Several years ago I took care of an elderly woman in the ER.  She came in with a chief complaint of chest pain.  She came in via ambulance and by the time she got to the trauma bay she said she was feeling a little bit better.  She didn’t know she was about to die, usually people who are about to die look much worse. She looked good, all things considered.  ...

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He does not want to talk to me, that much is clear. He has had enough of doctors. He is a man of few words. His eyes do not meet mine. His coarse, calloused farmer’s hands play purposelessly with the starched white of the hospital bed sheet. The gentle hiss of his oxygen is barely heard over the hum of the city traffic below. Out of his element. “Tell me, what ...

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Movements come and movements go.  To be memorable, to last, depends on continuously refining the message.  The brand, by necessity blindingly clear in the beginning, must be anything but static.  Ideas mature, knowledge grows, and movements pivot.  They must pivot. The meteoric rise of hospice and palliative care has had untoward affects.  Specifically, the treatment of pain and suffering has dislodged itself from the moors of clinical medicine.  A new generation ...

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In 2005, my husband and I bought a small farmhouse in northern New England next door to Tom and Sally. They were in their early seventies, married nearly fifty years, with a large family. Tom's grandfather had built a farmhouse in 1900 on the family's small pig farm. In the 1970s, Tom and Sally had parceled off the land and built a modern house for themselves, a stone's throw from the ...

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Over the years, many people have shared with me their disappointment at the lack of acknowledgment from their physician when their loved one died. Especially, when their loved one had been a long time patient of the physician. In fact, many people have shared that they switched physicians because of what they perceived as a slight. When people go to a physician for many years, especially the family physician, it is ...

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Today, I hesitated to refer a patient to hospice. The patient is perfect for that model of care.  She has strong family and friend supports, multiple opportunities to maintain quality, independence and dignity, and while she has a disease we cannot fix, she will do very well with personal palliation. Nonetheless, I almost did not recommend hospice, because I realize that hospice is going to completely fail to take care of a ...

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Ben's first symptom was coughing up blood.  The cancer had been silently growing for months, if not a few years.  He had no pain or shortness of breath.  The chest x-ray showed a "5cm L hilar mass" and the subsequent CT scan showed enlarged lymph nodes and likely spread to the liver. "So Doc, what is it?  A cancer?  How much time do you give me?"  All these questions on a ...

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From MedPage Today:

  1. Primary Care Pay Bump Unlikely. The 10% pay raise select primary care services received under the Affordable Care Act likely won't be extended beyond 2015.
  2. New Guideline Lowers eGFR for Dialysis Start. New Canadian guidelines suggest that nephrologists can wait to start dialysis in some chronic kidney disease patients until their estimated glomerular filtration rate (eGFR) drops below the 10 to ...

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“No Margin No Mission” was a common saying when I studied about non-profits in business school. No matter how good your intentions are, whether it be creating new systems to get people access to care or opening a new animal rescue, if it couldn’t pay for itself it wasn’t going to happen. So it should come as little surprise that an up and coming darling of CEOs of health systems is ...

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When counseling patients and families about end-of-life care, I try to focus on a simple, clear standard.  Knowing that events are overwhelming and complex, I say,  “Look at each treatment, each action and each moment and ask; How does it improve quality of life?”  My goal is to reduce the choices during a chaotic time of life to the simple goal of comfort. For example, most families are very concerned about ...

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