now should focus on the long-term rewards rather than the short-term nuisances.
When I think about my own residency interviews 4 years ago, I realize that some aspects of interviewing for a fellowship are similar, but some are much different. The structure of the day is essentially the same: pre-interview briefing/presentation of the program, one-on-one or group interviews, didactic presentations of some sort, possibly rounding with a team, a meal with current members of the program, and then a tour.
The one striking difference for me is the actual interviews themselves. During residency interviews, I felt like the interviewer hardly spoke and I was trying to “sell myself” to the program: Why I should be selected, why I would be a good resident, why I would fit in. For fellowship interviews, many of the programs seem to be selling their program to me. Many of the interviewers speak about their research or their experience as faculty. The “interviews” themselves are much more informal and are more like conversations. This caught me off guard initially, but I have settled into the pattern and become more comfortable.
For me, it has been an honor to meet and talk with some of the leaders in Infectious Diseases, because who knows if I will have opportunities for one-on-one conversations like these later in my career? To be on a conference call with one of the authors of the “ID Bible” and to talk about his area of expertise is humbling and intimidating. I have found it interesting to hear the opinions of these leaders on why the ID field has seen such a decline in the number of applicants (that topic I will reserve for a completely different post).
I wanted to leave you with some essential “dos,” and “don’ts,” for the interview trail, no matter what level position you are interviewing for. Many of these concepts seem like common sense; however, I have been unpleasantly surprised by the amount of “don’ts” I see from candidates we are hosting or from fellow colleagues on the interview trail. Have a great interview season, and remember to cherish these experiences — they are unique to our profession!
- Be engaged throughout the whole interview day.
- Be yourself — don’t pretend to be someone or something that you’re not.
- Be truthful.
- Know your CV and what is on it; be prepared to discuss any aspect of it. If you are not comfortable discussing something on your CV, it should not be present.
- Ask questions, but direct your questions to the appropriate person at the appropriate time.
- Practice and focus on your initial introduction or first impression with your handshake, eye contact, posture, and mannerisms.
- Be professional. It’s an ACGME core competency for a reason.
- Stifle your preconceived notions. Let the interviewer guide the conversation, but reinforce (truthfully) the strengths of your application to each interviewer.
- Give thanks and be appreciative. Write thank you notes (digital or via snail mail) afterwards.
- Be Late. There is no excuse for this — give yourself plenty of time and then double that estimate.
- Be distracted. Whether by your phone or some other item. Everyone from the institution is watching you in some way or another (even people you’d least suspect; not just faculty or residents and fellows).
- Be unprepared. Research the institution, your interviewers, and the current residents/fellows prior to the interview.
- Be unkempt. Your appearance is as important as what is coming out of your mouth.
- Fall asleep or be disengaged during a didactic or grand rounds. (See #2.)
- Wear wool suits. Perspiration is not your friend.
- Ask inappropriate questions. Do not ask the program director if the cafeteria is open 24 hours or where he or she lives.
- Provide answers you think the interviewer wants to hear. This goes back to #2 in Dos.
- Try to “one up” or be disrespectful to other applicants. They may be your colleagues come next year.
September 20th, 2016
I began one of my PGY2 medical oncology rotations alongside my co-resident: an MD/PhD, fast-track (pre-matched into fellowship) future oncologist. Among my three interns that rotation, two were “Harvard kids.” Needless to say, I was intimidated. My colleague and counterpart not only had the entire catalogue of genomic alterations at the tip of his tongue, he knew and understood their implications on disease. I saw my intern having a long conversation with a nurse at our patient’s door, and when I approached to see if there was anything I could do, I observed him giving a flawless lecture on the approach to an abnormal urinalysis and what really necessitates antibiotic treatment. I wasn’t really sure what I could add to this equation.
Over the course of the rotation, I found my place, and we all settled in to our roles. We learned from and taught each other different things. We had sick patients, and we took good care of them. When we felt like we’d exhausted all of our medical options to potentially reverse whatever underlying condition that we were attempting to treat, we would joke, “it’s time for ECMO.” When the joke began, I knew what ECMO was, but I didn’t really know how ECMO worked. I silently laughed along, certain that my co-resident and intern possessed superior understanding of this process and would lose all faith in my future contributions to the team should they become aware of my knowledge deficit. But, as we sat at the workstation one day, my co-resident opened Wikipedia and asked, “How does ECMO work exactly?” From there, the intern opened a series of diagrams and images, and we stood together, learning. I look at that experience as an academic “near miss.”
This experience is admittedly mundane, but it highlights one of the turning points in my career. I realized that, for years, I was embarrassed to read. The one piece of advice we’re given as trainees is “read more.” It is tattooed onto our physician-in-training souls. And I did read, but I had been reading “in private,” ashamed to admit that any knowledge deficit existed. I was convinced, each time I read, that I was looking something up that “I should already know.” And yet, there we sat for 5 minutes, looking up something in broad daylight!
I now know more about ways to learn. Working for 12 or 18 hours and attempting to absorb an article or chapter on the subway ride home is self-sabotage. “Spaced learning” is on the rise. Gone are the days of walking to the library to check out a stack of books. Medicine programs (such as my own), major journals, and academic societies “feed” you information via Twitter. We have infinite access to information in real time and limited time to access it. Despite our own aspirations for perfection, not having infinite knowledge is human. A piece of advice to interns and residents: Ask questions. Look up your own answers. Read more. Let what you don’t know motivate you. Being ashamed to acquire knowledge is a tragedy.
September 12th, 2016
This basic lifesaving medication is cheap to produce. It should not be a way to make a billion dollar profit. Should EpiPens be inexpensive and available? I say yes, and here are my reasons. I am not going to blame Shkreli or Bresch for trying to make money; it’s the system of silence and inaction that I blame. Money, power, corruption, and political influence are the key factors that allow big pharma and the individuals who run them to get free publicity and millions of dollars in their pockets.
Remember Shkreli’s arrest? He posted bail of $5 million within 24 hours. Yeah, the same guy who drove the price of Daraprim from $13.50 to $750 a pill had no problem coming up with $5 million in a day. Surprising? No.
Currently, Shkreli’s company, Turing Pharmaceuticals, makes the only FDA-approved pyrimethamine to treat toxoplasmosis. Even though the patent expired long ago, any company who wants to make a generic would need considerable time to go through FDA’s approval process. Silence and inaction on drug reform mean that patients are now charged 50 times more for their medication.
When Bresch’s company, Mylan, first bought Epipen in 2007, the price was around $50 for a single pen. Now, it has climbed to $600 for a pack of two! Epinephrine is not a new drug. It was first isolated in 1901, and it is not under patent. It is on the WHO list of essential medications, and the wholesale cost in the developing world is between US$0.10 and US$0.95 a vial. In Canada, Epipens cost around $102 (American) dollars, because Canada regulates drug prices.
The Epipen autoinjector is patented. But, how much does it cost to make an autoinjector? I mean, it is not made of gold or platinum! Now, Mylan promises a cheaper generic for the U.S. market. This is the recent trend in pharmaceuticals — to raise prices (“temporarily”) with a promise of a future generic. Everyone quietly pays the “temporary” higher price, because “the generic is coming.”
However, the FDA takes a long time to approve generic medications and devices. Teva failed to obtain regulatory approval for its epinephrine-delivery device, and Sanofi recalled its autoinjector for incorrect dosage delivery. So Mylan alone sells Epipens and can increase the price without any competition. One might say that this is exploitation of a basic human need to obtain a life-saving medication — a medication that has been produced for almost 100 years.
Drug and device patents allow monopolies in the pharmaceutical industry: An average patent is enforced for 12 to 15 years. Although drug regulation obviously is important for patient safety, drug prices should be regulated, and approvals of generics should be prioritized. Right now, federal law prohibits Medicare from negotiating drug prices. We need legislation that limits the ability of pharmas to manipulate the system.
There is no transparency in the drug manufacturing costs, and a recent analysis, reviewed by NEJM Journal Watch, suggests that development costs do not explain the costs of patent drugs (Why Do Prescription Drugs Cost So Much?). In reality, the silence and inaction around drug pricing allows pharmas to charge “whatever the market will bear.” It is unfair to the general public, because medicine is not a choice, but a need. Silence and inaction are unacceptable responses.
September 5th, 2016
Last month, as I was adjusting to my new role as a newly minted attending (affectionately referred to by many as a “pre-tending”), I had the opportunity to precept some of our strong upper levels in our ambulatory clinic. Luckily for me, they were doing a great job, which helped the whole thing feel less scary to me. During this clinic, one of the residents came into the workroom to exclaim excitedly —”I just asked someone if they have sex with men, women, or both — and they said both!” This reaction was not because this resident is bigoted nor that he wasn’t incredibly professional with great bedside manner. It was exactly the opposite — he diligently screened all of his patients for all of the “checky-boxes” we learned about in medical school, and he was just excited about the opportunity to care for a relatively underrepresented patient. But it made me pause for a moment and reflect on something that has become a hot topic for me locally.
I am from North Carolina. And earlier this year, my state passed a House Bill (HB2) that bans transgendered people from using the public restroom that aligns with their gender identity. The original Bill also nullified local ordinances that protected discrimination based on sexual orientation. The outcry from much of the public sector has been very loud and very visible, with people adopting anti-HB2 slogans like #WeAreNotThis and #Ya’llMeansAll. Thus, sexual identity has become a topic of conversation here in North Carolina, and also nationally, as companies, artists, investors, and developers pull out of North Carolina, so as not to support HB2. Most recently, the NBA AllStar game announced that it would not be holding its event in Charlotte.
This means that we, as physicians, have been talking about this issue as well, many of us more so recently. Institutions in our state are now having Grand Rounds on Transgendered Identity and Development, and the new Center for Child and Adolescent Gender Care just opened locally. In an attempt by many to not “miss” the LGBTQI community in a time when many feel neglected or discriminated against, some of us well-meaning physicians are at risk for getting a bit sidetracked by gender identity. By that, I mean I think it is easy to excitedly focus on a patient’s sexual identity in an attempt to show that you are supportive, in a time when this group is being marginalized. To congratulate yourself for being hip and open. But in doing so, it sets us up to miss an opportunity to support this community with some of the well studied means that we already have.
Recently, in NEJM Journal Watch, a physician-author reviewed an article addressing the health and health risk factors of the LGBQ community. Of the more than 65,000 people surveyed, those who identified as gay/bi/lesbian had higher rates of psychological stress and higher self-reported rates of substance use and abuse.
Because sexual orientation has been stigmatized for so long, I think it is incredibly easy for physicians, regardless of their personal or political views, to become fixated on this aspect of the patient. This often happens with only good intentions — physicians trying to be open and supportive and talk openly about issues of sexual orientation. Unfortunately, this hyper-focus often can happen to the detriment of other important health issues. I have been guilty of this, as I am willing to posit, have many of my peers.
What this aforementioned study suggests to us is that one of the best things we can do is spend a little extra time with this (LGBTQI) subset of our patients to actually discuss substance use and support systems in more depth than just checking off boxes on an intake questionnaire form. We know how to do this, and when we take the time, we can do it well. We have long had data articulating the many benefits of tobacco cessation, and the myriad other adverse health events tied to it. We should ask (and actually listen!) about other substance use, and counsel appropriately. And we ought to recognize the unique stressors weighing on these patients and spend more time exploring support systems and making sure they are adequately addressed and recognized.
Asking if someone’s sexual partners are male, female, or both can be a useful question and tool. But rather than us having it be the “checky-box” that defines them, let us instead let it be the start of well-tailored care centered in listening well.
August 29th, 2016
You are currently on inpatient wards and notice your chief medical resident has been demonstrating erratic behavior, frequently muttering about MEN syndromes and antibodies associated with rheumatologic diseases and has been reciting gene translocations. What is the most likely cause of her symptoms?
A. Hospital-associated delirium
B. Conversion disorder.
C. Symptoms related to completing an excess number of multiple choice questions in preparation for taking Internal Medicine boards.
If you guessed C, you understand what I have been going through in the past several weeks. Although I hope no one actually thought my behavior was erratic, I spent the majority of my free time prior to August 19th preparing for the American Board of Internal Medicine Certification Exam. And I’m in good company. Recent graduates of internal medicine residencies across the country have also been preparing for and taking this exam in late August, often concurrently with starting their first “real” jobs or completing training with fellowships. It is a test that you prepare for throughout residency with didactics lectures and annual practice exams (in-training exams). Attendings are constantly preaching important clinical information on rounds, typically using the phrase, “this will definitely be on your boards.” As a chief medical resident, I have found myself spouting board-style questions to start off our morning reports and often using that same phrase to enforce the importance of this information to interns and residents.
Despite the significance of this exam to our training, I can’t help but wonder why this test alone is used as a judge of my capability to be a “Board Certified” physician. Having recently taken the exam, I believe the content is reasonable, but the truth is that no 240-question, multiple-choice exam can reflect all of the knowledge that is truly required to practice Internal Medicine. Most medical situations with real patients are not as simple as choosing a single answer. The clinical decision-making that goes into a case of a patient who is presenting with inconclusive work-up is much different than the characteristic cases seen on typical board exams. Most patients don’t present with the key words or pictures we learn to associate with different diseases. Far beyond knowledge alone, the communication and art of medicine is certainly not measured by selecting letters on an exam.
Admittedly, there is no perfect way to assess this knowledge for physicians today. Now more than ever, we actively rely on resources to look up information that we haven’t memorized and to collaborate across specialties to coordinate care. At the same time, it is appropriate to have some type of standard for a knowledge base that is important for trainees. Despite much criticism (and I haven’t even mentioned the cost!), board exam scores are important for obtaining and keeping positions as well as conveying to the public that we are appropriately trained and certified for our positions. However, I can’t help but wish this assessment of knowledge could be focused on clinical care of actual patients rather than selecting answers to a hypothetical situation on a computer.
I would rather housestaff learn how to deal with the reality of clinical uncertainty in medicine than memorize Reynolds’ pentad or how to treat babesiosis. I would rather have patients truly trust in residents and understand their explanations of the risks and benefits of anticoagulation than have them memorize the coagulation pathway. Despite the reality of standardized tests, I hope to frame knowledge to students and residents as important to the patient care they provide and not simply because “it will be on your boards.” Even with an always looming exam, there is a lot more to medicine than choosing A, B, C, or D.
August 22nd, 2016
“Medicine Purple is now rounding at Room 202.” The announcement rang throughout the hallways on the lower pavilion. It was an announcement I had heard many times before, but this time it was quite different. As I glanced in the upper right hand corner of the electronic medical record of my first patient, the following glared back at me in all capital letters: “ATTENDING: COOPER, JOSEPH DAVID.” I had imagined the transition from resident to attending would be quite easy. I was in for a shock.
The first month of my chief residency had been primarily administrative, and I found myself becoming more frustrated and going home upset and with a short fuse at times. But not in my wildest dreams could I have imagined the responsibilities surrounding the role of being the Attending Physician of record. Everyone looks to you for answers: my team, including medical students, interns, residents, pharmacists, nurses, and ancillary staff, and, most importantly, patients and their families.
But this week — my first week on service — reaffirmed my passion for clinical care and my ultimate goal to become a clinician-educator. At first, I was unsure about my teaching abilities. But teaching, whether formal or informal, occurs at all levels of training, and I threw myself into it. I was surprised to find that I could deduce out how much or how little my team knew by simply asking questions and waiting. Ask the medical students first, and if they don’t know, move up to the interns, then the residents. I reminded myself to ask in a nonconfrontational style and engage every learner. Asking questions is an art rather than a skill and even the most experienced and knowledgeable clinician-educators can refine and improve upon it.
The highlight of my week on service actually occurred on day 1. An older gentleman with multiple comorbidities was admitted to the special care unit with septic shock secondary to gram-positive cocci bacteremia. He had progressively declined in the last few months secondary to vascular surgeries and postop complications. A family discussion was held after admission, and he was made a No Code (DNR). Throughout the night, his blood pressure became more tenuous, and his peripheral phenylephrine requirements continued to increase. The intern approached the patient and his family at bedside and explained the need for a central venous access to continue the higher doses of vasopressor medication. Neither the patient nor his family wanted any further invasive procedures, and they decided against the central venous catheter.
I arrived early in the next morning and sat down with the family and the patient. We talked about his previous occupation, what he did for fun, how many children he had, and even about his pets. The patient was ready. He said, “Doc, thank you for everything, but I want to be comfortable here with my family.” After my patient passed, his son had tears in his eyes. He pulled me aside and said, “I appreciate everything you did and the time you spent with my family and my dad. Thank you.” I was humbled and appreciative and couldn’t hold back my own tears.
As trainees, we forget sometimes about the human aspect of medicine and why we went into medicine in the first place. Throughout our training, we sometimes become blinded by money, prestige, burnout, and other extenuating factors and forget that, ultimately, we are here to take care of patients. And not only our patients themselves but also their families and close friends.
The next time you feel overworked, burned out, stressed, upset, or anxious on the job remember why you went into medicine in the first place. To help others. Sometimes we just need a simple reminder that this is one of the most exhilarating and gratifying careers in the world. Embrace it, love it, strive to improve, be human, be good to yourself and others. All in all, I have to say this has been a great “first week on service.”
August 19th, 2016
I will never forget Sunday morning, June 12. I was off that day. I usually sleep with my cell phone on silent mode, and I slept late after binge watching some movie marathon the night before. I was still half asleep when I picked up my cell phone to see what time it was — but what I actually saw on my phone was a jumble of texts from friends and loved ones. I knew instantly that it wasn’t a good news. I opened the first text from a friend: “Are you okay? I am worried about you. I am very sad to hear about Orlando.” I thought at first that my friend was referring to Christina Grimmie’s heartbreaking incident, in which she lost her life at an Orlando concert. But that didn’t seem right — my friends wouldn’t be worried about my personal safety in relation to that event.
I had to swipe my phone for some news. The news that I read will haunt me for the rest of my life. The feeling that I had reminded me of the dementors that J.K. Rowling describes in her book. For the very first time, I understood the meaning of soul-sucking creatures. I felt as if every happy feeling literally was sucked out of my soul.
I turned on the TV. I was in a state of shock. I was in denial. I thought that this couldn’t be real, that this was just a nightmare, and that I was probably still asleep. It couldn’t be happening here. But, no, it WAS real. I lost my appetite. I couldn’t sleep well for the next few days.
I watched Anderson Cooper’s coverage on the news. He was saying the names of the people who lost their lives, one by one. It was the most heartfelt coverage I have ever seen from a television journalist. It took me back to the tragedies of Sandy Hook, Charleston, and San Bernardino.
I am still very upset when I think of how anyone, any lunatic, can buy guns without a background check. Right after the Pulse incident, when I stopped at a gas station, I saw advertisements for gun shows. Gun sellers were trying to take advantage of this whole situation. It was shameful. There was no respect for the victims who lost their precious lives.
Gun violence is a public health issue
The morbidity and mortality associated with gun violence is a serious problem. In a 2014 paper by Braga et al. about focused deterrence on the prevention of gun violence, the authors stated, “Public health researchers and practitioners have historically prevented many deaths and illnesses by applying public health’s fundamental problem-solving capacity to develop actions such as water quality control, immunization programs, and food inspection regimes.”
In another review, from 2010, Narang et al. noted that access to guns affects risk for death and gun-related domestic violence. Narang et al. based their review on data from the Centers for Disease Control and Prevention and National Center for Injury Prevention and Control, and Internet-based injury statistics: They found that high prevalence of guns is associated with high rates of suicide, accidental injury, homicide, and domestic violence. Suicide is the leading cause of death among gun owners in the initial years of acquisition. According to the authors, “Out of 395 fatalities occurring at a family home where a gun was present, suicide accounted for 333 cases (84%); 41 were domestic violence homicides, and 12 were accidents, while only nine were shootings of an intruder.”
Do guns make others safe?
Presence of a firearm in the home reportedly results in death or injury to household members or visitors over 12 times more often than to an intruder. Trauma centers receive many people with gunshot wounds said to be “accidents,” but circumstances in some of these cases indicate that they initially were stress-related shootings, done with an intent to die. Self-inflicted gunshot suicides outnumber both homicides and fatal accidents combined.
As Narang et al. note, guns are the most commonly used weapon in domestic homicides, accounting for about 65% of all such deaths. Risk for intimate partner homicide is increased by fivefold. Gun ownership results in loss of life to women by suicide three times more often than where no such weapon is available.
The most remarkable statistic this review mentions is, “In 2005, it was documented that 5,285 US children were killed by gunshots according to data collected over a full year time period by the Centers for Disease Control; compare this to none in Japan, 19 for Great Britain, 57 in Germany, 109 in France, and 153 in Canada.”
This study also talks about how the consequences of gun-related violence, death, injury, disability, and/or dysfunction have a powerful effect on our society and healthcare system. Loss of loved ones, economic hardship, and psychological trauma is devastating. Bereavement compromises the quality of life, specially for children. It results in spread of fear in communities. It also affects medical costs, which indirectly affects the general population, government, and the healthcare delivery system.
What is the cost?
According to Narang et al., “In 2005, approximately 30,000 Americans died of gunshots and nearly 70,000 received emergency treatment for nonfatal wounds. Emergency facilities are constantly burdened by the services required in such traumatic events. Medical care for these patients costs up to $4 billion per year. The overall economic cost due to these injuries in America, including healthcare, disability, unemployment, and other intangibles is about $100 billion per year.” This study also mentioned the case-to-fatality rate for gunshot trauma. It is about 30%, which is much higher than for other injuries. Death occurs following a shooting 18 times more often than after motorcycle accidents. Moreover, the hospital stays for patients with gunshot injury are in the range of nearly 2 weeks’ duration. The disability from such events averages approximately half a year. This affects taxpayers. Each homicide results in approximately $244,000 of incarceration expenses for our taxpayers.
In Kentucky in 2008, 73% of gunshot victims were uninsured, 10% were covered by government plans, and 17% were privately insured. Nationally, data reported in 2001 documented that government programs pay for about 49% of this amount, 18% is covered by private insurance, and 33% by all other sources.
Gun violence costs about 2.4 billion dollars annually to the criminal justice system in America. Local governments across our country spend up to $100 million each year just on bulletproof vests. Most of these bills are then passed on to the taxpayers. Why have no reforms been introduced after the mass shootings involving Sandy Hook, Charleston, and San Bernardino? What new laws could have potentially prevented the mass shooting at Pulse Orlando?
The U.S. has the highest rate of firearm homicides amongst developed countries
With less than 5% of the world’s population, the United States has 35%-50% of the world’s civilian-owned guns. As of now, no federal laws ban semiautomatic assault weapons, military-style 0.50 caliber rifles, handguns, or large-capacity ammunition magazines. In fact, gun sales increase exponentially after deadly mass shootings. Everyone knows how easy it is to obtain guns in the United States in the name of the Second Amendment.
Japan which has the lowest firearm homicide rate (1 in ten million) in the world. Here is how Japan does it. Most guns are illegal, and ownership rates are low. Japan’s firearm and sword laws only permits shotguns, air guns, guns that have research or industrial purposes, or guns used for competitions. Before you can obtain such a weapon, you must obtain formal written instructions and pass a battery of written, mental, and drug tests and a rigorous background check. Furthermore, owners must inform the authorities of how the weapon and ammunition are stored and provide the firearm for annual inspection.
Then of course, there is an example of Australia’s Port Arthur massacre of April 1996, after which Australia prohibited automatic and semiautomatic assault rifles, stiffened licensing and ownership rules, and instituted a temporary gun buyback program. Since then, there have been no mass shootings in Australia.
Gun violence is a public health epidemic that is on the rise. The AMA has called gun violence a public health crisis. It vows to overturn a decade-ban on studying gun violence research by the Centers for Disease Control and Prevention. The NRA opposed the assault weapons ban in 2013, because, according to CNN Money, “the organization’s overall revenue, which includes membership dues, program fees and other contributions, has boomed in recent years — rising to nearly $350 million in 2013.” According to a 2012 Forbes article, “Over 50 firearms-related companies have given at least $14.8 million to the NRA according to its list for a donor program that began in 2005.” In April 2016, Forbes published another article on the NRA. It mentioned, “The gun industry says it has grown 158% since Obama took office. The total economic impact of the firearms and ammunition industry in the U.S. increased from $19.1 billion in 2008 to $49.3 billion in 2015.”
More than 17,360 American children and teens are involved in firearm-related injuries every year, and 111,779 people of all ages are hurt annually. One out of 3 homes with children contain firearms, and nearly 1.7 million children live in homes with at least one unlocked, loaded gun, according to the Brady Campaign.
I dedicate this blog to the victims and families of Pulse Orlando, Sandy Hook, Charleston, San Bernardino, and all other gun-violence related mass shootings in the world. I would like to end this discussion on a quote by Albert Einstein:
“The world is a dangerous place to live; not because of the people who are evil, but because of the people who can’t do anything about it.”
August 15th, 2016
We had known Ms. B. for weeks. She was a “bounce-back” to the unit. Every day, an intern would enter the ICU room and ask, “How do you feel?” “OK.” Do you have any pain?” “No.” “Any trouble breathing?” “No.” “Tightness in your chest?” “No.” “No? OK.”
I was the senior resident following the case, 1 of 22 in the ICU. I walked in that morning and asked, “How do you feel? Are you nervous?” “Yes.” We’re trained as physicians to accumulate and analyze large amounts of information and condense it all into one-liners. I had known this patient as “a 74-year-old female admitted with acute hypercarbic respiratory failure in the setting of a large pleural effusion, atrial fibrillation with RVR, diastolic heart failure, and an extensive prior course complicated by an acute cardiac ischemic event, refusing catheterization.” That morning, the patient, whom I had also come to know as a dedicated mother, a strong-willed woman, and a funny, caring human being, was, in a one-liner, “tired and scared.” She was scheduled to have a thoracentesis that morning; we would remove fluid that had been occupying her lung space and test it for infections and cancer. We hoped the procedure would be diagnostic and therapeutic. She said she might not want to know if it was cancer. She just wanted to be able to go home. “We want that too, Mrs. B.”
Checklist: The patient was prepped in sterile fashion, and the area was cleaned and dressed appropriately. Risks and benefits were explained: check. A time-out was performed: Patient name—correct; Procedure—correct; Site—correct. Site was marked.
The patient sat at the edge of her bed with her arms outstretched across a rolling tray table. This was the table that usually held snacks, her small blue leather Bible, and the phone to call her son and daughter. Her children came to visit every single day and night. Today, the table held a plastic pillow, which crackled with the slightest movement. I squatted in front of the table and held her hands, while the fellow prepped for the procedure. “What procedure are you having, Ms. B?”, the attending physician asks. “They just told you. I’m having a thoracentesis.” “And what does that do? What is the purpose of the procedure?” “To take the fluid out of my lungs so I can breathe better.” The checklist was complete.
Ms. B held her small blue leather Bible by her side every day. She prayed and thanked the Lord every day she awoke to breathe. Despite 18 years of Catholic school, I probably haven’t “said my prayers” since I had to be reminded to take a bath.
“Were you born in New York?”, I asked. “I was born in South Carolina. My mother brought me here when I was 2… to be educated. I was educated in New York City.” She spoke with a pride that not only filled me with a sense of gratitude, it fractured me with guilt. I too was educated in New York City. I had always regarded my education as an expectation, as opposed to a gift, despite neither of my parents having attended college. Knowledge was, to a certain extent, a collector’s item, to be acquired and displayed within various carefully chosen venues. My mother was hard on me when it came to my performance in school. If I scored a 98% on an exam, she would ask, “What happened to the other two points?” I had never been any more proud of my education than proud of my ability to wake up every day and brush my teeth. I’ve been reminded on more than one occasion that I do not have a “pedigree.” As an older African-American woman, Ms. B remembered a time when simply attending school was a right to be fought for.
“I like your scarf,” I said. Ms. B wore a bold orange headscarf with an asymmetric bow. I’d seen her wear it many times over the course of her stay. There was something fearless about that scarf. Silence. “Are you nervous?” “Yes!” Silence. “What kind of music do you like?” “The Blues… and I love Christmas music. It just makes me happy.” I placed my iPhone on the tray table and opened a Spotify playlist called Christmas Hits. “I’ll Have a Blue Christmas Without You” was the first song. I made a joke about the song being best of both worlds. Silence. I found out during our conversation that she loved scary movies and zombie shows. “I love The Walking Dead, Night of the Living Dead, all those shows.” I told her that I can’t watch those shows because I am actually afraid of them. “They don’t scare me.”
Her hands were small. There was a cyst on her left little finger, which I hadn’t noticed before, any of the times I’d seen and examined her. I wondered what other observations I’ve failed to make. “Does this hurt?” “No.” “Has it always been there?” “No.” “What happened?” “I was carrying a heavy grocery bag, and it never went away.” When she felt discomfort or anxiety, she would quietly dig the tip of her fingernail into the pad of my gloved finger, staring straight into my eyes. I have the same self-soothing mechanism: I press the pads of my fingers, subtly and often subconsciously against the edges of my fingernails, bilaterally and symmetrically, until I’ve traveled from my indexes to my little fingers, and occasionally I’ll start the process over again from there. I usually don’t recognize my own nervousness until someone looks at my hands and says, “Are you OK?”
I whistled along to “Let It Snow” as the fellow continued with the procedure. The procedure was simple, “uncomplicated” as we say, no bleeding, no hemodynamic instability, no pain. Her son and daughter came in patting her on the shoulder, “You did great mom! See? You did great.” We all left the room to begin rounds. A post-procedure chest x-ray was unremarkable; decreasing pleural effusion, no evidence of pneumothorax. Ms. B spent the morning with her children and sister, breathing more comfortably. “She’s doing great!”
Later that afternoon, a nurse told me that the patient was having some difficulty breathing. When I arrived in the room, Ms. B’s heart rate was rapid and irregular. Simple breathing was laborious, and her face wore the expression of desperate fear. “Not the mask! No mask!” She had intermittently required a biPAP mask to support her breathing. She hated that mask. We thought the thoracentesis would alleviate its necessity. As I placed my stethoscope on the right side of her chest, I heard no sounds to accompany the arduous rise and fall of her ribcage. “We need a STAT chest x-ray!” The x-ray looked as if the image were split in two and inverted, as if the right side was a negative. Hemothorax. “She needs a chest tube,” the attending said.
As they prepared for a second procedure, I walked outside and placed my hand on her son’s shoulder. He was a large, loud, boisterous man who many of our staff members found intimidating. He had a plethora of very specific questions every day. The attending reviewed the new procedure with him, and he looked at me, timidly, with the same frightened eyes I had seen earlier that day. “Is she going to be OK tonight, Doc? I’m scared.” He previously had never called me anything but my first name. “What’s going to happen?” “I don’t know,” I said, “but we’re going to do everything we can to take care of her.” I walked away to the next room, to check on another patient, a “sick patient,” a GI bleeder receiving his 5th unit of PRBC repletion under our massive transfusion protocol. This was my education, my training as a physician, education that I was not always grateful for in the moment.
Overhead, the operator called, “MEDICAL CODE STAT TO ICU SOUTH, ROOM…” There was a cardiac arrest in my unit, right where I was standing. I started to run. “Who is it?” My chest became hollow as I realized who it was. Ms. B was dead. As we rotated through cycles of chest compressions, I felt her third and fourth ribs shatter shatter under my palm. My abdominal muscles burned. I knelt on the bed next to her and used my weight to compress. Her face no longer wore any expression of fear; she was lifeless. Her orange scarf, missing. “Pulse check.” Nothing. After [what seemed to be countless] minutes, she regained a pulse, which she was able to sustain long enough for her family to come in. She was unconscious and immobile, with a tube entering her mouth and another exiting her thorax, draining liters of blood. “Mom, you were the best mother.” Her children were draped across her bed, praying, crying, praising her life and her accomplishments, pouring out gratitude. “Jesus will come to this room tonight!” We stood and watched, fully aware of the transience of the pulse.
The last time I saw my own mother alive was in the ICU. We decided to place a DNR order before she died, knowing she wouldn’t have wanted anything more.
As the line flattened on Ms. B’s monitor, I knew the next series of chest compressions, shocks, and epinephrine pushes would be the last. “I’m running this.” Running a code had formerly been my most feared responsibility. I remember my intern year as if it were yesterday: chest compressions, running to the lab, grabbing the chart, being grateful to do anything except run the code. Throughout my training, this task has become like many others: systematic, ordered, implemented without difficulty. In this moment, I felt an enormous responsibility: to assure that we had done everything possible to give our patient and her family what they needed in that moment [for them to know they had done “everything”], to provide her the dignity she deserved in her death, to spare her from any excess undue harm, and to honor and care for her until her time of death. “6:53 PM,” I said, with final and deliberate certainty. Tears immediately filled my eyes and began falling in rapid succession as I stood, surrounded, witnessed by, the entire ICU team. The nurses rushed to the patient’s body to clean and dress her for the family to view. The family stood outside, intoxicated with fear, shock, and sorrow. “Let’s go,” one of my co-residents said, as she escorted me to the stairwell where, for a few sacred and uninterrupted minutes, I cried. I cried until it was time to wash my face, sign the required documents, and gather my papers for evening ICU rounds. “Check MR. F’s urine output overnight and dose the Lasix accordingly… Try to taper Mrs. C’s levophed…”
These are days where we not only experience but also participate in and often direct the most poignant moment of someone’s life; then, we move on with apparent simplicity. I’ve not had any more intimate experience than to learn someone’s history, wishes, and fears, to listen to her words, her breath, and her heart… to feel the contours of her hands, the fragility of her ribs, her fleeting pulse… and to witness her last breath.
I walked out of the hospital at midnight and, as I waited for a cab at the entrance, Ms. B’s family emerged, one by one: son, daughter, sisters, brother, in-laws… We hugged and cried. They told me they would take her home to South Carolina to be buried. “That’s good.” They thanked me for saying “I don’t know.” I said, “I’m sorry.” I was sorry. I am sorry for their loss, their pain, their mother’s suffering. I am also grateful to have had the experience of knowing her and her family, to have taken care of her, to have learned from her experiences, both good and bad… to have been changed by her gratitude.
Days later, I couldn’t stop thinking about this patient and how much she taught me. Although it felt strange, I googled my patient’s obituary. Among the many lines, it reads: She was educated in the New York City public school system.