Monday, November 5, 2012

Moving On to New Website

Thanks for following my blog which since 2007 has provided a home for my thoughts and musings about the challenges for doctors and patients to get the right care each time. This blog was the starting point for my first book - Stay Healthy, Live Longer, Spend Wisely - Making Intelligent Choices in America's Healthcare System.

I hope you continue to enjoy much of the terrific content here as well as follow me to my new home which features the latest commentary and insight at Davis Liu, MD as well as my newest book - The Thrifty Patient - Vital Insider Tips For Saving Money and Staying Healthy.

Of course you can still follow me on Twitter @davisliumd


Davis Liu, MD

Tuesday, October 16, 2012

NYT Kristof's A Possibly Fatal Mistake Shows Future of Health Care. It Isn't Good.

NY Times columnist Nicholas D. Kristof wrote a heartfelt piece "A Possibly Fatal Mistake" about his college roommate Scott Androes, who recently was diagnosed with metastatic prostate cancer. His story illustrates the problem with the current health care system.  It isn't about the lack of health insurance. It's about the obstacles all patients face in making the right decisions and the right treatment.

Something that will increasingly be harder with consumer driven health care.

Kristof lets his 52 year old friend, who is well-educated (graduate of Harvard, financial and pension consultant) and also was uninsured starting in December 2003, tell the story.
In 2011 I began having greater difficulty peeing. I didn’t go see the doctor because that would have been several hundred dollars out of pocket — just enough disincentive to get me to make a bad decision.
Early this year, I began seeing blood in my urine, and then I got scared. I Googled “blood in urine” and turned up several possible explanations. I remember sitting at my computer and thinking, “Well, I can afford the cost of an infection, but cancer would probably bust my bank and take everything in my I.R.A. So I’m just going to bet on this being an infection.”
I was extremely busy at work since it was peak tax season, so I figured I’d go after April 15. Then I developed a 102-degree fever and went to one of those urgent care clinics in a strip mall. (I didn’t have a regular physician and hadn’t been getting annual physicals.)
The doctor there gave me a diagnosis of prostate infection and prescribed antibiotics. 
Androes, after being diagnosed with metastatic prostate cancer, like most of us, would reflect on what went wrong.
I read Nassim Taleb’s book “The Black Swan” and imbibed his idea that you should keep an eye out for low-probability events that have potentially big consequences, both positive and negative. You insure against the potentially negative ones, like prostate cancer.

So why didn’t I get physicals? Why didn’t I get P.S.A. tests? Why didn’t I get examined when I started having trouble urinating? Partly because of the traditional male delinquency about seeing doctors. I had no regular family doctor; typical bachelor guy behavior.

I had plenty of warning signs, and that’s why I feel like a damned fool. I would give anything to have gone to a doctor in, say, October 2011. It fills me with regret. 
What can we learn about his experience and the future of our health care system?

Smart educated patients can make bad decisions

Androes is highly educated. If anyone should understand the cost benefit analysis of money and health, it should be a pension consultant educated at Harvard. He had opportunities to seek care sooner, but chose not to. Understanding this psychology is important as it is the underpinning of consumer driven health care - patients will choose more rationally if they have more financial skin in the game. Yet all I continue to see is evidence to the contrary.

First, Androes had many obstacles and not all related to lack of health insurance. He didn't choose to see a doctor when symptoms started in October 2011 because the cost didn't seem worth it. This is where our common sense and experience falls short. We've all had experiences of an ache, pain, or symptom. Many go away on their own. Androes like many other patients have this "success" and filed it away. Plus, work is too busy or important to put on hold (another major problem with the economic crisis of 2008) and personal health takes a back seat. The problem is our previous success with other symptoms may not necessarily apply to the current symptom.

It isn't clear if at that point he researched his symptoms with the always available Dr. Google. Unfortunately, like many patients he winged it hoping for the best. Had he thought about it some more, he might have realized that he never had urinary complaints prior to this episode. Having urinary problems are quite uncommon in young or middle-aged men.

So, Androes, like many others, he extrapolated his prior experience to his current situation, which may not have been appropriate.

Who has time to be sick? Don't "bet" on the wrong diagnosis with Dr. Google

Second, when he did have blood in the urine, Androes did consult Dr. Google. Dutifully, Dr. Google pulled up two possibilities. Infection or prostate cancer. Androes "bet" that it was infection. This is no different than "winging" it. Unlike the first episode of urinary problems, Androes clearly is informed about the possibility of cancer. Problem is he can't afford a catastrophic illness like cancer either from a financial or time point of view.

Here is the reality. None of us can afford it. There is never a good time to be diagnosed with cancer or any other serious life-altering illness. Yet is behavior is common among many patients I see. Their job or their financial assets are more important than their health. Androes "chose" to go after April 15th, after tax season, when it was most convenient for him. Dr. Oz nearly made a similarly bad decision regarding his colonoscopy and colon cancer screening a few years ago and then again when he failed to follow-up as recommended for colon cancer surveillance. Part of the reason we all fall into this cognitive trap is that for the most part, our body does a good job in running despite what we eat, our sedentary lifestyle, and long hours of work.
The most important financial asset is your health. With good health you can always make more money, with more money you can't buy good health.  So certainly, Androes had his less than optimal choices.

Did doctors miss a chance to diagnose prostate cancer earlier?

What about the health care system and doctors? Did we miss an opportunity?

Yes. It is possible there were two, though unclear if it would have made a difference in his case.

When Androes sought care with a doctor in urgent care and a urologist, he noted the former diagnosed him with a prostate infection and the latter did blood work. It isn't clear whether either doctor did a rectal exam to feel the prostate. A patient with metastatic prostate cancer with a PSA of 1,110 (normal range less than 4) should have a very abnormal prostate exam.

Had a prostate exam been done, either doctor had a very good chance in telling him he had prostate cancer prior to any confirmatory blood work. At that point, however, even with this knowledge it would have been too little and too late to alter the outcome or overall prognosis.

The second issue is whether the benefits of physical examinations or lab testing, like PSA, would have made a difference. Neither have been demonstrated to save lives. In other words, as a nation we might feel better that everyone gets an annual check-up or lab testing, but there is no scientific evidence that either help. Also, as noted previously, it isn't clear patients will seek preventive care for the reasons above.

So, how does this one story, which sadly is repeated too often by different writers and involves different protagonists, predict our health care future?

It does in the following ways:

Common sense does NOT apply to health care- four challenges in making good decisions about health

Common sense does not apply to health care. Patients may have symptoms they have never had before and erroneously assume based on prior experience, that this new problem is nothing to worry about. Denial is a powerful emotion and can cause inaction precisely when action is needed.

Second, when patients feel fine they don't protect against low probability but high risk problems. Will people buy health insurance? Will they demand for preventive screening tests that save lives? Will they willingly get vaccinated against preventive illnesses? Increasingly we see more parents choosing not to have their children immunized and then nationally see many preventive illness, like pertussis, return again with significant consequences.

Third, there are many obstacles preventing good decision making. Whether higher deductibles, copays, or simply working too hard to focus on one's health, people ignore their health until they have no choice or have symptoms. If Androes who had the good fortune of being educated at an elite Ivy League school made poor medical decisions, what are the implications for the rest of society? Patients should be more motivated to take charge of their health, yet it is likely the drive to consumer driven health care will make the nation's overall health care worse, not better. A similar experiment was attempted in retirement planning with devastating outcomes for retirees.

Fourth, people are increasingly devaluing the important of expertise and experience with the increasingly ease and availability of information on the internet. That isn't to say that non-experts cannot make a contribution to furthering progress. The challenge is that the availability of data provides many non-experts a false sense of certainty and absolute truth which is not necessarily true in medicine. We do have genomics, but it is in its infancy. We do have personalized testing, but it isn't clear if knowing the results will be medically important.  When dealing with the complexity of the human body, nuance and ambiguity are prevalent.

More patients are emailing me requesting for CT scans or MRIs because the office visit copay is too expensive. They don't feel that seeing a doctor, taking a detailed history or examination is worth it.

Yet, to counter the issues above it is doctors who can convince people to act in getting testing, treatments, and interventions when they don't want to emotionally or are uncertain what to do. It is doctors who can encourage patients to get preventive testing and immunizations when faced with the overwhelming amount of information and clutter from the media, the internet, and friends. It is doctors who can tell patients when they must seek care and when they can safely skip. There is medical science and then there is everything else.

However, this is not where our country is headed. Too many believe that to lower costs and improve health outcomes, patients must make better decisions. Patients will do so if they have more financial responsibility and more cost transparency.

Show me the evidence because I don't see it.
What I do see, unfortunately, is more cases like Scott Androes.

Wednesday, October 10, 2012

Is the Iron Triangle of Health Care a Law or an Observation?

A recent commentary in the Journal of the American Medical Association titled, "The Iron Triangle of Health Care: Access, Cost, and Quality" reflected that any health care system can only optimize two of the three elements - quality, access, cost.  A health care system which provides the finest quality and best access cannot do so without raising costs to unaffordable levels. An inexpensive health care system available to all cannot do so without sacrificing quality. The iron triangle of health care was introduced to me during my medical school training in the 1990s. Like many others, I simply assumed it was a fact. An immutable law. A fixed certainty that could not be altered any more than gravity.

What if this iron triangle isn't a fundamental truth or law? Why don't other industries have their own iron triangle? Is health care really different than aviation or computing?  Asking this simple yet basic question is something medical students and doctors don't ask. Fortunately, this was not the case for Harvard Business School Professor Clayton Christensen, author of the Innovator's Prescription. His book not only details the theory of distruptive technologies, but also how companies who do "disrupt" the incumbent companies and the status quo are the ones that ultimately provide goods and services which are more affordable, more accessible, and of higher quality. Might there be analogies for health care? Professor Christensen highlights aviation and computing as two examples.

Commercial flight for the masses was not a realistic possibility over a century ago when the Wright Brothers navigated their winged contraption in Kitty Hawk. Even decades later, as epitomized by Pan-Am in the 1960s, air travel was for the affluent and a special event. At that point, air travel was not accessible or affordable for the general public. Yet, in the 1970s, a Texas start-up known as Southwest Airlines provided discounted travel to the general public by offering low fares, no amenities, and a point to point service rather than hub and spoke system.

And traveling by air was never the same again.

Now, more people travel by air than anytime in history with unparalleled safety. More accessible. More affordable. Higher quality.

Computers had a similar beginning evolving from a product where only available to a few due to cost and complexity of the systems to now where computers are affordable, ubiquitous, easy to use and of even better quality than the past. One of the first computers in the 1940s, was Eniac, a huge and expensive mainframe computer which was not reliable, extremely complicated, and accessible only to academics. Years later, the general public typically accessed these mainframe computers at work via technicians. Access was limited. It wasn't until the late 1970s that desktop computers appeared. Hobbyists and others, like Steve Jobs, built computers which were less expensive and underpowered compared to the mainframe computers, but they were more accessible to the general public. It wasn't until many years later that subsequent computers became more affordable, more powerful, and more accessible in the form of laptops, netbooks, and now smartphones and tablets. More people had access to computing because the products were more affordable and of even higher quality.

And computing was never the same again.

Based on Christensen's model, we can predict that health care will indeed break the iron triangle and demonstrate it is not a law but an observation. The question is who will lead these changes? Insurers? Doctors? Patients? Entrepreneurs?

Our next generation of doctors must be trained in other disciplines outside of health care. We must collaborate and accept other ways of looking at the same challenges through the lens of other disciplines including business school. Yet, there is a loathing for this. There is the belief that health care is different. Yes, we can continue to talk about the iron triangle of health care and accept that as a reality.

We can also say no. The iron triangle is not a law but an observation. We choose a different path.

The truth is that this is the most exciting time in health care with the intersection of better medical understanding, the availability of technology, and the best and brightest minds working on the issues of better quality, better access, and lower costs. As doctors and educators, it is our job to make sure the next generation is equipped with the right mindset to team with others. If not, others will define the future of health care.

This is what worries me the most.

Wednesday, September 12, 2012

The Truth About Ovarian Cancer Screening - book excerpt

The New York Times editorial "False Promises on Ovarian Cancer" says it all. What is most concerning is that a third of doctors recommend what medical science shows not to be true: screening for ovarian cancer does NOT work.

Enjoy the excerpt from my book - The Thrifty Patient - Vital Insider Tips to Staying Healthy and Saving Money - and be smarter than 1/3 of doctors! Simple to read and incredibly informative.


Ovarian Cancer Screening

One of the most feared cancers for many women is ovarian cancer, which occurs in one out of sixty-eight women. Unfortunately, like many cancers (lung, pancreatic), there is no screening test that has been helpful to detect the illness early and reliably proven to save lives.

Until organizations like the American Cancer Society (ACS) recommend certain tests or examinations, everything you may hear on the news or from friends about breakthroughs in screenings is inaccurate.

In the latest update by the American Cancer Society, women are urged to seek medical care if they have had the following symptoms, which could be early signs of ovarian cancer:

  • Abdominal swelling or bloating (due to a mass or accumulation of fluid)
  • Pelvic pressure or abdominal pain
  • Difficulty eating, or a feeling of being full quickly
  • Urinary symptoms (having to go urgently or often)

Certainly many benign causes also can cause similar symptoms. If you have these symptoms, they are not typical for you, and you aren’t sure what the cause might be, check with your doctor. The ACS acknowledges that two tests often used to “screen” for ovarian cancer are the blood test CA-125, a tumor marker, and/or a transvaginal ultrasound, an ultrasound probe placed in the vagina to evaluate the ovaries. The update correctly notes that in women at high risk for ovarian cancer and those with no risk, neither test has been shown to save lives.

Unfortunately, until medical researchers find a better and more precise test, women will need to be observant about their bodies. This is the best medical science has in trying to detect ovarian cancer early.

Friday, August 31, 2012

Rock Health, Enterpreneurs, Doctors and Witchcraft?

I recently viewed health care through the lenses of a technology entrepreneur by attending the Health Innovation Summit hosted by Rock Health in San Francisco. As a practicing primary care doctor, I was inspired to hear from Andy Grove, former CEO of Intel, listen to Thomas Goetz, executive editor of Wired magazine, and Dr. Tom Lee, founder of One Medical Group as well as ePocrates.

Not surprising, the most fascinating person, was the keynote speaker,
“Health care is like witchcraft and just based on tradition.”

Entrepreneurs need to develop technology that would stop doctors from practicing like “voodoo doctors” and be more like scientists.

Health care must be more data driven and about wellness, not sick care.

Eighty percent of doctors could be replaced by machines.

Khosla assured the audience that being part of the health care system was a burden and disadvantage.  To disrupt health care, entrepreneurs do not need to be part of the system or status quo. He cited the example of CEO Jack Dorsey of Square (a wireless payment system allowing anyone to accept credit cards rather than setup a more costly corporate account with Visa / MasterCard) who reflected in a Wired magazine article that the ability to disrupt the electronic payment system which had stymied others for years was because of the 250 employees at Square, only 5 ever worked in that industry.
Khosla believed that patients would be better off getting diagnosed by a machine than by doctors. Creating such a system was a simple problem to solve. Google’s development of a driverless smart car was “two orders of magnitude more complex” than providing the right diagnosis. A good machine learning system not only would be cheaper, more accurate and objective, but also effectively replace 80 percent of doctors simply by being better than the average doctor. To do so, the level of machine expertise would need to be in the 80th percentile of doctors' expertise.

Is it possible technology entrepreneurs can disrupt health care? He challenged any doctor in the room to counter his points.


Was it because everyone agreed? Were the doctors in the room simply stunned? Was there a doctor in the house? And where did he get that 80 percent statistic?

Was Kholsa serious that technology could make health care better by utilizing large data sets and computational power to clinch better and more precise diagnoses?  Was he simply being provocative to hear other points of view to learn even more? Like many others in the conference, he believes that giving consumers more opportunities, access, and choice to information about themselves and their bodies would empower them to do the right thing. He held up an EKG attachment to the iPhone which was just one of many consumer directed products in the pipeline his company has invested in.

Kholsa is a very smart and successful entrepreneur. Does innovation mean the two guys in a garage who come up with a radical idea or is it possible that innovation is having people with different experiences and point of view looking at the same problem as best selling author Malcolm Gladwell noted in his New Yorker piece Creation Myth -  Xerox PARC, Apple, and the Truth About Innovation? Surely to make health care better, technology entrepreneurs must engage with doctors. All the speakers before and after Kholsa spoke about the incredible value and insight different stakeholders to bring to the table.  The most vocal? The doctor entrepreneurs and those who worked with doctors to bring their ideas to market.

Kholsa's criticism of the health care system is completely valid. Can we do better in being more reliable, consistent, and creating a system process and design that is comparable to highly reliable organizations and industries? Of course. Can we be more systematic and doing the right things every patient every time on areas where the science is known to level of the molecule? Yes. Care must be incredibly simple to access, extremely convenient and intensely personal.

It isn't that we don't have smart people. Compared to a century ago more illness are understood, specific medications and treatment protocols can be designed. But we haven't solved it all. When we thought we knew it all, we were shown how little we truly knew. Thirty years ago, doctors predicted the demise of infectious diseases as a specialty, another footnote in medical texts as more powerful antibiotics and vaccines were available. Enter AIDS, the swine flu, and many super-bugs which have humbled our profession. Ask accomplished physician and writer Dr. Abraham Verghese about his experiences.  Dr. Verghese is rightly worried, as many others are, that even doctors are being too focused on the iPatient and not on the real patient as he writes in his New York Times op-ed Treat the Patient, Not the CT Scan. Is this what we want our health care system to look like?

Health and medical care is an incredible intersection of technology, science, emotions, and human imperfections in both providing care and comfort. As conference speaker Dr. Aenor Sawyer, an orthopedic surgeon from UCSF noted, we need to figure out how to have our different cultures of doctors, gamers, designers, and technologists interact. Fixing health care is more than simply "we know the problem and we know the solution". She reflected that the level of dedication, perseverance, and a willingness to make impact among the different groups demonstrates more similarities than differences.

I know health care can't simply be solved by smart people in Silicon Valley alone.  To solve health care we need everyone to collaborate. As Harvard Business School professor Amy Edmondson noted in her book Teaming

"For over a century, we've focused too much on relentless execution and depended too much on fear to get things done. That era is over...human and organizational obstacles to teaming and learning can be overcome...Few of today's most pressing social problems can be solved within the four walls of any organization, no matter how enlightened or extraordinary... Generating ideas to solve problems is the currency of the future; teaming is the way to develop, implement, and improve those ideas."
Perhaps Kholsa's call to action was simply an entrepreneurial mindset, but simply ignoring those who have chosen a field to improve and safe lives and who meet humanity everyday on the front-lines is problematic and dangerous. There are some things that may never be codified or driven into algorthims. Call it a doctor's experience, intuition, and therapeutic touch and listening. If start-ups can clear the obstacles and restore the timeless doctor-patient relationship and human connection, then perhaps the future of health care is bright after all.

Tuesday, August 21, 2012

Five Vital Skills to be The Thrifty Patient

From my upcoming book - The Thrifty Patient - Vital Insider Tips For Saving Money And Staying Healthy

Chapter 2 - The Thrifty Patient

Five Vital Skills to Staying Healthy and Saving Money

Throughout the book, we’ve covered various important aspects of getting the right care. It boils down to five separate but important areas you should be knowledgeable about: the doctor’s office visit, prescription medications, preventive screening tests and interventions, selecting the right doctors, and using the Internet. Each is also important to help save money. For example, learning how to communicate with doctors clearly about your concerns and needs as well as providing the doctor the information he needs can decrease the likelihood of unnecessary testing and medications. When seeing a doctor, the goal is to solve the problem you are having. It isn’t to get all of the imaging tests, lab work, or prescription medications available. When focused on the right goal, you get the right care and save money.

Sometimes, paradoxically, this may mean spending money to see the doctor to pick his brain and get his expertise. You may be tempted to ask for blood work or a MRI first and skip the office visit. Talking to a doctor seems so old-fashioned and out of date. Yet, as we will review, lab work and imaging tests are simply tools to help doctors. By themselves, without a good patient history, the test results have little meaning.

If your doctor recommends prescription medication, then there are ways to ensure that the medications you receive are effective and affordable. Many prescription medications are simply me-too or copycat drugs. Pharmaceutical companies market and promote these medications as aggressively as beer and soda. Don’t be fooled. When a medical condition is common, such as heartburn, seasonal allergies, high cholesterol, high blood pressure, and diabetes, save money by avoiding the latest advertised medication. There are often plenty of excellent and less expensive alternatives.

Focusing on prevention is extremely important. 

Getting screened for cancer and requesting vaccinations can keep you healthy. 

It isn’t particularly sexy, trendy, or even fun depending on these tests, but they can save your life. Periodically check out what the latest guidelines are, as the recommendations can change with continued medical research.

Identifying which doctor to go to is also important to getting the right care. 

It is extremely rare that any one doctor is the “best.” Don’t worry about finding the best, but rather focus on finding doctors who provide excellent quality care and who also listen to you. How do you determine if a doctor is good? How do you find one? Who is on your medical team? Should you always have a primary care doctor? If you need a specialist, how do you choose?

We also will review the use of the Internet and social media as a way to keep you informed. 

The ease of accessing information can both be a blessing and a curse. Used correctly, information from the Internet, whether from trusted health care organizations, patient or doctor blogs, or tweets, can improve decision making. It may help you determine if a symptom requires medical attention or can be safely treated and managed at home. Yet the access to this information can be equally as problematic.

The Internet, much like the lab tests and imaging studies doctors use, is still a tool. Like any tool, it can be helpful or harmful depending on how a person uses it. A simple rule of thumb—if an answer or solution sounds too good to be true, it often is.

Increasingly, you are being asked to pay more for medical care and be more responsible in making medical decisions. Knowledge is power. It isn’t that hard. Let me show you how.

Five simple skills can make you a thrifty patient who is staying healthy and saving money.

Finally, just a brief primer on what you should do outside of where I work regularly, the medical system. For most of us, life is not filled with doctor visits. That’s a good thing. Sometimes you or a loved one does, however, need our help. This is the first step to getting you the skills you need to stay healthy and choose wisely.

Let’s get started.

Thursday, August 9, 2012

Update on The Thrifty Patient - Vital Insider Tips For Saving Money And Staying Healthy

New book is finally taking shape. A revised and streamlined version of my previous work with new content is nearly completed and will be available soon on Amazon and Kindle.

Here is a sneak peak of the first chapter!


Introduction –

Why This Book Matters To You

After you finish this book, you will know what I know when it comes to medical care. I believe it can be boiled down into these short but important phrases.
  • Newer isn’t necessarily better.
  • More isn’t necessarily better.
  • Common sense may not apply.
  • Staying healthy and well means sometimes seeking medical care.
  • You need to be informed and educated to get the best care.
Or I could burden you with statistics from the health care system
which you probably already know.
  • Twenty-three seconds.
  • Fifteen minutes.
  • Forty percent.
  • Medical costs.
  • Increasing dissatisfaction.
  • Worst among industrialized countries.
These are the questions to the previous answers.

  • Twenty-three seconds: How much time do you have before your doctor interrupts you?
  • Fifteen minutes: What is the average face-to-face time at a doctor’s office visit?
  • Forty percent: What is the misdiagnosis rate based on autopsy?
  • Medical costs: What is the leading cause of personal bankruptcy? Many had health insurance.
  • Increasing dissatisfaction: How does the public feel about the American health care system?
  • Worst among industrialized countries: How does the United States rank in terms of health care quality for prevention and treatment?
Staying healthy and well means sometimes seeking medical care. 
I could tell you that too many Americans die every year unnecessarily and too soon due to missed opportunities. Healthy patients forget to get screened for colon cancer or breast cancer. Heart attacks and strokes that could have been prevented occur. Grandfathers and grandmothers aren’t around to attend holidays, graduations, or spend time with their grandchildren. Parents leave their children alone because their cancer was caught too late. No one is the wiser to this.

Newer isn’t necessarily better. More isn’t necessarily better.
You may have noticed that increasingly doctors rush through office appointments and don’t listen. Too often blood work is done, medications prescribed, and x-rays ordered, and despite all of the additional treatments patients don’t feel healthier. Television, radio, magazines, and the Internet inundate you with the latest prescription medications or therapy promising you better health. The news warns you to check with your doctor about the latest therapy with quick, thirty-second sound bites. You are fearful that you might be missing something important that could save your life.

Common sense may not apply.
Increasingly more parents are not having their children immunized against preventable illnesses such as measles and pertussis (whooping cough). Now news reports note more cases. Some children die. Many have lost faith and look for alternative and more “natural” therapies. Doctors who are supposed to help guide you and distinguish truth from fiction are just too busy, so more people are relying on family, friends, and the Internet for medical advice.

You need to be informed and educated to get the best care.
To add even more stress, health insurance is becoming too expensive. Small and large companies are trying to control costs by offering health insurance with health savings accounts (HSAs). These plans have lower monthly premiums with high deductibles. Since 2004, these plans have become more common. Many patients are now asked to choose when to seek care and when to safely skip care based not only on their health needs but on their ability to pay, even as research consistently shows that they don’t want the financial responsibility to do so.

There is good news.
Despite all of these challenges, there is good news. You aren’t alone. When I took the Hippocratic oath to do no harm and help patients to the best of my ability, I didn’t realize that pledge included writing a book. I’ve always wanted to be a doctor. Never a writer. I hated English. I only took the class because I had to, not because I wanted to. 

Despite that, I am compelled to write because of what I know is occurring with alarming frequency in our country. Americans are skipping needed and recommended care that could save their lives and allow them to live to their fullest. Patients are more distracted, as life is more complicated and busier than ever. Households have both parents working, sometimes two jobs, just to make ends meet. They easily would make the right choice if someone would be willing to explain things in a simple, understandable manner. They would prefer a health care system that was so incredibly simple to use, convenient, and personalized that it would anticipate their needs so they could get the right care and get back to living life.

Instead, our health care system offers patients higher co-pays, deductibles, and out-of-pocket medical expenses. It shifts the burden of making the right choices to people who frankly are just getting by. It asks people to fend for themselves at a time when they need us, doctors, the most.

How do I know? Two things occurred that changed my life.


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