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Courtesy of NPR from npr.org
On April 15th, 2013, I woke up at 5:30am and walked to Mass General Hospital to begin my ER shift. It was the day of Boston marathon, and we were prepared for the usual influx of people with heatstroke and dehydration. That day, as other days, we also treated dozens of critically ill patients with heart attacks, strokes, and severe infections.

Just before 3pm, we received the call that nobody could have predicted. Bombs had detonated at the Boston marathon. Many people were gravely injured.

Minutes later, they arrived in our ER. Some were not breathing. Others were missing limbs. All were covered with blood and soot.

As an emergency physician, I am trained to treat traumatic injuries. But while I helped direct our trauma teams to triage then resuscitate these patients, I was terrified. My husband and I lived in Back Bay, next to the explosions. He had texted me not long before to say that he was headed to the finish line to watch the marathon. I didn’t know where he was; I feared that the next patient I took care of could be him.

I wrote about this fear and guilt in an NPR article, and subsequently about the need to care for the many healthcare providers who served on that day.

Now, one year later, I no longer live in Boston, but I will always remember April 15th. I remember the bravery and resourcefulness of the first responder, bystanders, and volunteers. I remember the teamwork in our hospital among every service—not just those of us caring for the victims themselves, but also those oncologists and obstetricians who jumped in and provided excellent care for other patients in our ER. I remember the support from our city and indeed our broader community in the U.S. and around the world. 

Most of all, I remember the courage of the victims and their families. Their resilience serves as inspiration for all of us.

As I remember April 15th, I am grateful to have had the opportunity to take care of these brave men, women, and children. I’m honored to be able to serve and proud to be a physician and emergency care provider.
Danielle is a 21-year-old woman with a headache. Her doctor tells her that she needs a CT scan and a spinal tap. Danielle doesn’t want these tests; she knows that she drank too much last night and feels like she has a bad hangover, but should she really say no to her doctor?

Nancy is a 38-year-old woman with vomiting and diarrhea. Her toddlers have the same symptoms. The doctor says she needs to get a CT scan of her belly. He says her blood pressure is “borderline high” and that she should also start taking medication. She’d prefer to avoid drugs if possible—what should she do?

As an emergency physician, I see dilemmas like these every day, yet they get very little attention. For so long, the rhetoric has been about the danger of too little medical care. Newspapers are full of stories about deaths that have resulted from missed diagnoses and lack of access to care. TV shows glorify the detective-doctor who doesn’t give up and persists on ordering test after test in order to solve an esoteric case.

While many people still lack access to care, there’s mounting evidence that many people also receive too much care. The prestigious Institute of Medicine estimates that 30 percent of all medical tests and treatments are unnecessary. This is not only wasted money—an estimated $700 billion of unnecessary spending per year—but also potentially harmful. Every test has risks and possible side effects. A CT scan has a risk of radiation, for example, that may lead to cancer later in life. And one test often leads to another, even riskier, test.

There are many causes of overtreatment. Drug companies and technology manufacturers have their own incentives for wanting people to receive more, rather than less, care. While doctors generally mean well, they also have financial incentives for over-testing. A study in the New England Journal of Medicine found that 94 percent of doctors have some relationship with a drug company or medical device company, and many are paid more for conducting more tests. On top of that, fear of malpractice can also drive doctors to do more, just to be sure.

The problem isn’t just doctors, though. Patients also believe that more is better. New tests and treatments succeed in part because the general public tends to idolize technology. 

Unfortunately, this issue is complicated because medical advances can be helpful and save lives in certain circumstances. So how do you know when testing is appropriate—and when it’s simply too much?

There isn’t an easy answer to this question, but I recommend that you ask your doctor five key questions every time he or she recommends you undergo a test:

What Do You Think My Diagnosis Might Be?
Your doctor always has some sense of possible diagnoses before you get any tests done. You should find out what he or she is thinking; that way, you know why the tests are being done and how likely the various possibilities are. If Danielle had asked her doctor this, for example, he likely would have told her that odds are she just has a hangover and that it’s far less than a 1 percent chance that she has brain bleeding.


What Evidence Exists Suggesting this Test or Treatment is Beneficial?
This is particularly important for screening tests like checking for high blood pressure, cholesterol, and cancer. Ask your doctor what studies there are to show that a test improves quality of life. If there is no evidence for the test or if the jury is still out, you should ask why your doctor thinks you need the test and keep in mind your doctor’s possible incentives for testing and treatment.


What are the Potential Side Effects?
Every single test, even just getting your blood drawn, has side effects—and you should know what they are before you consent to any tests. Without knowing the side effects, you can’t weigh the risks against the benefits.


Is Watching and Waiting an Option?
Very few situations are so urgent that a test has to be done ASAP; most of the time, it’s perfectly fine to wait and see if other symptoms emerge or if you get better. With Nancy, for example, it would have been appropriate for her to go home and see if she gets better; she didn’t need to get a CT scan right away.

 
What Other Treatment Options Do I Have?
Doctors are trained to “fix” problems with treatments. Many of us don’t have the knowledge or time to counsel patients on other options, like diet and exercise changes and/or alternative treatments. But these other treatments may be just as effective and may help you avoid potentially harmful side effects. Perhaps Nancy’s blood pressure could be controlled with diet alone, for example. There are always alternatives; ask about them.


Ultimately, you should have a trusting partnership with your doctor and feel comfortable asking hard questions. You are your own best advocate, and you have to speak up to make sure you get the right medical care—and avoid unnecessary tests and treatments.

This article was previously published in Women's Health Magazine (posted here with their permission).
This week, I wrote an article in Slate with the provocative theme of "10 Types of ER Patients". 

My intention in writing the article is not to stereotype or imply that patients don't have good reasons for coming to the ER. 

Rather, in my work as an emergency physician and separately as a patient advocate, I've met many patients who are frustrated by their care. I've seen the same missed opportunities and miscommunication happen over and over. This is my attempt to provide advice and guidance before they came to the ER.

The 10 Types of Patients I See in My Emergency Room

What do you think? Is this advice helpful? I'd love to hear your thoughts.
Being an emergency physician is an honor and a privilege.

Along with primary care physicians, we ER docs are the frontlines of medical care. We have to be able to take of every patient, no matter their age or ailment (or, thankfully, their ability to pay).

Our job is often very challenging because we have to make decisions with little information. It's often easier to second-guess decisions we made, because the answer is always clearer in retrospect.

My latest NPR article discusses the challenge of being an ER doc and practicing medicine in a fragmented medical system.



When Facts Are Scarce, ER Doctor Turns Detective to Decide on Care


Please read, and comment! I'd love to hear your thoughts.

My patient, a 40-year old woman named Sally, broke into a wide grin when she saw me enter the room. 

"Are you my doctor?" she asked. I nodded and started to introduce myself, but she cut me off. "I'm so glad that I have a woman doctor! I think women are much better than men."

That's in stark contrast to the previous patient I had seen just before Sally. Frank, a 72-year old man, looked at me askance and asked me if I was sure I wasn't his nurse. His wife explained (nicely) that they preferred a male doctor. 

These preferences don't always abide by gender or age divisions, either; plenty of female patients have said they prefer male doctors, and vice versa.

A new study from the University of Montreal finds that there may be real differences between the care provided between female and male doctors. Female doctors are more likely to follow evidence-based guidelines, and they score higher on care and quality, according to the study. Other research has found that female doctors tend to show greater empathy and are perceived as being better listeners. 

Some researchers have hypothesized that the differences are cultural and rooted in our upbringing. From an early age, girls tend to serve as confidantes to their friends, which may then result in greater attention to listening in the clinical context.

At the same time, I have worked with many men who display great empathy and care deeply about their patients. I also know of female doctors who don't hold up to the traditional gender stereotypes and don't like to spend time listening. 

In selecting a doctor, gender is one component. For some people (like Sally and Frank), it may matter a lot, in which case it should certainly help guide your choice of doctor. Other people just want to find someone who they can trust; they aren't as concerned whether their doctor is male or female.

So how can you identify a good doctor? Here are some characteristics to look for—regardless of gender:

Your doctor should listen to you: Research shows that 80 percent of diagnoses can be made just by listening to your story. Listening leads to better care, and your doctor should make an effort to hear you out and learn about you.

Your doctor should view your relationship as a partnership: Today's medical care is not about the doctor telling you what to do; rather, your doctor should involve you in your care as an equal partner. He or she should actively involve you in every step of the decision-making process about your treatment. 

Your doctor should be willing to ask for help: There is so much information on diagnostics and treatments—one person cannot possibly know everything. A good doctor is one who isn't afraid to admit that he or she doesn't know everything. Asking for help doesn't mean your doctor is incompetent; rather, it should increase your faith in his or her abilities and humility.

Your doctor needs to be available: It's unrealistic to expect that your doctor will be at your beck and call 24/7; however, before you leave your doctor's office, he or she should communicate to you how you can get help if necessary. Make sure you understand your follow-up plan. Are there any specific signs or symptoms you should watch out for? What should you do if something new or worse happens? 

You should feel comfortable with your doctor: This is perhaps the most important of all. If you do not feel at ease with your doctor, you might not share critical information, and important pieces of the puzzle might be missed. That's the most compelling argument for choosing a doctor of a particular gender—and only you can decide whether that's a characteristic that matters a lot to you.

One of my heroes, the Nobel prize-winner, humanist, and cardiologist Dr. Bernard Lown, talks about how a doctor is someone who should always make you feel better after having seen them. You go to your doctor because you want to feel better. You should find someone—female or male—who helps you accomplish this goal.



This article was previously published in Women's Health Magazine (posted here with their permission).
Recently, I learned of some shocking statistics:
* Every year, pharmacies dispense 257 million prescriptions for opioid painkillers — one for every adult American.
* While the U.S. makes up less than 5 percent of the world's population, Americans consume 80 percent of its total opiate supply.
* 1/3 of people who used illicit drugs for the first time start by using a prescription drug.
* Prescription narcotics kill 6 times more people per year than heroin.

As an emergency physician, I prescribe narcotic drugs for pain every day. I began to wonder how complicit doctors are in furthering this epidemic of prescription drug abuse.

My recent article in NPR explores this struggle, between relieving people's pain, and possibly fueling this worsening epidemic.


When a Prescription for Pain Becomes a Gateway to Addiction


Please read, and comment! I'd love to hear your thoughts.



What does a healthcare dystopia look like?

In my recent TED talk, I introduce you to a world where people die waiting for healthcare, where corporate interests reign, and where doctors get paid to do more rather than to the right thing.

I’m a Chinese-born, American-trained physician. A couple of years ago, I was given an opportunity to conduct a research project on China’s healthcare system. I traveled to 15 cities from Beijing to Inner Mongolia, visited over 50 hospitals, and had unprecedented access to doctors, medical students, nurses, administrators, and government officials. Given how China’s developed into a major world power, I expected to find a fair, functional system.

However, instead of this utopia, I found a dystopic world. People spoke about the 1980s, when universal healthcare was dismantled, and 900 million people lost coverage overnight. Everyone had a story of friends and family who died in front of hospitals because they couldn’t pay.

Doctors were unhappy too. Imagine you’re a doctor, and you trained all your life to listen and heal; suddenly, overnight, you’re a businessman and you have to work your patient to get every cent.

On the other hand, if you’re a well-off patient and you hear that poor people get denied services, what do you want for yourself? You want everything to be done. Because you have the money, nobody will tell you about the risk of radiation of a CT scan. Same for expensive but untested medications, or potentially dangerous procedures. People got what they wanted, but at what cost?

No doubt, China has been very successful. The government has lifted millions out of poverty. But there is a fundamental problem, a blind spot that’s been missed in the rush towards economic reform.

This blind spot is our belief that being a consumer enables choice, and that choice is power. I’m all for empowering people to have choices. But turning patients into consumers means that healthcare is a commodity, not a right. It becomes possible to deny life-saving treatment, and to sell unnecessary, even harmful, interventions. The doctor-patient relationship becomes a transaction between salesman and client.

That blind spot, and the consequences, are not unique to China. Here in the U.S., costs of healthcare are escalating out of control. While millions remain uninsured, 30% of all tests and treatments are done are unnecessary. It’s far more profitable to peddle drugs than prevent illnesses. According to the New England Journal of Medicine, 94% of doctors have some affiliation with drug and medical device companies.

By no means am I romanticizing the pre-1980s Communist state. My family left on political asylum, and I am very grateful for the opportunities afforded to me by my adopted country. But capitalism doesn’t have to equate consumerism, and the beauty of a democracy is that we as citizens can decide what type of society we want to live in.

To prevent further problems in our country, and to stop the rest of the world from following us down this path, we have to make a difficult decision. We must decide if it’s important to us to preserve our core tenets of liberty, democracy, equity, and justice. If not, we know what the dystopic future will look like. If so, the time is now to decide that there are some things that are not for sale, and that we must realign incentives to help people be their best selves.