The Surprising Lesson from My Cross-Country Book Tour

It’s been two and a half months since the publication of my book, When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests, and I’m exhilarated and exhausted. Since January, I have been traveling around the country to talk about why it’s so important for doctors to listen and how patient empowerment can transform medical care. The reception to these messages has been excellent, and I’m very grateful to my colleagues around the country for inviting me to speak.

Having given dozens of talks on When Doctors Don’t Listen, I can predict most audience questions. Invariably, someone will ask about medical malpractice: aren’t doctors just protecting themselves by ordering more tests? (My response: the primary cause of malpractice is lack of communication, and tests don’t replace communication.) There will be another question about how the medical profession has reacted to the book. (My response: quite well—who wants to admit that they’re the doctor who doesn’t listen?)

There is one more question that is consistently raised, from Boston to Los Angeles to St. Louis to Cincinnati, one that I wouldn’t have predicted. What do you think about integrative medicine, someone will ask. Why don’t doctors advise patients on other options beyond pills and CT scans? What about treating the whole person, and preventing disease from occurring in the first place?

This question surprised me, as did my lack of knowledge of how little I actually knew about integrative medicine. Even though I was born in China, a country steeped in combining Western practice with Eastern philosophies, my medical training has been exclusively from conventional Western institutions. I cannot recall one course during medical school or residency that focused on complementary medicine or holistic care, or anything other than the disease-oriented model of Western medical care.

In fact, it wasn’t until I was asked this question during my book tour that I began looking into the concept of integrative medicine. I learned that integrative medicine is not synonymous with complementary and alternative medicine, but rather is “healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.”

This sounds like the type of medicine that all doctors should all strive to practice, and all patients strive to receive! In the words of physician and noted humanist Dr. Abraham Verghese, integrative medicine isn’t “wedded to a particular dogma, Western or Eastern, only to the get-the-patient-better philosophy.” Indeed, millions of patients in the U.S. and around the world embrace this holistic medical practice, and the pioneers of integrative medicine, such as Drs. Andrew Weil, Bernie Siegel, Deepak Chopra, and Dean Ornish, are widely revered.

Yet, from my own experience, I know that integrative medicine is not something we are teaching future doctors. I can also see that, based the persistence of this one question asked around the country, patients are hungry for knowledge on what they can do that goes beyond our Western concepts of disease. Instead of prescribing a pill for blood pressure and cholesterol, what is an exercise regimen that I can try first? Is there an alternative to surgery for my back pain, including yoga and massage? How can doctors coordinate my care with more “traditional” healthcare providers like nutritionists and physical therapists, as well as more “alternative” providers such as acupuncturists and naturopaths? Health is not just about illness, but about prevention and maintaining wellness—how can patients partner in all aspects of their health?

I am in the midst of writing a series on medical errors that occur in the hospitals. We know that conventional Western medicine can save lives, but we also know that medical error happens far too frequently. We also know that 30% of all tests and treatments are unnecessary. Patients are seeking an alternative approach to health. They want information about prevention and natural approaches to health. They want to talk to their doctors about it, but are finding that their doctors—like me—know precious little about integrative care.

During my research in China last summer, I spent some time observing the practitioners of Traditional Chinese Medicine, who were adept at integrative medicine. Unfortunately, this, and my brief but educational visit to Emperor’s College, an oriental medical school in California, is the extent of my interaction and knowledge of integrative medicine.

Now that the book tour is coming to a close, I am looking to learn more about the surprising topic that has emerged and to think more about how to educate conventionally trained doctors like myself to practice a holistic approach to patient care. Please reply with your suggestions for resources. Include links. Recommend books. Suggest places for me to visit, virtually and in person. Contribute your experiences. I’ll post more from my journey in this blog.

10 Medical Errors that Can Kill You in the Hospital

In my last post, you met Paul Hastings, the recently-retired accountant about to embark on an around-the-world trip who ended up with one-way ticket to the hospital instead. More people die from medical mistakes than they do from car accidents, pneumonia, and diabetes.

No doubt, this is a shocking statistic. Before we discuss what you can do about it, let’s first talk about the 10 most common errors that can occur during your hospital stay:

#1. Misdiagnosis. The most common type of medical error is error in diagnosis. This is not surprising, since the right diagnosis is the key to your entire medical error. A wrong diagnosis can result in delay in treatment, sometimes with deadly consequences. Not receiving a diagnosis can be dangerous too; this is why it’s so important to aim to figure out what you have, not just a list of things that you don’t have.

#2. Unnecessary treatment. Patient advocate Patty Skolnik founded Citizens for Patient Safety after her then-healthy, 22-year old son underwent brain surgery that left him partially paralyzed and unable to speak. He fought for his life for two years before succumbing to multiple infections. His story is incredibly tragic—especially since his surgery was never needed in the first place. Like Michael, thousands of people receive unnecessary treatment that cost them their lives.

#3. Unnecessary tests and deadly procedures. Studies show that $700 billion is spent every year on unnecessary tests and treatments. Not only is this costly, it can also be deadly. CT scans increase your lifetime risk of cancer, and dyes from CTs and MRIs can cause kidney failure. Even a simple blood draw can result in infection. This is not to say that you should never have a test done; only to be aware that there are risks involved, and to always ask why a test or procedure is needed.

#4. Medication mistakes. Over 60% of hospitalized patients miss their regular medication while they are in the hospital. On average, 6.8 medications are left out per patient. Wrong medications are given to patients; a 2006 Institute of Medicine report estimated that medication error injure 1.5 million Americans every year at a cost of $3.5 billion.

#5. “Never events”. Virtually everyone has heard the story of operating on wrong limb or the wrong patient. There are more horror stories. Food meant to go into stomach tubes go into chest tubes, resulting in severe infections. Air bubbles go into IV catheters, resulting in strokes. Sponges, wipes, and even scissors are left in people’s bodies after surgery. These are all “never events”, meaning that they should never happen, but they do, often with deadly consequences.

#6. Uncoordinated care. In our changing healthcare system, the idea of having “your” doctor is becoming a relic of the past. If you’re going to the hospital, chances that you won’t be taken care of by your regular doctor, but by the doctor on call. You’ll probably see several specialists, who scribble notes in charts but rarely coordinate with each other. You may end up with two of the same tests, or medications that interfere with each other. There could be lack of coordination between your doctor and your nurse, which can also results in confusion and medical error.

#7. Infections, from the hospital to you. According to the Centers for Disease Control, hospital-acquired infections affect 1.7 million people every year. These include pneumonias, infections around the site of surgery, urinary infections from catheters, and bloodstream infections from IVs. Such infections often involve bacteria that are resistant to many antibiotics, and can be deadly (the CDC estimates nearly 100,000 deaths due to them every year), especially to those with weakened immune systems.

#8. Not-so-accidental “accidents”. Every year, 500,000 patients fall while in the hospital. As many “accidents” occur due to malfunctioning medical devices. Defibrillators don’t shock; hip implants stop working; pacemaker wires break. There are supposed to be safeguards to prevent these problems from happening, but even if they happen for 1 in 100 people, do you want to be that one person who experiences the “accident”?

#9. Missed warning signs. When patients get worse, there is usually a period of minutes to hours where there are warning signs. You may feel worse, and there are often changes in your heart rate, blood pressure, and other measurements. Unfortunately, these warning signs are frequently missed, so that by the time they are finally noticed, there could have been irreversible damage.  

#10. Going home—not so fast. Studies show that 1 in 5 Medicare patients return to the hospital within 30 days of discharge from the hospital. This could be due to patients being discharged before they are ready, without understanding their discharge information, without adequate follow-up, or if there are complications with their care. The transition from hospital to home is one of the most vulnerable times, and miscommunication and misunderstanding can kill you after you get home from the hospital too.

Hospitals recognize these medical errors as a significant problem, and they are taking steps to make care safer. But if you or your loved one needs medical care now, what you can do to ensure that your hospital doesn’t kill you? I’ll be writing more tips soon on my blog and on Psychology Today—please share your sstory, and thank you for reading.

How Hospitals Can Kill Us

Paul Hastings never imagined that his retirement would kick off with a near-death experience. After forty years of filing taxes for corporate clients, he was looking forward to the around-the-world trip that he and his wife had always talked about. Before the trip, he saw his doctor for a check-up. He mentioned that he sometimes had trouble catching his breath, and his doctor encouraged him to stay in the hospital overnight for some tests “to get a clean bill of health”.

In the hospital, he underwent blood draws and x-rays, which led to heart tests and a CT scan. A cardiologist told him that he had mild heart failure; a pulmonary specialist diagnosed him with borderline emphysema; an endocrine doctor thought he had early-stage diabetes. He was started on new medications, one of which made him so confused and disoriented that he fell out of bed and broke his hip.

The operation went well, but afterward, he developed a blood clot in his legs and a bladder infection. Some days later, a nurse gave him a medication that was intended for another patient, and his heart stopped for nearly two minutes.

“I’m lucky to be alive,” Paul tells me. He is in a special nursing home for recovering patients, and says he’s getting stronger by the day. I watch as he demonstrates how he pushes himself up with his hands until he can support his weight with a walker. Going eight steps from his bed to the commode takes significant effort, and he’s out of breath at the end.

“Hard to imagine that two months ago, I was running five miles a day, right?” he asks. “My life isn’t quite what it was, but that’s the way things go. Everyone knows that bad things happen in hospitals, and there’s nothing we can do about it.”

Paul is right on some accounts. Hospitals are dangerous places. In 1999, a landmark study by the Institute of Medicine found that 100,000 people die every year because of medical error. This is more than the deaths due to car accidents, diabetes, and pneumonia, and is equivalent to a fully-packed Boeing 747 crashing and killing all onboard every single day.

Despite advances in medicine, recent studies estimate that the number of people who die because of medical error is actually closer to a quarter of a million per year. In a stunning 2011 Health Affairs article, researchers found that medical errors occur in one-third of all hospital admissions, as much as ten times previous estimates. During a single hospitalization, many patients experience more than one error. Another study of Medicare patients found that one in seven hospitalized patients experience at least one unintended harm that prolonged the stay, caused permanent injury, required life-sustaining treatment, or resulted in death.

Perhaps this data is shocking to you, or perhaps it’s not. In a survey of the American public, a third reported a personal experience with medical error, and nearly half stated that a relative was the victim of a medical mistake. The vast majority of errors were reported to occur in hospitals.

If so many people have experienced medical errors, and if we know that hospitals can kill us, why do we accept this status quo? More importantly, what can we do to stop hospitals from harming us?

I am beginning a series in this blog and in Psychology Today, that will discuss the 10 most shocking medical errors that occur in hospitals, and the 10 things you can do to prevent medical error during your hospitalization. I welcome your stories, and please stay tuned!

Guest Post: 3 Common Hospice Myths Worth Clarifying

This week, I am honored to host a guest post by Paula Spencer Scott, the Senior Editor at Caring.com, the leading online destination for caregivers seeking information and support as they care for aging parents, spouses, and other loved ones. Paula is a 2011 MetLife Foundation Journalists in Aging fellow and writes extensively about health, caregiving, and hospices.


Hospice care is an underused resource that can make a loved one's waning days more comfortable and less stressful. Unfortunately, misconceptions about hospice abound. As a result, many families avoid it or wind up having less-than-ideal experiences.
Frank conversations about hospice care are useful, whether you're wary about choosing hospice in the first place or you've decided to put a hospice plan in place.

The following three myths come up again and again, hospice providers say. If they strike a chord with you, use them as starting points to clarify what to expect from the experience.

Myth: Hospice is only for the tail end of life. 
When to start hospice? Usually, "earlier than you think," palliative care experts say. Sometimes families, or even doctors, are reluctant to bring up the subject for fear they'll be thought of as "giving up." As a result, their loved ones spend only a few days in hospice care, although it's designed to provide a peaceful end-of-life transition for weeks or months.

The general rule of thumb for admittance to hospice is that a patient is diagnosed with a condition that generally will result in six months or less of life. But nobody has a crystal ball -- and nobody gets kicked out of hospice because they're still alive six months and a day later. Many patients check in and out of hospice programs.

Ask your care provider: What comfort care options your loved one has at the same time you're discussing treatment options, especially if he or she wishes to have a noninvasive death experience at home. It's also possible to pursue both comfort care and curative care at the same time, so ask about that.

Myth: Hospice can't know what my loved one needs as well as his or her doctor. 
Hospice focuses on providing comfort and support, rather than curing an illness. It's a form of specialty care, although the patient's doctor can remain in the loop about care management. Regular medical treatment is not usually front and center, however, because the focus is shifting to allowing the person to live with as much privacy and dignity, and as little pain, as possible.

Hospice services differ by individual need and preferences but may include basic care management (such as chores, meals, personal care), counseling, physical or occupational therapy, caregiver respite, spiritual care, and bereavement support. There's some evidence that people at the end of life live slightly longer when enrolled in hospice than they would if not, possibly because there's less stress from futile invasive therapies.

Ask your care provider: What kind of services he or she recommends, how your loved one's primary doctor plans to interface with the case, how communication will flow between hospice and the medical practice, or whether a hospice doctor will now manage care.

Myth: The medication will "dope up" my loved one. 
Pain medication given as part of palliative care is meant to ease suffering -- not to hasten your love one's decline and demise. Dosages are carefully calibrated to manage pain, which makes it easier for your loved one to talk, rest, or spend time with family and friends. Uncontrolled pain is a common reason for poor quality of life at the end of life.

What's more, pain management is only one part of the full picture of comfort care. Your loved one can receive talk therapy, spiritual counseling, and physical support (even things as basic as help avoiding painful bedsores) that help him or her feel better than he or she might otherwise.

Ask your care provider: What the pain medication is for, how to use it, how to know when it's necessary, and what signs of pain and discomfort to watch for.

For more information about caregiving and hospice, visit Caring.com. Thanks to Paula for joining us at The Doctor is Listening!

What the U.S. Can Learn from China’s Health Care Reform

Wang Li is a 48-year old farmer from Dalian, China. After a two-day trip to the major provincial hospital, he’s heading home to his village to die. Wang has lung cancer, and even with insurance, his surgery will cost him 20,000RMB—$3,000, which is twice his annual salary. The surgery would be curative, but it doesn’t matter. “I cannot burden my family,” he said.

I am a Chinese-born, American physician who just returned from a two-month research trip spanning twelve cities and nine provinces in China, where many of the healthcare reforms in contention in the U.S. have already been tried. As Americans contemplate the decisions ahead, consider China’s cautionary tale.

Today’s China is one of great disparity. The wealthy minority receives top-notch care, while the poor majority suffers from little access to care and no way to pay for it. Stories abound of patients like Wang Li who sign out of hospitals when they run out of savings, knowing they will die without treatment.

It wasn’t always this way. In the mid-twentieth century, China had universal healthcare with a robust primary care system. Millions of “barefoot doctors” provided basic medical services in villages, and attention to prevention ensured significant gains in life expectancy.

The reforms of the 1980s changed healthcare from being a social good to a commodity. Universal insurance was dismantled, and 900 million people lost coverage overnight. Healthcare was decentralized to provincial governments, who allowed the market to operate with few restrictions.

What’s emerged is a fragmented system fraught with inefficiencies and perverse incentives. In Beijing, if a doctor diagnoses someone with a common cold and sends the patient home, she gets paid, 4.5 RMB, less than a dollar. But if she orders tests and administers IV antibiotics, she gets paid 400RMB, 100 times more.

There are additional ethical concerns. Because local governments have ultimate responsibility for service provision, poor provinces can afford to pay their doctors little more than manual workers. Doctors are expected to “top up” their salary through other means. Some earn up to 5 times their salary through kickbacks from pharmaceutical companies by prescribing new, expensive medications; others accept direct bribes from patients (“hong bao”) as promise for better care.

The commoditization of healthcare has caused direct harm to the patient-physician relationship. Patients question whether doctors are acting in their best interest. Threats against doctors occur daily, and doctors have become terrified of the people they serve.

Understandably, the attrition rate among doctors is multiplying. The lack of doctors is particularly acute in rural areas. With low pay and few opportunities there, doctors flock to cities, leaving many villages without any doctor. The high reimbursement for treatments has resulted in a huge pay differential in favor of specialists, and China has gone from a model primary care system to having virtually no general practitioners.

To its credit, the Chinese government has recognized the inadequacies of its healthcare reform, and is making amends including a nationalized health insurance system and a code of conduct for doctors. For the U.S. in considering similar reforms, China’s failures offer three important lessons:

First, health insurance does not equate access or coverage. In China, those with insurance still have to pay 60-70% out of pocket, leaving many without actual health coverage. Taking “personal responsibility” for our health may be important, but we should not price people out of life-saving treatments. 

Second, fee-for-service should be abolished in favor of fee-for-diagnosis, with a specific illness billed a fixed amount regardless of the tests and procedures performed. Not only does such “bundled payments” require accurate diagnoses, they reduce cost and the potential for inefficiency and corruption.

Third, healthcare regulations need to be national decisions. Given the variability among states and our mobile healthcare workforce, decentralized policies don’t make sense and will exacerbate inequalities. Market-based innovation can still be encouraged with pilot projects starting at the state level, but the U.S. needs national consensus on overriding principles.

This year, America has a once-in-a-generation chance to fix our broken healthcare system. As policy-makers discuss implementation of the Accountable Care Act, they should learn from China’s experience and decide whether they see medical care as a commodity or social provision, and what are the responsibilities of the government to ensure the health and well-being of its citizens.

Preserving the Humanity of Patients and Physicians

Everyone knows that life in the E.R. is fast-faced, extremely busy, and ever-challenging. When things get crazy, it becomes habit for busy physicians to see patients as “the chest pain in room 6” or “the broken wrist in the hallway.” We turn people with their amazing lives and fascinating stories into a nameless number and a “chief complaint”.

It’s a practice that’s easy to justify—after all, taking a long time with one patient can delay care for all the other people who are waiting to see us. However, the story of the patient, the story of why he is there, and the context of his illness—these are all critical to us taking care of him.

Learning our patients’ stories also makes our professional life that much more fulfilling. Last moth, I was supervising an intern, who saw a patient that she was confident she knew what to do with. “Room 8 is an old guy from a nursing home with dementia, who was recently here for pneumonia. He comes in with altered mental status and a cough. He is confused, has a fever, his lungs sound junky. I’m going to get a chest x-ray and do an infectious workup. He probably has pneumonia, and will need to be admitted.”

That sounded like a straightforward plan to me. It was a busy day, and I went into see this “old guy” who probably had pneumonia. I introduced ourselves to a woman in his room, his daughter, who was holding a book. It was on love: the metaphysical interpretation of love.

She saw me looking at the book. “Have you ever read it?”

I shook my head. “Well, it’s my father’s book,” she said. “It’s been printed in 100 countries.”

Indeed, this “old guy from a nursing home” was one of the foremost experts on the philosophy of love. He had had a phenomenal career, filled with interesting adventures. The daughter was one of many people who made up his loving family—they were more than happy to tell me about him. In a few minutes, I had learned so much more about him as a person, and as a patient.

How often do doctors find out, really find out, about our patients? Well, here’s how NOT to find out. Ask: “Do you have chest pain? Shortness of breath? Abdominal pain?” These yes/no questions may seem important to us as we check off a list that doctors feel compelled to ask, but they don’t tell us anything about who is the person in front of us. We have no idea of the careers they devoted effort to, accomplishments that they are proud of, and goals that they strove for.

As I think back to the most memorable moments of my medical training, what stands out aren’t the never-ending lectures, or heroic surgeries, or terrible traumas. What I remember are the people I met and their stories.

I remember Sharon, a lady who was dying of cancer. Her husband showed me a picture of the two of them when they were both three—they had met in a sandbox 80 years ago, and had been inseparable since then. I remember Fan, a middle-aged man who was so serene after a serious car accident that resulted in tetraplegia. I later found out that he was a Buddhist monk, one of the most revered in Asia. I remember Sydney, a drug addict I saw as an intern who returned two years later saying that he was now totally clean and running a recovery program for teens. These are the stories I cherish, of the patients I have been privileged to care for.

Physicians, nurses, and our team of health professionals are part of a humbling profession, an incredibly rewarding one, where we are honored to meet people from all walks of life. Instead of shying away from this task and turning people into a compilation of their symptoms, we need to embrace the gift that our patients are giving us. We should ask our patients about themselves. Not just what pain they have, or do they have this symptom or that symptom, but ask them who they are. What they do. What drives them. What makes them happy. Not only will it add so much depth and accuracy to their diagnosis and their care, knowing our patients will make doctors happier people—individuals who are more attuned to the humanity of our patients, and ourselves.

This column is modified from an article published in the American Academy of Emergency Medicine’s magazine, “Common Sense”. I explore these ideas and more in my new book, When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests.