Author: Laurie Reed

Just What the Doctor Ordered

Book Review: Braving Chemo by Dr. Beverly Zavaleta

Book Review: Braving Chemo

In her book, Braving Chemo, Dr. Beverly Zavaleta provides a comprehensive guide for anyone facing chemotherapy treatment for cancer. Dr. Zavaleta, a Harvard-educated physician, based the book on her own experiences after chemotherapy for breast cancer. But this book defies the confessional, physician turned patient revelations.

Braving Chemo offers an honest, detailed, and practical template on how to prepare for and navigate one of the more arduous steps in the patient journey. In the Introduction, Dr. Zavaleta outlines her reason for writing this book, “I discovered that for all the challenges I faced as a patient, my training as a family physician and a hospitalist gave me insight that very few cancer patients have.” This book aims to fill the gap for others with credible, reliable information.

The layout of the book is linear beginning with the Diagnosis, taking deep dives into each of the major issues with chemotherapy – side effects, infections, nutrition, appearance, mind games – and ending on Recovery. Such a detailed narrative makes it easy for the reader to pick out information most relevant as needed. And segments within chapters are packed with great material, in an easy-to-read format, punctuated with definitions, helpful hints, checklists, medical alerts, exercises, and resources with links for further research.

Dr. Zavalata brings the objective perspective of a clinician with the humanity of the lived patient experience. Any patient about to start chemotherapy, or in the midst of treatment, should have this book as a key resource to read and to reference as questions arise. Caretakers could also benefit from information in this book for guidance and perspective. Braving Chemo provides an authoritative guide for the chemotherapy experience.

4 Points to Remember During Recovery After Illness

The Path to Recovery

As I’ve learned through my interviews with patients experiencing serious illness, treatments can be grueling, leaving patients emotionally and physically exhausted. During her treatment for breast cancer, Jackie, a single mom with a teenage son, recalls:

Many, many times, you get home and you just, you feel so alone, and I’ll have that emotional breakdown. I’m like, this is really hard. I had no one there to just hold me, But, you have to allow yourself to do that too, you really, really do. You have to allow yourself to let that out.

Jackie

The focus for patients in treatment is making it through each day, as it should be. Getting through to the other side of treatment is a goal, wrapped in hope and the expectation of reclaiming the life, the way of being in the world so cruelly interrupted by illness. The reality though is often different.

Jaime, a young mother with two children, was diagnosed with Stage 4 colon cancer after a year and a half of chasing doctors in search of an answer for her pain. Our interview happened just a few months after she was told the cancer was gone so her answer to my question about how the disease had affected other areas of her life surprised me.

[With] survivorship a lot of times, people will say okay, well, you’re cancer-free now, so, everything goes back to normal. Not so much. [She laughs] I would almost rather go through treatment and knowing what I’m dealing with then, you’re disease free and having that fear in the back of my head… There’s always that little seed of doubt that, what if it comes back.

Jaime

The challenge of recovery is a reoccurring theme in my interviews. It is also a theme that is beginning to be shared by other writers who are former patients. These writings sharply illustrate the surprise to find post-treatment often more painful, difficult, and frightening than treatment. Jamie Aten, founder and executive director of the Humanitarian Disaster Institute, utilized techniques he teaches PTSD patients to manage his own experiences post-treatment¹.

Beth Stebner, a Brooklyn-based writer and editor diagnosed with ovarian cancer six months before her wedding, describes what she felt after leaving treatment²:

I carried more sadness, anger, anxiety, and fear than I’d ever had before – or even during – my health scare. I was terrified that the second I became comfortable in my old routines my disease would return, taking away everything that I worked so hard to rebuild.

Beth Stebner

In all of these experiences, there is an element of surprise. Recovery remains somewhat shrouded in mystery. Patients don’t talk about it and the focus of healthcare dollars and research is on diagnosis and treatment rather than what happens after treatment ends.

In fact, recovery, similar to a serious illness, hits the trifecta of factors that contribute to a healthy balance for living – psychological, social, and physical. Here are some of the ways issues emerge during recovery:

  • Physical – Pain, Nauseousness, Fatigue, Unsteadiness, Weight gain/loss, Side effects from treatment
  • Psychological – Anxiety, Fear of a recurrence of illness, Depression, Lack of self-esteem/confidence, Shame
  • Social – Isolation, Loneliness, Support systems after treatment wane or vanish, Reluctance to reach out and ask again for support

It is critically important to recognize recovery is just as much a part of the patient journey as diagnosis and treatment. Here is an opportunity to begin a dialogue for change. Key points to consider:

  • Awareness – A recognition that just because treatment ends, doesn’t mean that all is better. In fact, recovery is a new beginning. Recovery is a time to allow the body to rest and heal.
  • Communication – Let people know what is going on, rather than trying to pretend that all is well. Be honest with yourself and others.
  • Advocacy/Support – Trying to go it alone only slows and impedes the body’s ability to recover. Support is needed as much in recovery as in times of serious illness.
  • Compassion – Be kind to yourself. Patience and understanding are needed in abundance.

Please know that although illness and recovery can be very isolating experiences, you are not alone. Others have travelled this path, and there is an opportunity to learn from these experiences.

* Quotes in this post are from interviews conducted for my book, Navigating Illness: The Patient Experience, a work in progress. Names were changed upon an individual’s request.


¹ Aten, J., (April 29, 2019). Coping with Trauma. Cancer Today.
² Stebner, B. (May 9, 2019). After Beating Ovarian Cancer at 30, The Real Battle Began.

The Practice of Medicine is Both Art and Science

The Practice of Medicine is Both Art and Science

Learning medicine is a scientific endeavor, practicing medicine is an art.

Dr. Ricardo Rosenkranz

During my visit to the Urgent Care Center for an infected eye late last year, I was reminded that medicine is both art and science. The physician brought in the final paperwork with the instructions for discharge. As we exited the exam room and walked down the hall toward the exit, I peppered the physician with questions – Did he think my eye infection was caused by a virus? Did I have a virus? Did I, in fact, have the flu?

To all of my questions, the physician simply shrugged his shoulders, as if to say, he didn’t know. Now there are tests that could determine if my eye infection was bacterial or viral. However, results from such tests would take a few days. The doctor’s approach — treat the symptoms, watch for improvement, and if my eye got worse return for follow-up.

I was curious though and pushing for answers, wanting his perspective. The physician finally said, ‘you know, it’s all just a bunch of voodoo. There’s so much we really don’t know.’ I burst out laughing. How refreshing to hear a physician say, in so many words, that doctors don’t always have the answers.

Medicine as Science

Unfortunately, many physicians will not admit to not knowing, particularly in interactions with patients. There is an expectation, stubbornly held by both physicians and patients, that physicians are always supposed to have the answers. This is simply unrealistic. Patient harm often results when physicians fail to admit they do not know. Patients are diagnosed and treated for ailments they may not have. Communication and coordination of care often falters. And there is a general reluctance to call in specialists and experts for different perspectives or recommendations. Calling in reinforcements, in fact, may be just what is needed to achieve better outcomes. Recent research published in JAMA Network reveals higher diagnostic accuracy with a collective versus an individual approach

Medicine as Art

Acknowledging the mystery in medicine is a step in the right direction. According to Dr. Ricardo Rosenkranz², magic may serve to provide the insight, perspective, and passage to a deeper connection between physician and patient.

In December of 2016, I had the privilege to attend a magic show highlighting this relationship between magic and medicine.³ The magician was Dr. Ricardo Rosenkranz, a practicing physician and Assistant Professor in Clinical Pediatrics at the Northwestern University Feinberg School of Medicine.

The performance, as all good magic does, mystified and dazzled. But this particular magic show also highlighted –

  • the value of listening
  • the need for ritual
  • the importance of storytelling
  • and the power of empathy

— all essential ingredients not just to a great magic show but to best practices in medicine as well. Dr. Rosenkranz is committed to changing medicine . He uses his skills as a magician to first spark the imagination, with the intent to transform behavior, acknowledging both the art and science of medicine.

Creating a New Path

In addition to his performances, Dr. Rosenkranz has created a “curriculum on magic and medicine for the Medical Humanities and Bioethics Program at Northwestern targeting first and second year medical students. The intent of the program is to help medical students develop a deeper understanding of the doctor-patient relationship.” [as stated in the program]

Dr. Rosenkranz is teaching medical students how to be better doctors. In turn, Dr. Rosenkranz asks patients, as he asks his audience members, to come prepared to engage. By improving the dynamic between physician and patient, there is an opportunity to positively influence the experience, not necessarily the outcome, but the experience.

During times of serious illness, moving forward in the face of uncertainty is challenging. It is essential, however, for both physicians and patients to acknowledge medicine as an imperfect science. There might not always be answers, but it is in this acknowledgement that both physicians and patients can move forward in a healthy way. Medicine is both art and science, come prepared and stay engaged.

¹JAMA Network Open. 2019;2(3):e190096. Doi:10.1001/jamanetworkopen.2019.0096

²The Rosenkranz Mysteries, the Show, About Ricardo Rosenkranz. December 2016

³Medicine is a performance art: combining magic and medicine | Ricardo Rosenkranz | TEDxNorthwesternU. 2015

Are These Medical Tests Really Necessary?

Are These Medical Tests Really Necessary?

Have you ever stopped a doctor from ordering and performing medical tests and procedures that may be a repeat test, nice to know but not critical, or perhaps even unrelated to your issue or concern? If so, how did that go for you?

I’ve discovered I’m not good at saying ‘NO’. I worry about the consequences: Will my care get compromised? Will I get labelled as a ‘difficult’ patient? Perhaps even denied care? However, data indicates unnecessary testing only drives up costs for healthcare which are already high and out of control. Kaiser Health News estimates the costs of unnecessary medical tests and procedures at $200 Billion.¹ Such data suggests there may be value in asking questions and becoming a better advocate for my own care and treatment.

Test Now, Ask Questions Later

Two years ago, I made an appointment with a podiatrist because I was having foot pain, specifically, heel pain. Before ever seeing the doctor, the technician asked me to stand on a platform and two separate x-rays ($88 each) were taken of my foot. By the time the doctor walked into the exam room, based on my description of the pain to the technician, she was ready with a diagnosis. I had Plantar Fasciitis, a condition that occurs when the ligament, that stretches from the heel to the toe, begins to pull away from the heel and becomes inflamed.

X-rays provide images of bones, they don’t provide a view of ligaments and tendons. In some cases, Plantar Fasciitis can produce a heel spur. Heel spurs though rarely cause pain and wouldn’t change the recommended initial course of treatment. Perhaps my physician used the x-rays to ‘rule out’ other diagnoses, but I’m confident the doctor knew my diagnosis even before the first x-ray was taken. As it said in the literature sent home with me after my appointment, “Heel pain is one of the most common conditions podiatrists treat. It accounts for approximately 15 – 20% of our practice.”

Based on her years of experience, this doctor could have arrived at a diagnosis based on a conversation with me about my pain and by manipulating my foot. However, in today’s healthcare system, physicians are financially rewarded for medical tests and procedures conducted in their offices. A fee-for-service healthcare system, benefits the practice while also driving up healthcare costs. This is a horrific waste of time, money, and resources.

Wait a Minute, Why Did You Ask For My Previous Records?

More recently I accompanied my husband to the eye doctor. He was following up with a specialist due to an unusual speck in his eye discovered during a routine eye examination. When setting up the appointment, my husband was asked to have his records forwarded to the specialist’s office, which was in the same building as the original optometrist. The records were all relatively new, certainly within the past month.

However, at the specialist’s office, the technicians proceeded to conduct the same tests as the first doctor (eye charts, dilation of the eyes) rather than building on information already collected and moving directly to the tests to aid with diagnosis and recommendation. By repeating these tests, the office is able to bill insurance, which pads the monetary return to the specialist.

In the ongoing debate on the future of healthcare there’s a lot of binary discussion – ‘medicare for all’ vs. a private/public option. The main focus for these debates is on access, which is important, but access to a broken system is rather problematic. Medical testing is intrusive taking time away from patients as well as exposing patients to additional tests and procedures which in the end might not actually be necessary. It is not a harmless practice.

The Importance of Patients Asking the Questions

In her book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, Elisabeth Rosenthal outlines reasons for the high cost of healthcare. According to Rosenthal, insurance companies, hospitals, physicians, and pharmaceutical companies – all share in the blame for rising costs. As she states in the introduction: “These days our treatment follows not scientific guidelines, but the logic of commerce in an imperfect and poorly regulated market, whose big players spend more time on lobbying than defense contractors. Financial incentives to order more and do more – to default to the most expensive treatment for whatever ails you – drive much of our healthcare.”²

Much needs to be changed in the delivery of healthcare in the United States today. But, as Rosenthal asserts, the current situation demands that consumers must be active participants in their own healthcare. As patients, this would suggest we need to begin to ask questions about tests and procedures during a physician or hospital visit. Questions might include: What is the reason for this particular test/procedure? What is the cost? How does this fit with the reason for my visit?

As patients, we have an opportunity to change how medicine is currently practiced. I am more willing to ask questions knowing how critical it is for me to be an active member of my own care team. I hope this article will give you some courage as well. Let me know how it goes.

¹https://www.healthcarefinancenews.com/news/unnecessary-medical-tests-treatments-cost-200-billion-annually-cause-harm

&sup2Elisabeth Rosenthal, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (New York: Penguin Books, 2018), p. 5

Does Direct Primary Care Offer a Better Alternative?

Does Direct Primary Care Offer a Better Alternative?

The healthcare system in the United States today misfires on communication and fails to coordinate patient care. In the current system there is little patience for listening to and caring for the whole person. And physicians are burning out. Doctors are forced to spend more time and effort on paperwork navigating systems than actual patient care. The two participants that matter most, the very reason for healthcare — the physician and the patient — have lost control. Does Direct Primary Care offer a better alternative?

What is Direct Primary Care (DPC)?

Direct Primary Care provides patients with access to a primary care physician for a monthly fee. This fee is paid directly to the physician rather than paying for healthcare through an insurance premium. Monthly fees average $77.38 depending on the range of services offered or the location of the practice.

In some DPC practices, lab tests and pharmaceuticals are available at a discounted rate. DPC is not insurance. In order to cover major medical expenses and hospitalizations, patients are encouraged to carry high deductible insurance.

DPC practices have fewer patients than traditional primary care practices. With fewer patients, physicians spend more time with patients during each visit. In theory, more time allows for deeper discussions. Physicians gain insights needed to assist with diagnosis. Additionally, physicians may uncover potential barriers in a patient’s ability to follow through with treatment recommendations.

The intent of DPC is to help realize the benefits of preventative care. Identifying health concerns earlier prevents the escalation of issues that lead to poorer medical outcomes and increased hospitalizations.

Benefits to Patients
From a patient perspective there are many attractive elements of DPC.

  • More time with a physician which increases the odds of feeling listened to, establishing trust that improves quality of care.
  • Greater continuity of care improving communication, understanding, and decreases in medical errors.
  • A focus on the whole person rather than compartmentalization and defining a person by a diagnosis.
  • Guaranteed access to care through a comparatively low monthly fee. For patients with chronic conditions like hypertension, asthma, and diabetes there is comfort in having guaranteed access to care³.
  • Controlling costs with the monthly fee rather than paying high insurance premiums per visit.

In the end, patients are paying the person providing care rather than lining the pockets of organizations that have hijacked the practice of medicine – insurance companies and pharmacy benefit managers.

Benefits to Physicians
Physicians attracted to the DPC model see it as an opportunity to reclaim the practice of medicine. Costs are transparent. In this model, medical care is not limited by billing restrictions and fee-for-service incentives. Furthermore, DPC provides a viable alternative to physicians that might otherwise exit the system due to burnout.

Potential Concerns
At this time, there are no comparative studies and performance statistics on DPC versus traditional models of Primary Care. Concerns about DPC include:

  • The potential cost burden for patients that pay both a monthly retainer and insurance premiums for high deductible coverage
  • Laws that restrict the usage of insurance premiums to cover the retainer fees
  • More pressure on a system with a shortage of primary care physicians.

DPC as an Opportunity to Begin Change

As costs for insurance premiums continue to rise, DPC may be an affordable option for patients that might otherwise not have any coverage. Current models of healthcare are already failing physicians. Burned out physicians are leaving the system either through early retirement, exiting for other lines of work, or by suicide (U.S. physician suicides are twice the national average.)

There is a need for change. While DPC may not be a perfect model, it may very well be a viable alternative at the present moment. Today, insurance companies and pharmacy benefit managers control the practice of medicine. Physicians and patients need to regain control. The practice of patient care belongs in the hands of physicians and patients, and in their hands only.


¹Cole, E.S., (July 2018) Direct Primary Care: Applying Theory to Potential Changes in Delivery and Outcomes. The Journal of the American Board of Family Medicine, 31 (4) 605-611.

²Huff, C., (October 3, 2017) Flat-Fee Primary Care Helps Fill Niche for Texas’ Uninsured. Kaiser Health News.

³Andrew, L.B., MD, JD. D

Delays in a Medical Diagnosis and Why It Matters

Delays in a Medical Diagnosis and Why It Matters

One reason for delays in getting a medical diagnosis is a failure to believe the patient. Coleen’s symptoms started with leg and back pain. At the time, she had a daughter at home who was about a year and a half old. Coleen played a lot of tennis, so she thought perhaps she had pulled something during a match.

When heat and ice didn’t help the pain, Coleen’s primary care physician referred her to an orthopedic physician. The doctor’s comment: “perhaps you lift your kid too much.”

When Physicians Don’t Listen

Coleen is one of many people I have interviewed regarding their experiences with serious illness. Coleen wondered how to care for a young child without lifting her in and out of the car, the crib, or the high chair. The doctor’s response, “just try to minimize those events.” He sent Coleen home with a “jug of pain pills.”

After a few days, Coleen stopped the pain pills because she didn’t like the way they made her feel. She tried to minimize lifting her daughter but the pain continued to get worse. Coleen’s mother came to stay for a few weeks to help.

During this time, Coleen’s husband got a job in another state requiring the family to re-locate. She could barely walk. After the move, a family physician friend referred Coleen to a neurologist. This physician questioned Coleen about her symptoms, her pain. He was skeptical, wondering if perhaps she was faking her pain to obtain pain pills.

Coleen broke down in tears.

This is not in my head. This is in my back. I am unable to perform my duties as a mom, and as a wife, and as a human being on this planet Earth. I am in so much pain. I am not faking this. I don’t want your damn pills, I want to find out what’s going on.

Coleen

Consequences of Delays in a Medical Diagnosis

Tests finally revealed a ruptured disc in her lower back. The disc pieces embedded in her spinal column explained the excruciating pain. Surgery relieved the pain, and Coleen finally felt validated.

Living with excruciating pain shouldn’t be the default option because doctors aren’t taking health concerns, and symptoms, seriously. When concerns are dismissed, it is often difficult for patients to push forward for answers:

  • Pain, like the kind Coleen experienced, makes daily functioning extraordinarily difficult.
  • When a physician fails to take health concerns seriously, it depletes emotional and physical reserves.

If troubling symptoms continue, it is essential to persist, to get an explanation. Only then can the work begin to address the core problem. Here are additional reasons for getting the medical diagnosis right.

Reasons for Delays in Medical Diagnoses

Reasons for delays in a medical diagnosis are numerous and often inter-related. Here is a short list of reasons from my interviews and patients’ experiences:

  • Symptoms ignored or dismissed by either patient or physician
  • Misdiagnosis
  • Lack of insurance or adequate coverage
  • Rare conditions
  • Physician lack of knowledge/expertise
  • Multiple health issues that mask the primary concern

These reasons are a complicated mix of personal, medical, and institutional issues. Both recognizing and understanding the reasons for delays helps to take the necessary next steps.

5 Paths to a More Timely Medical Diagnosis

Here are a few tips, based on patients’ experiences:

  • Listen (and trust) what your own body is telling you. Only you know what is normal and what is not.
  • Be sure to follow-up with a medical expert when your body is telling you that something isn’t right.
  • Find a physician that will listen to what you have to say about your symptoms and concerns.
  • Get a second opinion, or perhaps even a third or fourth.
  • Ask a friend, or hire a professional patient advocate to join you for doctor’s appointments.

A timely diagnosis is critical. Treatment may begin earlier and perhaps lessen medical complications. Reducing the length of treatment also helps to ease the strain on financial and emotional resources.

* Quotes in this post are from interviews conducted for my book, Navigating Illness: The Patient Experience, a work in progress. Names were changed upon an individual’s request.

A Medical Diagnosis – The Importance of Getting it Right

A Medical Diagnosis - The Important of Getting it Right

I am waiting for the dermatologist, paper gown open to the back. I made this appointment in search of a medical diagnosis due to a bruise, or discoloration, under my big toe on my left foot.

Based on my experience, some physicians keep patients waiting for long periods of time in the exam room. I brought a book to read. This particular dermatologist is one that usually runs on time; on this visit the wait is 30 minutes.

In the exam room, the table folds into more of a chair shape. So I sit, book in hand, and initially feel relatively comfortable. But then I begin to notice the cold. I’ve been asked to remove my clothes, and the paper gown doesn’t offer much in terms of warmth.

In Search of a Medical Diagnosis

I’ve been to see this dermatologist only once previously. My husband is a regular thanks to basal cell carcinoma. Over the years, this dermatologist has dug out small hunks of my husband’s skin for lab testing. Other suspicious spots were zapped with liquid nitrogen, all in an effort to keep his cancer in check.

My first visit was nearly two years ago. Since I am fair-skinned, and given my husband’s experience, I wanted to get a baseline reading for any potential skin damage. Fortunately, I got a thumbs up. Skin all clear, with a parting, ‘See you next year.’

I didn’t return in a year but return only when prompted by a specific concern. The bruise under my big toe seems odd to me. When it appeared, I remembered this happening before, the sudden appearance of what seems to be a bruise under the toenail on my left foot. The previous ‘bruise’ eventually disappeared without incident.

I find the bruise a bit unnerving though. I don’t remember injuring my foot or dropping a heavy object on my toe. And I’m not a runner so I haven’t hurt my toe by repetitive pounding against the unforgiving end of a running shoe. Furthermore, there is no pain, as might be expected with a bruise or an injury to the toe.

A quick search on the Internet reveals that in some cases, although rare, a bruised toe may signify a subungual melanoma, a type of skin cancer under the nail. Given that I have no explanation for the bruised looking toe, and that it has been over a year since my last visit to the dermatologist, I make an appointment.

I’m anxious for some professional expertise, hoping the medical diagnosis is right.

Why Worry About a Bruise?

As a patient advocate, I am aware of concerns in healthcare regarding the over-use of medical resources. Do I really believe my bruised toenail is melanoma? I honestly don’t know. I could take a wait and see approach. I’m bothered though that this discolorization under my big toe has occurred before. Just because a symptom goes away doesn’t mean there isn’t a problem.

Perhaps this is an indication of something more serious. When something is wrong in the body, when there is an underlying illness, there are often signs. And sometimes these indicators are brushed off either by the patient, or the physician, or both. As a result, there is a failure to make a link to the real issue, to make the right diagnosis.

This failure to make the critical connections is what happened with my sister. When she reported to her physician of being out of breath during her regular walks, it was attributed to getting older. When my sister developed a hacking cough, she was given antibiotics for an infection, and when my sister began to have mini-strokes, she was treated for cardiovascular issues.

There was a failure to make the link to the underlying problem.

Five days before she died, my sister was told she had lung cancer.

For my sister, the delays in a medical diagnosis were too costly.

When Seeking a Medical Diagnosis, Be Persistent

I do not want to be surprised by serious illness, or even death. Although I know I may have little control over such outcomes, I can listen to my body, and to question when things seem amiss. There are always clues. So here I am in the doctor’s office with my toe.

The dermatologist tells me it looks like a bruise. She’s quite certain it is a bruise, but she asks me to come back in two months. She’s covering her bases, which is fair.

I am covering my bases as well. It is my body. It is okay to ask, and to ask again. I accept her diagnosis, but I make the appointment.

Food as Medicine: A Recipe to Share

Food as Medicine: A Recipe to Share

Soup. Glorious Soup. Warm concoctions of vegetables, broth, and spices feel nurturing and satisfying to both body and soul. During times of illness and recovery, certain food, like soup, can be good medicine. Nourishing and sustaining us, food is powerful medicine, as we struggle to heal and regain our strength.

Food as Medicine

The concept of “food as medicine”¹ is growing among a small number of insurers in an effort to control healthcare costs. Such efforts are proving successful as highlighted in recent studies.

  • In Health Affairs², when medically tailored meals are provided there are fewer emergency department visits, fewer inpatient admissions, and lower medical spending in comparison to a control group.
  • Another study in the American Journal of Managed Care³ reveals similar benefits. Patients receiving tailored meals show a drop in hospital readmission rates and dramatic cost savings compared with patients without the specially tailored meals.

Unfortunately, such programs are currently limited to specific geographic areas. Expansion of these programs will require a shift in the medical model of how we pay for health care and how it is provided. Given success rates to date, it would be encouraging to see such efforts expanded to other geographic areas and broadly supported by insurance companies.

Food as a Gift

Food is also a gift. Sometimes, when someone you know is not feeling well or may even be facing a serious health challenge, we just don’t know what to do. Foods, such as soup, are often welcomed because planning and preparing meals can be difficult during times of illness. And quite simply, food is good medicine.

As discussed in another post, soup can be a great way to show you care. However, at the tail end of summer, a hot soup on a blistering, sultry day may not be a great choice. Fortunately, the end of summer also brings a plentiful supply of fresh tomatoes. And fresh tomatoes are a great opportunity to make gazpacho. A soup from Southern Spain, gazpacho is particularly refreshing since it is served chilled.

Gazpacho

Julia Moskin
By
Cook Time 20 mins
Resting Time 10 mins
Servings 12

Ingredients
  

  • 2 lbs Ripe Red Tomatoes Cored and roughly cut into chunks
  • 1 Cubanelle Pepper Seeded and cut into chunks
  • 1 Cucumber About 8 inches long, peeled and roughly cut into chunks
  • 1 Mild Onion (white or red) Small, peeled and roughly cut into chunks
  • 1 Garlic Clove
  • 2 tsps Sherry Vinegar More to taste
  • Salt
  • .5 cups Extra-Virgin Olive Oil More to taste, plus more for drizzling

Instructions
 

  • Combine tomatoes, pepper, cucumber, onion and garlic in a blender or, if using a hand blender, in a deep bowl. (If necessary, work in batches.) Blend at high speed until very smooth, at least 2 minutes, pausing occasionally to scrape down the sides with a rubber spatula.
  • With the motor running, add the vinegar and 2 teaspoons salt. Slowly drizzle in the olive oil. The mixture will turn bright orange or dark pink and become smooth and emulsified, like a salad dressing. If it still seems watery, drizzle in more olive oil until texture is creamy.
  • Strain the mixture through a strainer or a food mill, pushing all the liquid through with a spatula or the back of a ladle. Discard the solids. Transfer to a large pitcher (preferably glass) and chill until very cold, at least 6 hours or overnight.
  • Before serving, adjust the seasonings with salt and vinegar. If soup is very thick, stir in a few tablespoons ice water. Serve in glasses, over ice if desired. A few drops of olive oil on top are a nice touch.

Notes

Having prepared gazpacho from this recipe several times throughout the summer, here are few suggestions based on my own experiences:
  • Plan ahead! This soup is best when it is chilled so making it requires some planning. (Six hours according to the recipe.)
  • The cubanelle pepper is a sweet pepper. A good substitute for a cubanelle pepper is an Anaheim pepper which has a little more heat but, is generally mild. The first few times I made this recipe, I used a jalapeno pepper which added too much heat. The best batch of gazpacho I made all summer was when I used an Anaheim pepper. Recently I’ve used Poblano peppers, since they were on hand, which adds more heat than an Anaheim but are not as hot as jalapeno peppers.
  • Instead of the Sherry Vinegar, I’ve used Red Wine Vinegar, which seems to work. Although, if I ever make the recipe with Sherry Vinegar I may never go back, it might be just that good.
  • My version does not contain the full allotment of salt, more like one teaspoon rather than two.
  • The first few times I used this recipe, I held back on the olive oil but I think the soup really needs the full ½ cup.
  • So far, I haven’t had to work in batches. I stuff my blender to the top and watch the magic happen.
  • Straining the mixture through a food mill or a strainer seems like a messy, unnecessary step that only takes out nutrients which I prefer to leave in. I like the small bits in the soup because I think it adds interest.
  • I also serve the soup in bowls rather than in glasses since I’d rather spoon my soup than drink it from a glass.
  • Toppings! This particular recipe does not call for toppings on the gazpacho (other than the mention of olive oil drizzled on top) but I know gazpacho toppings are common and should be considered if you prepare this recipe. Here are some topping suggestions: chopped green pepper, red onion, cucumber, roasted corn, avocado, hard-boiled egg, capers, or yogurt.

Final Words

Sam Sifton, food editor of The New York Times writes, “Today, then, would be a good one to cook for others, … to take note of how in giving to others we make our little worlds stronger and more full of joy.”⁵ So, with the bountiful supply of tomatoes available now at summer’s end, whip up a batch or two of this fabulous soup. Keep one and take one to a friend who may be in need of a little extra care.

¹Galewitz, P. (2018). Rx: Zucchini, Brown Rice, Turkey Soup, Medicaid Plan Offers Food As Medicine. Kaiser Health News. https://dhn.org/newsrx-zucchini-brown-rice-turkey-soup-medicaid-plan-offers-food-as-medine/

²Berkowitz, S.A., Terranova, J., Hill, C., Ajayi, T., Linsky, T., Tishler, L.W. (2018). Meal Delivery Programs Reduce The Use Of Costly Health Care In Dually Eligible Medicare and Medicaid Beneficiaries. Health Affairs, 37(4). https://doi.org/10.1377/hlthaff.2017.0999

³Martin, S.L., Connelly, N., Parsons, C., Blackstone, K. (2018). Simply Delivered Meals: A Tale of Collaboration. American Journal of Managed Care. 24(6):301-304. https://www.ajmc.com/journals/issue/2018/2018-vol24-n6/simply-delivered-meals-a-tale-of-collaboration?p=1

⁴Moskin, J. (2018). Best Gazpacho. New York Times – Cooking. https://cooking.nytimes.com/recipes/1017577-best-gazpacho

⁵Sifton, S., (Sunday, Sept. 16, 2018). New York Times – Cooking. What to Cook This Week.

How Doctors Talk With Patients

How Doctors Talk With Patients

Good communication is usually a two-way street; an exchange of information between two parties of relatively equal status – economically and socially. Patients are inherently vulnerable, however, cast in a role not of their choosing. And much of what patients encounter is often new, difficult, and sometimes frightening. Such vulnerability creates an inherent imbalance of power between physicians and patients. Furthermore, some patients view physicians as authority figures due to their experience, knowledge, and training. As a result, communication between doctors and patients can, at times, be challenging. And yet, how doctors talk with patients can impact medical care and treatment.

What Good Communication Between Doctors and Patients Feels Like When It’s Working …

Jackie spoke highly of her oncologist because he listened, he took the time, and he was willing to take her input.

I really liked his manner and the way he went through things, but most importantly he was willing to listen to me like when I said, ‘hey, I know you’re going to recommend chemotherapy’, and he’s like, ‘well okay let’s look at this.’ And then he’d pull out his laptop and then go online… to that company and, look at the statistics that they have there… then he’d show me. ‘These are the reasons why… you might be able to convince me about this, but let me just show you that these are risks.’… very busy guy, but if I had a question, he was going to sit there and answer it.

Jackie

Additionally, Jackie’s oncologist listened when she wanted to incorporate cooling cap therapy¹ during chemotherapy in an effort to minimize hair loss. Even though the hospital didn’t offer such therapy, the treatment team was willing to support Jackie’s efforts to make this happen.

Ultimately, Jackie chose not to incorporate cooling cap therapy, but having an oncologist willing to listen and help make this happen established trust. As the patient, she felt she had some control in the decision-making and her treatment options. Good communication between doctors and patients begins with the actions a physician takes – for Jackie that meant a willingness to listen.

… and When It’s Not

Jaime, in her search for answers as to what was causing her pain, was not as fortunate as Jackie. She spent a year and a half visiting different doctors trying to get an answer. “Initially, I felt like I truly was the patient, and I didn’t know anything. And they treated me like I was an imposition, and I, it was all in my head; I was a hypochondriac, and you know, high maintenance patient.”

Once Jaime found the physician that properly diagnosed what was causing her pain, stage 4 colorectal cancer, it all changed. Jaime describes the difference:

I actually felt like I was part of a team, which made me feel 100% better; it’s not all in my head… I listened to my body, and I knew something was wrong, and they agreed with me. And I felt a whole lot more comfortable then, working with them, and, and getting their opinions and going through treatment options because I was part of the team.

Jaime

5 Examples of Good Communication Between Doctors and Patients

Finding ways to humanize patient care is essential. And as difficult as it might be at times, patients need to hold doctors accountable Here is a short list of how your doctor should communicate with you:

  • Takes your concerns seriously and is not dismissive
  • Asks questions and listens to your concerns
  • Considers you, the patient, part of the treatment team
  • Consults with you regarding treatment options
  • Treats you as a person first, and a patient secondarily

Many doctors make tremendous efforts to ease communication with patients. But when that doesn’t happen, patients must speak up. And if you feel dismissed as a patient, perhaps it may be time to find another doctor.

* Quotes in this post are from interviews conducted for my book, Navigating Illness: The Patient Experience, a work in progress. Names were changed upon an individual’s request.


¹ (2018) Cold Caps and Scalp Cooling Systems. Breastcancer.org.

The Value of Pre-Surgery Consultations

What is the Value of Pre-Surgery Consultations?

All Caroline wanted was a pre-surgery consultation. The opportunity to meet with the surgeon scheduled to perform her husband’s eye surgery. She was told ‘No.’ The doctor wasn’t available for pre-surgery consultation.

As a patient advocate, I bristled at the perceived arrogance and the rigidity of this physician. What type of surgeon would refuse to meet with the patient, and those responsible for caring for that patient? How does a surgeon get away with this practice?

Reasons for Pre-Surgery Consultation

Scheduling the eye surgery prompted a number of concerns for Caroline:

  • Necessity of the surgery given her husband’s age?
  • Consequences if the surgery was postponed or cancelled?
  • What to anticipate for recovery after surgery?

Contacting the physician’s office with these concerns, Caroline was told the surgeon would not meet with them. The office did propose an option of meeting with a surrogate (a nurse? a patient liaison?) from the office. Surrogates are not the same (neither positive or negative, just not the same) as meeting with the physician.

I first heard about Caroline’s dilemma in my writing critique group. During the past few years, I’ve immersed myself in the experiences of those with serious health challenges. My interviews with patients have translated into writing about these experiences, and I am now compiling these narratives into a book. At one critique meeting, Caroline, a spry woman in her eighties mentioned her husband’s eye surgery.

Pre-Surgery Questions and Concerns

Caroline was frustrated and she shared this frustration with the group. Caroline questioned whether or not to go forward with the appointment. There are many reasons patients may be afraid to speak up with doctors. Her big concern, was the surgery appropriate given the age of her husband and her husband’s other health issues.

Clearly, some event triggered the scheduling of the procedure. However, the couple’s internal medicine doctor felt such surgery was not necessary based on the husband’s health and age. Caroline wanted to discuss these concerns with the eye surgeon. Additionally, she just wanted an opportunity to meet the person performing surgery on her husband.

Caroline’s questions and concerns are legitimate. Research shows that almost 1 in 3 Medicare patients¹ will have surgery in the year before they die. And surgery performed on seniors may not always lead to an improvement in the quality of life². Furthermore, seniors do not recover as quickly from anesthesia. The recovery rate, the body’s ability to mend, is often slower.

When surgery is recommended, conversations about the quality vs. quantity of life are appropriate. Here are some concerns to discuss with a surgeons during a pre-surgery consultation:

  • Clarify the reason for surgery
  • Ask for an explanation of what will happen during surgery
  • Request information on what to expect after surgery:
    • Recovery rates
    • Side effects
    • Long-term prognosis

Every patient has the right to meet with the surgeon and have these questions answered.

Options When A Surgeon Is MIA

When a surgeon refuses a pre-surgery consultation, there are a few options available to caretakers and patients in this situation. Here are some potential paths:

  • Insist on a meeting. Inform the office of your concerns. Underscore a reluctance to move forward with the surgery without such a meeting.
    • Cons: Patients and caretakers are often hesitant to strike a hard line with physicians.
    • Pros: The surgeon may just meet with you. Be sure to bring your list of questions/concerns with you to the meeting and take notes.
  • Meet with the surrogate. Press hard for answers to all your questions and concerns.
    • Be sure to bring a list of all questions/concerns to the meeting
    • Bring someone with you to help navigate the conversation
    • Take notes during the meeting.
    • Review your understanding of the explanations before leaving the meeting.
    • Review your understanding of next steps before leaving the meeting.
  • Cancel the surgery. Find another surgeon if the surgery is necessary AND/OR will improve the quality of life.

Surgeons are highly trained experts in their respective specialties. These skills, however, should not empower arrogance and a disregard for patients’ concerns. [Many physicians have found better ways to communicate with patients.] If the surgeon will not meet with you, perhaps this is not the physician to entrust with your care and well-being.


¹Kwok, A.C. MD, Semel, M.E. MD, Lipsitz, S.R. ScD, Bader, A.M. MD, Barnato, A.E. MD, Gawande, A.A. MD. The Intensity and Variation of Surgical Care at the End of Life: A Retrospective Cohort Study. The Lancet, October 15th, 2011; 378(9800): 1408-1413.

²Nabozny, M.J. MD, Kruser, J.M. MD, Steffens, N.M. MPH, Brasel, K.J. MD, MPh, Campbell, T.C. MD, Gaines, M.E. JD, LLM, Schwarze, M.L., MD, MPP. Constructing High-Stakes Surgical Decisions: It’s Better to Die Trying. Ann Surg. 2016 January; 263(1): 64-70.