Why healthcare isn’t just another commodity

If you are a person with a lot of choices, with a job that offers health insurance, with a social security number and a safe place to sleep and knowledge of where your next meal is coming from, I can see how you might think a market-based healthcare model is a good idea. You might be annoyed at your doctor, or the confusing bill, or the insurance company, but when something shitty happens to you, you aren’t really worried that you’re not going to be able to get help.

And I know that a lot of people in this position of privilege think (wrongly) that these basic pieces of a stable, comfortable life are accessible to anyone willing to work hard enough to get them. That everyone has basically good options but some people take advantage while others are lazy, entitled, or whatever other excuse might bubble up. This is infuriating because it is so, so wrong. It’s like that old adage of being born on third base and thinking you hit a triple. A lot of folks were born without even a bat to swing. Those folks are just as human as you are.

So imagine you are 58 years old, and your daughter just had a baby. Continue reading

who’s the expert?

It sucks to be sick. Full stop. A UTI sucks. Pneumonia sucks. Cancer sucks. People who have chronic illnesses, though, have an additional set of challenges to face. Some of these challenges are summed up in the idea of self-management, which is complex in and of itself. The definition of self-management that I like comes out of academic work* and it has three parts:

1. Medical managment

2. Role management

3. Emotional management.

I like this definition because it recognizes that there’s more to having an illness than remembering to take your meds and go to your appointments **. Continue reading

Sound bite: Lifestyle measures

In medicine, “lifestyle measures”  is code for diet (DASH, or myplate) and exercise (20 minutes/day!) — not for sleep, for relationships, for stress management, meditation, personal growth. . .

Can these things be taught in 15-minute office visits? How can we move away from  the sound-bite advice and into meaningful change?


wanting to do vs. doing

I saw a patient recently who came in for knee pain. Fairly typically, he was a fifty-ish, smiling, slightly chubby guy who thought he was pretty healthy, felt ok, and never went to the doctor. As I like to do with people like this, I evaluated his knee pain and then suggested we look at his overall health and risk factors, since he was here. “Yeah, OK, my dad died of a heart attack, so it’s probably a good idea,” was the response.

That’s how, a week later, I had this genial guy sitting across from me looking crestfallen when I told him he had high blood pressure, high cholesterol, and the beginning of type II diabetes. “But I feel fine, doctora!” is the refrain of these patients. And that’s the hard part– they do feel fine. How do you tell someone who feels fine that he could make himself healthier, extend his life, and feel great, but he’d have to change, a lot? Yes, we could start drugs to control the blood pressure, the blood sugar, the cholesterol, but these might make him tired, give him diarrhea, give him muscle pain. They might take a guy who feels fine and make him feel less fine. So, with this patient, as I often do, we decided to start with so-called “lifestyle measures,” which is really code for diet and exercise. (There could, and should, be so much more to it than this, but that’s a rant for another day). We talked about what this means, about what kind of diet to follow, how to evaluate food choices, what level of exercise is needed. We talked about how to make it work– getting family members on board, finding which healthy foods he likes, how to phase out the soda and the bacon. We talked about how tiny, incremental changes likely wouldn’t be enough to reverse disease without medication. We made a plan to follow up for support and retesting. And he left, resolving to change.

He wanted to make himself healthier. I truly believe that he did. He had the information about what to do. He had access to a place to walk outdoors and a place to buy fresh produce. He had recipes and lists of good foods to seek out. So why, when he came back to see me, had we not moved the needle?

I think I wasn’t able to offer him anywhere near enough support to make the kind of change necessary to transform his health. Have you ever tried to change something in your life that you knew would be good for you? It can seem truly impossible, insurmountable, even undesirable.  Discussions in the office and pamphlets can’t remove these obstacles. I think about how we treat substance addiction in facilities where you stay for weeks or even months, spending all day removed from the ability to use, learning about yourself and your history and the skills you need to function in the world. Yes, you have to want to change to succeed here, but you also have the support and tools and time to learn. Insurance often pays for this. But we don’t have this for people who need to learn nutrition and activity and relaxation and stress management. Yes, there are spas and fat farms and medical weight-loss programs, but there’s nowhere for regular people to go to learn “lifestyle management.” I would love to teach and facilitate this. I want to. But I can’t do it from my clinic, 20 minutes at a time. Let’s find a better way, shall we?



what I wish I could tell my patients

This stuff is the truest truth I know, but it’s hard to impart it 20 minutes at a time to people who want you to fix what’s wrong with them. My clinic is full of people– good, hardworking, courageous people who want to be healthy, and who have diabetes, high cholesterol, high blood pressure, or back pain. Or else they don’t feel good– they’re fatigued, they don’t sleep well, they just aren’t themselves. So we look for serious problems, we treat the symptoms. . . and then we talk about what kind of changes might help them. But so often, I just want to scream that all the blood tests and prescriptions in the world won’t make you well– you have to do that! So, to all the wonderful people who want to be well but don’t know how, I have this advice for you:

the truth about change

what is a nurse practitioner?

I work as a nurse practitioner. NPs are becoming much more common, more respected, and more understood, but I still often get questions about what being an NP means– questions from patients, acquaintances, even physicians. So I thought I’d go over some common questions here– both because you’ll understand me better, and because NPs will be integrally involved in the future of health care, and if you’re lucky, we’ll be involved in your care.

The NP will see you now.

The NP will see you now.

Q: What does it mean to be a Nurse Practitioner?

A: An NP is an advanced-practice registered nurse. We are educated in universities, and all NPs have a regular nursing license as well as an advanced practice permit. NPs must pass a certification exam before applying for the permit. NPs work in different roles, and the scope of practice varies by state– in some places, NPs practice independently like a physician would, and in others, they work only as part of healthcare teams. We can work in outpatient clinics, hospitals, or community settings. We practice with more autonomy than RNs, and are generally trained to diagnose and treat certain illnesses or injuries, which includes performing procedures and prescribing medications.

Q: How long do NPs have to be in school and how much clinical training do you get?

A: Currently, you need a master’s degree to get an NP license. That’s generally at least two years beyond the 4-year bachelor’s degree in nursing (although there are some programs that don’t do it quite this way). At least 500 hours of supervised clinical experience are required, but often more are included. There is also a doctorate for nurse practitioners, called the Doctor of Nursing Practice, or DNP. This degree is becoming more common and some organizations are calling for this to be required for entry to NP practice. It’s not without its detractors, but the idea is to strengthen competencies in translational research, evidence-based practice, and leadership. A DNP takes about two more years. There is no post-graduation residency required for entry to NP practice– this is one major difference from physician training.

Q: Why didn’t you just go to med school?

A: Not to bust out a cliche, but. . . apples and oranges. They’re both fruits, they’ll both fill you up when you’re hungry, but they’re not the same, and even though they overlap, they’re good at different things. You want an orange pie on thanksgiving? NPs and physicians both provide healthcare and they can both diagnose and treat many ailments. But NPs are trained with a different philosophy– we are taught to approach people as wholes, and to focus on peoples’ health in the context they live in. Some physicians may do this also, but this approach is really central to nursing practice. In my opion, NPs are typically very good communicators, educators and problem-solvers, and those skills are invaluable in promoting health. That said, if you have serious, complex health issues, like those that require surgery, having a physician on the team is important. There’s certainly a need for both practice models.

Q: Can’t I see the real doctor?

A: Probably, if you are willing to wait. But know that NPs have comparable outcomes, and often higher patient satisfaction*. If your problem is outside the NPs expertise, she’ll consult, or get you in with someone who can help ASAP.

Q: Where do NPs work? What do you specialize in?

NPs work in all kinds of healthcare settings. Certification is done by patient population: NPs may be certified as Adult/Geriatric acute care NPs, Adult/Geriatric primary care NPs, as family NPs, as psych/mental health NPs, or as pediatric NPs. There are not sub-specialty certifications, though NPs may receive additional training and experience and work in these areas, such as dermatology, GI, cardiology, or others. A lot of retail clinics and urgent cares are staffed by NPs (often family NPs). They often work as part of hospitalist teams or may work in specialists offices with more routine cases. Many (like me!) work as primary care providers.

So, folk, I hope this helps clear up some of the confusion!

*Some medical groups have tried to discredit the notion that NPs provide comparable care in certain clinical settings, such as primary care. It is my belief that such attempts are politically motivated and not directed towards achieving high-quality, high-value care. Arguments against NP use tend to be emotionally motivated rather than data-driven– e.g., claims such as “when you’re sick don’t you want to see a real doctor?” And “the fewer hours of training clearly mean NPs are not prepeared”. I made sure to include references here from both medical and nursing sources.