The Value of a Physician’s Care

The other day, I learned about value-based healthcare.

The talk was given by a passionate UCSD faculty determined to change the status quo and fire up future physicians (like us MS1’s hungry for free lunch) against the corruption that favors the 1% of the nation and disfavors the 99% who are taken advantage by the insurance companies, pharmaceutical industry, hospital administration and even physicians themselves–sworn to protect and serve the patient at all costs.

The U.S. healthcare will soon takeover 40% of our federal budget by the mid 2030’s. Because physicians and the system is afraid to “cut corners” and

  • For a patient suffering from excruciating pain, the U.S. healthcare system will help with and push $150,000 in chemotherapy that doesn’t do anything for thousands of end-stage patients but cause more pain. However, the same healthcare system will not provide hospice care which would cost only a few thousand dollars, which would do so much more for a patient in the last few weeks of life than hooking them up to painful chemicals. (I further clarified, they’ll provide drugs here and there and perhaps a visitor nurse to check on them, but will not provide a personal health aide)
  • As a cancer patient, what would you rather do with $100,000?
    • Avastin to extend your life for maybe 2-6 more weeks in the hospital
    • Spend your time relaxed on vacation, traveling around the world, managing the pain, spending as much time as you can with your loved ones, etc.
  • If you provide good palliative care, it is proven so many patients can and do live much longer. By simply managing the pain well. Some people are scared of opiates because of its abuse and mismanagement throughout the country’s hospitals. However, this is the one case where it is needed and where it’s deserved.
  • Pharmaceutical companies are like animals: Do only what you can to survive.
    • Mylan increased the price of a simple epipen from $57 to $600. No change in formula. Simply because patients relied on them and they monopolized the market.
    • In a truly free market, a better product means the older less effective product should lower their price. Gleevec’s super drug increased the market from $26,000 to $146,000 even after better competitors entered the market.
    • Insulin drug market is dominated by 3 companies and are under investigation for price fixing.
    • Albendazole used to cost $6. It now costs $724 ($250 copay).
    • Doxycycline used to cost $20. It now costs $1,849.
  • What can we do as physicians to better care for our patients?
  • Oncologists or physicians in general should never have an incentive in prescribing certain medicines. Oncologists currently have financial incentives for giving certain medicines. They buy certain anti-cancer drugs for a certain price, then they make profit by selling it at 3x the price. This would be fine, but what about the instances when a simpler, cheaper drug could be even better for the patient? What is the physician with debt more likely to prescribe to a trusting patient?
  • U.S. hospitals will be paid to injure you. If you’re healed and out of the hospital in 3 days for a GI problem they get paid. If they rupture something in surgery, an infection erupts, etc. the patient stays another 2 months and the hospital makes 30x what they were originally going to charge the patient. There is no incentive not to harm the patient as quick, as efficient as possible.
  • One neurosurgeon, Dr. Chris Duntsch, harmed patients for fun and drilled into spines nowhere near injuries. He was reported, but never stopped. It was always someone else’s problem. They didn’t want to be annoying to superiors. But he maimed and permanently injured and even killed dozens of patients.

A lot of these thoughts are sporadic here and there, but conclusively… I’m disappointed in the healthcare industry. Will I one day choose to turn a blind eye out of convenience?

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Jollas del Amor

The beauty of studying medicine in such close proximity to another country is the overflow of culture I can learn from everyday through the people around me.

Today, our medical class hosted a ceremony to honor the dead as part of Dia de los Muertos. We shared the name of someone who is no longer with us in this realm, someone who had impacted in our lives in one way or another, as well as one quality they lived out that we admired. We closed our eyes and imagined them there beside us in the wide-windowed room overlooking the grassy lawn outside altogether.

I shared my mother’s name “Mijung Moon” and spoke the words “soft-hearted”

We pictured this person here smiling with us, proud of where we are, all that we are enduring in this present day and all that have endured. We remembered how much they meant to us, how much they’ve formed us, how still they push us to embody a certain trait that we may always strive after. How this life that ended continues on with us, those who remember them.

I loved this shift in perspective that this seemingly materialistic ceremony conveyed. As the alter holds the pictures and memorabilia of those we love and miss, we provide a space for them to visit us and share this physical space with us–to connect them back to us. Instead of carrying them only in our hearts, to see them beside us in the place that we are. The Christ-centered aspect of seeing this life as not the end was imbued into the discussion, to see the physical death of our patients as not the end of their spirit that lives on with us.

The physician who came to speak to us about how to process dying amongst our patients as well as our loved ones said something I will never forget. When you’re with your patient, you do not have to always hold back the tears. Let them be recognized as what makes you human. In Spanish, tears are poetically named “los jollas del amor” –as if our tears are the jewels of love. I thought about how beautiful this is–to see our tears not only as the hallmark of deep sorrow but also the overflow of our empathy, of our love for one another. Only in deep emotion can our body react in such a strong response.

To think about a patient who feels they are surrounded by loved ones who refuse to acknowledge what is to come. To see death as something unspeakable, even though it doesn’t have to be. It can be welcomed, it can be celebrated in addition to being handled with extreme love and care.

I hope I can be a physician one day–strong enough to be the one person a patient may be able to turn to and say, “I can’t say this to my family, they are not strong enough. But this is how I want my end to be like.”

Even though the days have been filled with this and that, I hope I can continue to remember to embrace sorrow when it comes, but let it go in the right time and place.

Pour your heart out once every day.
Then dedicate the rest of the day wholly dedicated to being in joy. 

Hippocratic Oath

I’ve ended my Fulbright grant in South Korea and now begin my medical studies. So much has happened in just one month that it’s been hard to take note of the transitions from Seoul to Philadelphia to medical school here in California. Hoping to continue brief anecdotes from what I’ve been learning here and there.

Standing there beside my classmates reading those heavy but proud words as a promise to be the best physician I can be. It felt unreal. What did I do to deserve this role? Will I measure up to the professors and physicians who led me here? The ones I’ve admired, scribbled notes down from, scurried behind from family to patient to family in hopes of piecing together how they step into each of these lives so seamlessly every single day.

I feel clueless here and not sure I can do this. But I am so thankful.

Quotes

  • Thinking about death in this way produces true love for life. When we are familiar with death, we accept each week, each day, as a gift. Only if we are able thus to accept life – bit by bit – does it become precious. — Albert Schweitzer
  • “Through our great good fortune, in our youth our hearts were touched with fire. –Holmes.” A friend directed me to the source — Oliver Wendell Holmes’ 1884 Memorial Day Address: “In Our Youth Our Hearts Were Touched with Fire.” 
  • Andrew has thought a lot about medicine and broader issues of “healing”, and ways in which collaboration based in universally-shared interests in health and healing can bring people together who are divided by other deep differences – including for Andrew through relationships he and others have developed with colleagues in DPRK.
  • Of the patients with advanced cancer, at least 60% will experience moderate to severe pain that requires opioids to control it. Pain rarely occurs in isolation; most patients live with multiple issues that are the manifestations (eg, symptoms, dysfunction) and predicaments (eg, change in roles, financial concerns, dependence) created by their underlying disease and its treatment.
    (Frank D. Ferris, Palliative Cancer Care a Decade Later: Accomplishments, the Need, Next Steps—From the American Society of Clinical Oncology, 2009)
  • One thing I am convinced more and more is true, and that is this: The only way to be truly happy is to make others happy. When you realize that and take advantage of the fact, everything is made perfect. — William Carlos Williams

 

New New New Centers

Metro Hospital (메트로병원 – 호스피스완화의료센터)

  • Hospice director worked hard to start this hospice ward over 20 years ago before the EOL movement began picking up speed in Korea
  • Director’s father owned Yong-In Psychiatry Hospital (용인정신병원) and created the Metro Hospital to treat schizophrenic patients who developed cancer. Usually, large hospitals don’t want to treat such patients because they are abandoned or no longer supported by their own families.
  • Was not meant to generate profit and functions off the profit from the richer head hospital
  • Recently renovated with new lobby and sharing space for performers, holidays, and celebration gatherings
  • Renovation due to the director growing old and ordering his son to update the ward
  • 4 bereavement ceremonies per year
  • Nurses have 52 hours per week due to federal law
  • Hospice ward run by a thoughtful surgeon physician

Namcheon Hospital (남천병원 – 호스피스병동)

  • $100 per night (3 patients per room)
  • 9 hospice nurses
  • Head nurse attends every patient’s funeral
  • View of 수리산 from every window
  • Provides blood tests, nutritional support, IV fluids, transfusions*
  • SNUBH refers the most patients to this hospice ward
  • Very new hospice ward (created 3 years ago)

*Former palliative care physician Beodeul Kang used to refer the most “difficult” patients and families here because Namcheon was the only hospice that provides additional medical services if requested. Difficult families referred to those who were hesitant to send loved ones to hospice thinking these centers don’t provide any medical services besides pain relief. Most hemato-oncology patients were sent here due to the availability of transfusions.

The first ever hospice in Korea was created in Gwangju (갈바리의원). It looks like a cute grandmother’s home and it was very very homey.

 

Little Things Become Big

Such small things are special to these patients.

“I want to see one of my best friends marry before I die.” — recent college grad, 24 years

“I want to see and make sure my 2 daughters go to college before I leave.” — engineer, 52 years

“It would be nice to celebrate one anniversary with my husband outside of the hospital.” —  newlywed, 31 years

Just a few of the ones I remember and noted from patients throughout this week… Ordinary things that are mundane to millions of people who may even be losing the will to keep going. But these people who learn of their limited time upon hearing their advanced cancer diagnoses–they learn how precious the little things can actually be, that they never saw as something they would yearn for so desperately. I love these patients and their families for this reason. It’s painful to hear and see, but it makes me remember what other patients can be thankful for so that I can remind and emphasize this in the future for them and their loved ones.

I even look at my life: the way I can run by Han River at night without an oxygen mask, the weekend trips I can take to visit my grandparents without complicating treatment visits, the independence I have to have dinner with friends and ride the metro by myself without worry of collapsing. I can have a child one day because my body is virgin to the foreign chemicals and drugs that flood these patients’ fragile bodies. I can plan ahead my career in a field I’m passionate about and can even take time to continue exploring if I wanted to because I’m not limited by the survival outcome of a clinical trial. I can read a book on the bus without feeling nauseous or light-headed. I can eat the spiciest, greasiest 곱창볶음 in place of the mechanical soft diet scheduled into portions of mashed bananas, green jello and oatmeal.

How lucky we are to even be alive.

Hospice Boom in Korea

Today, I visited my first hospice center in Korea at Bobath Memorial Hospital (보바스병원) and it was much more comfortable and luxurious than I could have imagined for a country still developing its concept of well-dying…

  • Bobath used to hold 40 patients but had to downsize due to less coverage and has no upgraded back to 20 beds since the recent increase in government funding
  • Since 2015, certified hospice centers around Korea are now covered under the NHI (Nationalized Health Insurance) and increasingly helping patients and their families during the EOL process. Increasing funding has grown hospice exponentially in terms of services, number of available beds, locations, etc.
  • There is usually a long wait list for patients to enroll at these certified hospice centers now that the view of dying has changed, and palliative hospice care has now become more integrated earlier into the process rather than saved for the last few days of life
  • Bobath hospice director noted that some hospitals (SNUBH) is incredible with counseling, preparing and explaining hospice care to families before arriving while others (Samsung) simply send them off abruptly without much explanation
  • Bobath allows patients to stay 1-2 months and can re-enroll after discharge (Saemul Hospice allows patients to stay indefinitely while other hospices only allow 1-2 weeks)
  • Patients are not allowed to undergo life-extending treatment (chemo/radiotherapy) while staying at Bobath. However, patients can enroll in between treatments to be more at ease.
  • There are now well-furnished luxury rooms for patients and families for $350-400 per night which I’ll include photos of later! They are beautiful and hotel-like.
  • Bobath has 2 palliative physicians treating pain control who are formerly trained in hematology or neuro-oncology who learned from the first hospice-focused hospital at Seoul Catholic Sungmo Hospital.
  • The palliative research nurses discussed the need for more local hospice centers now that patients and their families are requesting onyl locations close to home to allow easier visitation.
  • I asked the palliative physicians how they chose their palliative specialty after training in various oncology/critical care routes. They noted how there wasn’t much training (SNUH back then only included one 1-hour lecture on ethics/palliative care while other institutions only had one optional seminar) while they were students but they happened to learn about it naturally alongside palliative physicians when the EOL care movement was beginning about 20 years ago.

Another note: The clinical cancer research nurse who I sit beside in Dr. Chae-Yong Kim’s office noted how SNUBH held a “well-dying” lecture at the hospital by Professor Jung Hyun-Jae (정현채 교수님) yesterday while I was away. She noted how Korea usually does not take the concept of dying very well and how the process is filled with fear of the unknown and how families are filled with dread due to the suddenness. She shared with me how important she saw it to change the perspective of what’s happening: discussing the process more with families beforehand and shaping conversations in a positive light about how they will be going somewhere far greater than where they are now. How this eases and comforts the patients and families much more than simply talking about which treatments and surgeries to choose between. The role model in South Korea is currently England who have community-based hospices locally throughout the country. To see these kinds of lectures growing in the larger hospitals educating nurses who are coming to appreciate the formal concept of patient autonomy and shifting perspectives of what’s more important for peace and comfort at the end of life makes these last few weeks worth it…

I’m seeing how difficult this transition will be for the healthcare system here in Korea and East Asia overall, but these seemingly small steps toward educating healthcare professionals how to mitigate the moral distress that comes with withdrawal of futile life-sustaining treatments and overall EOL decision-making is powerful. I hope I can return to Korea after my medical training to visit these same hospice centers and cancer wards to see the progress Korea has made.

In the coming month I’ll be visiting:

보바스기념병원 – Bobath Memorial Hospital

남전병원 – Namcheon Hospital

샘물호스피스 – Saemmul Hospice

광주호스피스 – Gwangju Hospice