The proper terminology is “epistemic injustice,” whereby a person’s concerns are dismissed by someone else, causing that person to question their own perception of reality, or to make them feel “crazy.”

The article was describing the experiences of patients who were referred to a specialized clinic for vulvovaginal disorders. When I read the article and the term “medical gaslighting,” I reached out to the primary author, Dr. Chailee Moss, to have her come on my podcast (the link the episode is at the end of this article) to discuss her article and the “medical gaslighting” itself.

The findings of the article were eye-opening: less than half of patients said that past practitioners were supportive; a little more than a quarter were actually belittling, and one fifth were described as not believing the patient. What shocked me was that 20.6% of patients were given a recommendation to drink alcohol to relieve their symptoms. Moreover, 16.8% of patients felt unsafe during a medical encounter and 39.4% said they were made to feel crazy.

The actual narrative responses were also instructive, and they are reproduced here:

The most important takeaway from the article and my conversation was that we must do all that we can to ensure patients feel heard. Even if we can’t find something specific to treat, we should do our utmost to ensure that patients’ concerns are not perceived as being dismissed. This applies to all specialties, including critical care. Also, “drink more alcohol” should NEVER be a medical recommendation, in my opinion. It was a very important lesson for me, and it is one I will do my best to remember every day of my practice.

Listen to the podcast episode: https://www.healthcaremusings.com/the-freedom-fighters-of-medicine/

The post Can Doctors “Gaslight” Their Patients? appeared first on Medika Life.

I can safely speak for most people when I say that we went into Medicine to help people heal, to help prevent people from dying. This is especially so in Critical Care Medicine. And so, when our patients do die, it is very hard to not take a patient’s death as a failure, not to take it personally.

This was especially true during the pandemic. Over, and over, and over again, we tried our hardest – spent blood, sweat, and tears – to care for Covid patients, and they kept dying despite everything we do. It was very hard not feel like a failure when our patients died.

Dr. Chen’s words brought me such comfort. Death is not a failure, it is a transition. And, like it or not, some of our patients – despite doing everything right and trying our hardest – are going to die. They are going to make the transition.

We need to stop taking it personally. We need to stop feeling like our patients’ death are failures – so long, of course, as we did everything in our power to try and help our patients. And, when it is clear that our patients will die, that they are making that transition, as Dr. Chen puts it, then we need to do all we can to make sure our patients die with dignity and comfort on their own terms. It is much easier said that done, no doubt, and it is essential that we remember it as much as possible.

Helping our patients conquer critical illness is the honor and privilege of a lifetime, a fulfillment of a lifetime dream for me personally. And if we can also help our patients die with dignity and comfort, on their own terms, it is also as Dr. Chen says,

“a huge privilege to be with patients in that setting….to walk alongside them and their families as they are approaching a transition.”

Dr. Elaine Chen, Rush University Medical Center

Very well said indeed.

Listen to the entire conversation with Dr. Chen.

The post Death Is Not A Failure appeared first on Medika Life.

The migration of healthcare workers from low and middle-income countries (LMICs) to high-income countries (HICs) — the so-called “medical brain drain” — is not a new phenomenon. But its scale and impact have reached a point where we can no longer turn a blind eye.

Consider this: some HICs draw as much as one-fifth of their physician workforce from LMICs. This exodus is happening against a backdrop of a global shortage of 2.8 million physicians, with LMICs bearing the brunt of this deficit. It’s akin to siphoning water from a drought-stricken village to fill swimming pools in wealthy neighbourhoods.

The drivers of this migration are complex. Healthcare workers often cite poor working conditions, limited career advancement opportunities, and socioeconomic challenges in their home countries as push factors. As one study notes, “the top five reasons for respondents choosing to emigrate from their home country were: socioeconomic or political situations in their home countries; better education for children; concerns about where to raise children; quality of facilities and equipment; and opportunities for professional advancement.”.

But the consequences are far from complex — they are devastatingly clear. Beyond the immediate loss of skilled professionals, there are significant economic costs to LMICs. A study by Saluja et al. estimated that “LMICs lose nearly US$16 billion annually (95% CI $3.4 to $38.2) due to the cost of excess mortality that results from physician migration to HICs.” This figure represents the direct financial investment in training these professionals and the potential lives lost due to their absence.

The impact on healthcare systems in source countries is equally severe. As Misau et al. point out, “The health care system in the developing countries faces many problems, human resource being one of the majors. The system is structurally and systemically fragile and weak to provide effective service where it most needs. Brain drain appears to have complicated the situation and made matters worse.”

It’s easy to point fingers at HICs for “stealing” healthcare workers from LMICs. But this oversimplifies a complex issue. Many argue that individuals can seek better opportunities and living conditions for themselves and their families. One commentary notes, “when health-workers leave, they exercise their autonomy in pursuing their life plans; the freedom to leave one’s country and free choice of profession are codified as human rights in the UDHR.”.

So, what’s to be done? The World Health Organization has developed a global code of practice for the international recruitment of health personnel. But as Brugha and Crowe point out, “the code is ultimately voluntary. Recent research has suggested a lack of awareness of the code among relevant stakeholders and that the code has not affected policies, practices, or regulations in Canada or other developed countries.”

LMICs need to implement strategies to retain their healthcare workers. Kamarulzaman et al. suggest, “Investing in and strengthening domestic health care, providing career opportunities and attractive remuneration, and investment in research and development in a context of political stability are necessary to attract and retain health workers.”

But HICs cannot absolve themselves of responsibility. Ethical recruitment practices, support for health system strengthening in LMICs, and partnerships for medical education and training can help mitigate the negative impacts of healthcare worker migration.

The current situation is unsustainable and detrimental to global health equity. As Eaton et al. argue, addressing this issue requires “a comprehensive approach that considers the rights and aspirations of individual healthcare workers, the needs of source countries, and the ethical responsibilities of destination countries.”

The medical brain drain is not just a problem for LMICs — it’s a global health emergency. And like all emergencies, it demands immediate, concerted action. The health of millions depends on it.

The post Medical Brain Drain: A Global Health Emergency We Can No Longer Ignore appeared first on Medika Life.

It is inevitable that some people will die who get admitted to the ICU. It is always sad, and it makes us sad as critical care clinicians. It is reality, nonetheless. During the pandemic, it seemed that everyone who was admitted with COVID-19 ended up dying, and thank God, that was not the case at all.

Still, when it is clear that I will not win the battle against critical illness; when it is clear that my patient will die, then my fight changes to ensure that my patient does not die an ignoble death.

What is an ignoble death? It is one without dignity; it is a death not on the patient’s own terms; it is death of pain, distress, anguish, and suffering. No one deserves this kind of death.

None of us knows when we are going to die. None of us knows where we are going to die. None of us knows how we are going to die. Those things are, in fact, unknowable and beyond our control.

What we can control, however, are the terms of our own death. When we finally face death, how will we die? Will we die on machines? Will we die having the healthcare team pounding on our chests and shocking our hearts? Will we die having someone put a tube down my throat? Will my family be there?

We can choose the answers to those questions. We must choose the answers to those questions and make those answers known to our doctors and those taking care of us in the healthcare setting. It is absolutely essential – and dare I say it – critical that we make the answers to these questions known. Everyone deserves a death on their own terms.

And so, as a critical care specialist, I try my hardest to learn what the terms of my patients’ death are, and I fight my hardest – I battle to the fullest – to make sure that my patients die on their own terms. I battle to the fullest to make sure that my patients have a good death, one that is not ignoble: a death without pain, without suffering, without anguish, and on my patients’ terms.

During the COVID pandemic, it seemed that all we did for those afflicted with COVID was not curing the illness, but simply providing a good death. It did cause us a lot of anguish, because we are in the business of cure and healing. At the same time, there is nothing ignoble about providing a good death. If that’s all we can do for our patient, we have done our patient a tremendous amount of good.

Listen to the podcast episode about this topic here: https://healthcaremusings.substack.com/p/the-battle-against-an-ignoble-death

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Last year one of my patients was on the phone, lamenting about how long he had been in the emergency room. He had already waited several hours to get a CT scan. Medications he was supposed to be given were repeatedly delayed. I heard his voice rise and fall, with each swell more expansive than the one before. When I turned to look at him, he yelled a racial epithet before hurling a desktop computer into the area where doctors and nurses sit. A seasoned nurse ducked. As I pushed an intern and medical student out of the way, he charged at us with a steel tray. Thankfully, no one was injured.

According to the article, a 2022 survey of Emergency Medicine Physicians found that “55 percent said they had been physically assaulted, almost all by patients, with a third of those resulting in injuries. Eighty-five percent had been seriously threatened by patients.” For ER nurses, it is worse: 70% reported physical assaults at work.

This is unconscionable.

The article was written by Emergency Medicine physician and Columbia University professor Dr. Helen Ouyang. She wrote this:

In the E.R., there’s a certain level of resignation that violence is just part of the job, like getting bloodstains on our shoes. We have come to endure racist, sexist and homophobic slurs, choosing silence over confrontation, to fulfill our duty to care for human life. After all, we pledge to hold our patients’ well-being above all else.

Violence should never, ever, ever, ever, ever be “just part of the job.” This is unacceptable. Those of us who have answered the call of healthcare – whether physician, or nurse, or respiratory therapist, or physical therapist, or patient care technician – have sacrificed a great deal to be here. We have given so much of our time, our blood, our sweat, and our tears to care for those who are ill.

No part of this job should include violence directed toward the healthcare team. None.

I understand that sometimes, if not many times, patients are not in their right minds. They may be sick with infection, or organ failure, or substance abuse. That does not excuse violence against us. I always say that patient safety is “number one a.” Staff safety is “one b”: it is co-equal with patient safety.

We can’t easily fix the societal maladies that lead to violence against healthcare workers. At the same time, every healthcare institution must ensure that their staff is safe at work. It is an absolute necessity.

Please make sure you read the article and watch the opinion video accompanying it. It is heart-wrenching.

And I say again: violence should never, ever, ever, ever be “just part of the job.” It is absolutely unacceptable.

The post Violence in Healthcare Should Never Be “Just Part of the Job” appeared first on Medika Life.

I planned, and then God laughed.

The first flight got delayed initially because the incoming flight was delayed. Then, at the gate, when I still had hope to leave relatively soon, the plane had a maintenance issue and we had to change planes. 

Everyone was frustrated, and I must admit so was I. This whole delay disrupted my entire day, and I was already on a tight schedule because I was flying home the same day. I had to miss some meetings. 

Yet, the reason for the delay was that there was a maintenance issue, and this maintenance issue could place the safety of the passengers and crew at risk. This was a nonstarter. 

Better be late than risk the safety of people on an airline. Better cancel the flight altogether, like for bad weather, than risk loss of life and limb. Better I miss a meeting than never show up to that meeting or go back home ever again. 

Yes, it can frustrate passengers, and the airlines do have an obligation to help their passengers (their clients essentially) when their travel plans get disrupted. Still, safety is absolutely essential and no shortcuts can ever be made. 

Would that Healthcare have the same attitude. The airline industry has some of the best safety records in the world. It may not be as well known that it is much safer to fly than drive. This is because the airline industry never compromises on safety. We need to be the same in Healthcare. 

There are thousands upon thousands of medical errors that occur each and every year. Many of these errors can cause significant harm to patients. And when these errors are examined critically, too often the safety checks that were in place were bypassed in order to save time or assuage an angry or upset patient or family member.

This should never occur. 

Yes, I get very frustrated with the stops and safety checks my EMR places in front of me (that dreaded stop sign in Epic gives me PTSD). And sometimes it doesn’t make sense from a clinical perspective. 

But they are in place for the sake of my patients’ safety. That should make me patient with them. What if that patient who gets harmed by a medical error is my family? What if they are my child? I would be devastated to learn that safety measures were bypassed. 

Yes, flight delays can be terribly frustrating – especially those for maintenance and safety issues (why didn’t they figure them out sooner?). But they are there to make sure we get to our destinations safely. If we die because of a safety issue that was ignored, no vacation or work meetings will occur…permanently. In fact, I was able to write this article because my flight delay gave me time to reflect about this. 

At the same time, every time I travel I pray to the Lord this: “Lord, take me to my destination safely and on time.” Most of the time, it goes without a hitch. However, the “safely” part comes will always come at the expense of the “on time” part. I thank God for that, and we need to be better at it with the patients entrusted to our care. 

The post Just Like the Airline Industry, Safety Has to be Non-negotiable in Healthcare appeared first on Medika Life.

In order to make that money, however, it takes literally decades of schooling and many years of training, racking up hundreds of thousands of dollars in debt. In order to become a specialist, it can take more than half a decade of training to get there. It is not an easy path.

And, it is also true that primary care physicians are among the least paid of the profession. Primary care physicians are the bulwark of the healthcare system, the load bearing walls of our field, and it is truly unfortunate that, sometimes, they can make less than many other professionals.

Having said all of that, it is also true that the latest rounds of physician pay cuts announced by the Centers for Medicare and Medicaid Services (CMS) are quite distressing and truly unsustainable.

They state that these cuts are mandated by federal law:

By factors specified in law, overall payment rates under the PFS are proposed to be reduced by 1.25% in CY 2024 compared to CY 2023. CMS is also proposing significant increases in payment for primary care and other kinds of direct patient care.

The proposed CY 2024 PFS conversion factor is $32.75, a decrease of $1.14 (or 3.34%) from the current CY 2023 conversion factor of $33.89.

The conversion factor is multiplied by relative value units, which quantify how much “work” something a physician does, to arrive at a payment from CMS. And, CMS only pays 80% of that rate, the rest being paid by supplemental insurance (if a patient has it).

Immediately, physician groups decried the cuts:

“While the ACR [American College of Rheumatology] appreciates CMS’ continued recognition of the value of complex care provided by rheumatologists and other cognitive care specialists … we are gravely concerned that the proposed rule’s physician payment cuts contained in CMS’ conversion factor would add to physicians’ uncertainty about their continued ability to provide the highest quality of care to Medicare patients,” ACR president Douglas White, MD, PhD, said in a statement.

The President of the American Medical Association also weighed in with a statement, saying:

When adjusted for inflation, Medicare physician payment already has effectively declined 26% from 2001 to 2023 before additional inflation and these cuts are factored in. Physicians are one of the only providers without an automatic inflationary increase … Physicians need relief from this unsustainable journey.

Anders Gilberg, MGA, senior vice president for government affairs at the Medical Group Management Association chimed in as well:

The proposed 2024 Medicare Physician Fee Schedule (PFS) raises significant concerns for medical groups related to its 3.4% reduction to the conversion factor, which further increases the gap between physician practice expenses and Medicare reimbursement rates. Medicare already largely fails to cover the cost of furnishing care to beneficiaries, and the proposed cut to the 2024 conversion factor compounds the problem.

This is the key to understanding why physicians are upset about these cuts. It is not about greedy physicians. It’s not about a doctor previously earning $400,000 and now earning $388,000.

It is about the costs of running a practice. When adjusted for inflation, physician reimbursement has declined significantly, as the AMA correctly pointed out. But, the costs of running a physician practice has not decreased by the same amount. They have, in fact, dramatically increased: there has been 7% inflation in healthcare labor costs, and now CMS answers this increase in costs with another 3% payment cut. This math is not sustainable.

I used to be a partner in a small private practice. Yes, I earned a comfortable living. But, it costed a lot of money to keep the practice open: the salary of the office staff; the rent of the office space; the utilities; office supplies; among many other costs. Those costs didn’t go down. Ever.

Yet, our reimbursement from CMS and other payers did. Eventually, if the costs of running a practice exceed its income, the practice closes. Or, they stop taking Medicare because the reimbursement was not enough to cover the costs.

In very large practices, there are other costs – such as interest on loans to cover payroll – have increased dramatically in the past few years. With every cut in reimbursement, it makes staying in business that much more difficult.

This is what physician groups mean when they say these payment cuts by CMS threaten access to care for seniors. If practices close their doors because the math is not sustainable, then that means less doctors are available to care for seniors. There is already a shortage of physicians, especially in rural areas, and these payment cuts could make it worse by making it impossible to run a practice.

Now, it is great that CMS is paying primary care physicians more. It is high time they get the proper reimbursement they deserve. What I don’t understand is why the law forces CMS to pay PCPs more by taking the money from other physicians, most notably specialists. This makes no sense to me.

“Well,” some may say, “specialists make too much money anyway.” That’s a non-argument. The whole formula under federal law needs to be changed for something much more sustainable for everyone.

Physicians can’t just keep working harder for less reimbursement. That is part of what is driving physicians to burn out and leave the profession. How does this help our patients? And, no one tells a plumber, after he or she fixed your leaky shower or faucet, “Well, your bill is $200, but I’m only going to pay you $120.”

Yet, that’s what happens to physicians all the time, and the math is not sustainable. CMS spends only 1 out of every 5 dollars on physician and clinical services. It is not right to keep cutting physician reimbursement to reduce healthcare spending. There has to be a better way.

The post The Unsustainable Math of Medicare Physician Reimbursement Cuts appeared first on Medika Life.

In the classic rat sleep deprivation trials, total sleep deprivation ended up killing the rats in 11-32 days. When the researchers deprived the rats of REM sleep, or commonly known as “dreaming sleep,” the rats also died, although they did survive for a longer time period, 16-54 days. Nevertheless, sleep deprivation is very detrimental, and when I was training as a sleep specialist, I learned about myriad health problems when people become sleep deprived.

So, when patients are admitted to the hospital, why do we wake them up in the early morning to draw blood tests? Yale University researchers studied this, and they found that nearly 40% of laboratory studies occurred between 4:00 AM and 6:59 AM:

The traditional thinking behind this is that, by the time the physicians and APPs come in to see their patients in the morning, usually at 7:00 AM, the blood tests are ready for them, and they can act on the findings of those blood tests to help care for the patients.

Yet, this begs the question: do we really need to get blood tests that early in the morning? Would care suffer significantly if those blood tests were drawn at, say, 8:00 AM? There should be enough time to act on any abnormal test results in the morning and before morning rounds. At my hospital, we round at 10:00 AM, and so if blood tests were drawn at 8:00 AM, they should be back by the time I round with the rest of the team.

As far as I can remember – and into today – “AM Labs” are usually drawn at 4:00 or 5:00 AM by default or even tradition. Unless the patient is comatose in the ICU, getting a blood test at 4:00 or 5:00 AM can disrupt the sleep of our patients, which can be very detrimental and can hinder their recovery from illness.

It can also precipitate delirium in our patients due to the sleep deprivation, the effects of which can also be very detrimental to the recovery of our patients. Moreover, it can also disrupt the sleep of the clinicians caring for those patients at night, who have to be awakened also at 4:30 or 5:00 AM to receive notification of critical results and act on them. This sleep disruption can also affect clinician well-being and burnout.

Good sleep is often the elusive treasure of a hospital stay. Many clinicians chuckle when they hear this, but it really is no laughing matter. It may be time to rethink the necessity of getting blood tests so early in the morning, so that our patients can actually get a good night’s sleep and be well on their way to a good recovery from illness.

The post Are Early Morning Laboratory Studies Really Necessary in Hospitalized Patients? appeared first on Medika Life.

Imagine a medical grand rounds, where doctors and healthcare professionals from around the world come together to discuss cases, share insights, and learn from each other. Now, imagine being able to attend this grand round from the comfort of your own home, using nothing but your phone and a Twitter account.

This is the potential of Twitter Spaces.

Traditionally, grand rounds have been in-person events, often held at hospitals or medical schools. They can be an invaluable source of education and collaboration for medical professionals, but they can also be difficult to attend due to time and location constraints.

Twitter Spaces allows anyone with a Twitter account to host or participate in an audio conversation, bringing the benefits of a grand round to a wider audience. It’s easy to use and requires no additional software or downloads.

In a medical context, Twitter Spaces could be used to discuss cases, share research findings, or even provide continuing medical education. It could bring together experts from different specialties, enabling them to share their knowledge and experiences with a global audience. Further, the “event” can be held at any time or in association with breaking medical and scientific news or urgent matter.

Of course, there are potential challenges to using Twitter Spaces for medical discussions. Ensuring the accuracy and reliability of information shared is crucial, and it will be important for hosts to carefully moderate their Spaces to ensure that only credible sources are cited. But that’s the nature of an open dialogue—expect conflict and controversy.

Overall, Twitter Spaces has the potential to be a valuable tool for medical professionals looking to share knowledge and collaborate with their peers. By bringing the grand round experience to a digital platform, it has the power to connect doctors and healthcare professionals in a way that was previously impossible. So, it can be a new medical grand rounds where facts meet, insights collide, and medicine is advanced.

The post Is Twitter Spaces The New Medical Grand Rounds? appeared first on Medika Life.

I just attended our first in-person Medical Director Summit for our medical group in October. It had been more than three years since we came together as a medical group in person. It was a truly magical experience. No matter how many times I interact with colleagues virtually, it is simply not the same as meeting them in person; giving them a hug; smiling in their face; and interacting with them in the flesh. It was so good to see my colleagues from across the country and network and learn together with them in person. No screen could substitute that personal interaction.

Interacting with other people on a screen is deficient in almost every way. It is nearly impossible to read body language, true tone of voice, and personability through a screen. It is very difficult to garner trust between individuals through a screen. When we implemented a telemedicine program, we struggled early on to build trust between the physicians on one end of the screen, and the nurses on the other end. It was only when I visited on-site that this process of trust was able to develop. The few hours I spent interacting with the on-site clinical team were truly invaluable, even though I interacted with them multiple times virtually in the past. 

This speaks greatly about the nature of us as human beings. We are nothing if not social creatures. The disruptions in social gatherings, while I still understand why we did that early on in the pandemic, was truly disruptive to our nature as human beings. We need to be together as families, colleagues, communities, and peoples. It is in our very DNA.

What’s more, I think this also has to do with our spiritual natures. I believe each of us is infused with the spark of the Divine (all the while not having any sort of Divinity whatsoever). It was breathed into us when we came into being. Those sparks grow into burning flames when brought together, and those flames give off light and warmth and healing. That is further why it is so fulfilling to get together with friends and family. 

I do not criticize the decision to shut down everything and social distance early on in the pandemic. We had no idea what this virus was, or what it was capable of doing. We did the best we could with the information we had at the time. Looking back, whether continued lockdown had a net positive effect is debatable, and we should study every aspect of those decisions. That way, we know better, when the next in evitable pandemic strikes us.

In addition, sometimes, there is no other choice but to interact with someone on a screen: think a critical access hospital that has no Neurology or Critical Care and can only get this via Telemedicine. The pandemic has caused Telemedicine to grow exponentially, and it is going to be, in my estimation, a permanent fixture of clinical care in the future. One hopes and prays that policymakers do not get in the way of this inevitable trend. It is not a substitute for a real-live bedside clinician, but sometimes a clinician on a screen is better than no clinician at all.

That said, my experience during our Summit taught me one unshakable truth: a screen is absolutely no substitute for the real thing. We were made to be together.

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