Demystifying Medicine One Month at a Time

Bookends to the Year of Covid

Carl was in his early 70s. A Vietnam vet, he suffered from PTSD along with his diabetes, high blood pressure, and smoking-induced COPD. He’d survived a bout of kidney cancer, too, along his medical journey.

In late 2019 he came to see me because he was considering making a move to an assisted living facility. I thought it was a good idea—as an older male with previous suicide attempts, I was worried that loneliness would compound his difficulties.

Carl was estranged from his family. I knew he had an adult son and daughter, but he refused to talk about them let alone to them.

Assisted living would provide some community in addition to three squares a day. The facility also had a nurse who could help with medical care.

About a month after he moved there, the nurse called to tell me that she’d sent Carl to the hospital for fever and shortness of breath. His oxygen saturation had dipped below 90 percent.

This was in early March, when Covid-19 was still mostly in China and Italy. Our lives hadn’t stopped. Yet.

Carl was admitted to the ICU with “double pneumonia.” On his chest x-ray, there was evidence of it in both lungs. Not surprising for an older man with a long history of smoking, lung disease and diabetes.

Carl narrowly avoided intubation. With careful ministrations he turned the corner and was discharged back to his facility after a lengthy hospitalization. A nasal swab came back positive for influenza. Flu had been the culprit!

His return to assisted living occurred right around the time the world was shutting down. All of our lives were changing dramatically.

Carl was quarantined in the facility. The nurse working there actually lived in during March and April, until it was no longer feasible. She and the other staff did everything they could to keep their residents safe.

Prior to his hospitalization, Carl had come in every month. It helped quell his anxiety. Now that his facility was on lockdown, our visits had to be by telephone.

I was amazed he’d survived his hospitalization, let alone that he had somehow missed getting Covid. His lungs were practically kindling for this type of infection.

Throughout the spring, summer and fall, Carl and I talked, sometimes weekly. He was frustrated that he couldn’t go anywhere.

In one of the perversities of the pandemic, Carl started smoking again just so he could go outdoors to have a cigarette a few times per day.

The happiest I heard him this whole year was when he revealed that he and some friends in the facility would play late night card games—with an assist from a friendly aide who didn’t report them.

By fall, there had been sporadic cases in his facility. He and his fellow card players were remanded to their rooms again. He was not a happy camper.

All along, I was fearful that Carl would eventually test positive. He was high risk, and elder care facilities have acted as accelerators to Covid spread.

In December, it finally happened. Another fateful call from the nurse.

Carl was sent back to the hospital for fever and symptoms. He tested positive for Covid-19 this time.

Amazingly, after a three day observation, Carl was deemed medically stable for discharge. He’d had fever and aches without the pulmonary involvement this time.

Because of the number of cases at his facility, he had to first go into isolation in a skilled nursing facility—one used as a transition zone between the land of the sick and home.

While there on a Saturday, he began to decompensate. His oxygen saturation dropped, and he was sent back to the hospital.

I was able to converse with his bedside nurse, who told me he was struggling to breathe, but remained lucid. I was able to get there in time to say goodbye.

Carl was in a Covid-specific unit that had been commandeered from ‘regular’ hospital use because of the pandemic.

His bedside nurse was visibly pregnant. “I’ve already had Covid,” she told me.

Carl had clearly expressed his desire NOT to be intubated or have ‘heroic’ measures taken to try to prolong his life. He and I had talked about it a lot after his prior hospitalization.

He shook my gloved hand and said, “Keep doing the good work you’re doing,” knowing it would be the last time we spoke.

He died a few hours later.

Just one of more than 334,000 Americans.

Doctoring the CIA

One of the biggest attractions at medical meetings is the exhibition space, where publishers and companies peddle their wares and outfits looking to hire doctors sing what they hope will be a siren’s song.

The Exhibitors’ Hall at the annual American College of Physicians meeting is certainly among the most grandiose medical marketplace, if not the world’s largest. When I approach the hall, I’m always reminded of Louis Winthorp’s description of the NY Commodities Exchange to Billy Ray Valentine in the 1983 film Trading Places:

“This is it. The last bastion of pure capitalism left on earth.”

At ACP 2019 there were dozens and dozens of exhibitors, ranging from tech startups to health insurance providers. Digital stethoscopes? Check. Work for the newest telemedicine outfit? You bet. There were also journal and textbook publishers and purveyors of online medical information..

But by number, no category is larger than the recruiters — health enterprises all looking for medical personnel. Passersby definitely are made to feel needed in such a milieu.

Recruiting at ACP 2019 were hospitals, ambulatory groups, and academic practices all looking for help. There were also state, county and correctional facilities on the market for docs.

But I was surprised to see a recruiting booth from the CIA: America’s Central Intelligence Agency. It was one of the smaller booths, with but a flag, some brochures, and a lone recruiter, who by Agency policy couldn’t officially speak to me or be quoted.

So who is the Agency looking for? Primary care doctors and psychiatrists.

What does the job entail? Working abroad in embassies caring for CIA staff and their families.

Why, I wondered, if the job involves serving at U.S. embassies abroad, does the State Department not handle the recruiting?

Turns out that CIA doctors must be eligible for and able to obtain security clearances. In order to be considered, you must be physically and mentally fit, and able to pass both a background check and a polygraph test. You need to be a U.S. citizen, too.

The best of the brochures on the table dispelled 12 of the most common myths about working for the CIA: essentially, it ain’t what you see in the movies. Forget about car chases or secret gadgets.

Other brochures led with catchy slogans like, “Everything you do here matters,” or “Utilize your medical skills on the world stage.”

The CIA is not just interested in doctors. Like the real world around us, the CIA is looking for nurses (particularly with experience in occupational health), physician assistants, nurse practitioners, and clinical and research psychologists.

I asked the recruiter what a primary care doctor like me would do in the CIA. I’d once read about the CIA hiring doctors as medical analysts to render opinions on the health of world leaders. The recruiter told me that she was not charged with finding medical analysts at the ACP or her other recruiting stops–only doctors to work as medical professionals. Though with adequate experience and interest, changing roles while in the Agency is considered.

Through the conversation I learned that the CIA operates in five “directorates:”

  1. Analysis (think information gathering and synthesis);
  2. Digital Innovation (think cybersecurity and warfare);
  3. Operations (think spies–these are the folks in the famous clandestine service who handle missions and collect human intelligence);
  4. Science and Technology (think ‘tradecraft’) and lastly;
  5. the humble Directorate of Support (‘delivers everything the CIA needs to accomplish its critical mission of defending our nation.’)

Would-be CIA physicians apply for jobs in the Directorate of Support.

How much does a CIA doc earn? According to their website, the salary range is $157,000 to $164,000 per year, with ‘a progressive physician comparability allowance up to $30K per year.’

This might be the kicker, though. How young does one have to be to join up?

It might surprise you like it did me, but the recruiter said the Agency considers hiring doctors up to 60 years old!

So should you tire of domestic life and the day-to-day of clinical care here in the U.S., the CIA is an unusual way you can serve your country.

“Public Charge” is a Public Health Disaster in the Making

The following post was written by Sam Aptekar and Dr. Phuoc Le, Associate Professor of Medicine and Pediatrics at the University of California – San Francisco and Co-Founder of Arc Health.

I was born in a rural village outside of Hue, Vietnam in 1976, a year after Saigon fell and the war ended. My family of four struggled to survive in the post-war shambles, and in 1981, my mother had no choice but to flee Vietnam by boat with my older sister and myself. Through the support of the refugee resettlement program, we began our lives in the United States in 1982, wearing all of our belongings on our backs and not knowing a word of English.

Though we struggled for years to make ends meet, we sustained ourselves through public benefit programs: food stamps, Medicaid, Section 8 Housing, and cash aid. These programs were lifelines that enabled me to focus on my education, and they allowed me to be the physician and public health expert that I am today. Looking back, I firmly believe that the more we invest in the lives and livelihoods of immigrants, the more we invest in the United States, its ideals, and its future.

So, when I first learned of the current administration’s plan to make it harder for immigrants with lower socioeconomic statuses to gain permanent U.S. residence, the so-called changes to the “Public Charge” rule, I felt outraged and baffled by its short-sightedness.

Chart courtesy of

If this proposal comes into effect, government officials would be forced to consider whether an applicant has used, or is deemed likely to use, public benefit programs like Section 8 Housing, Medicaid, the Supplemental Nutrition Program (SNAP), and Temporary Assistance for Needy Families (TANF).  Additionally, applicants with pre-existing health conditions could be rejected purely on these bases.[1]

The implications of this rule are not hard to predict (and have already been observed throughout the country)[2]: noncitizen parents who are hoping to get green cards will not enroll their citizen children in government healthcare, which they have a legal right to obtain, out of fear that harnessing public benefits will prevent them from gaining legal permanent residence. According to the Kaiser Family Foundation, President Trump’s proposal could lead to a decrease in Medicaid and CHIP enrollment by a minimum of 15% and as much as 35%.[3]  Any proposal that decreases the number of insured American citizens, as this measure surely would, would increasethe financial strain on taxpayers who will be forced to compensate for unpaid coverage. Furthermore, Forbes estimates that Trump’s proposal would decrease legal immigration to the United States by more than 200,000 people a year and therefore “would have a negative impact on the Social Security System”- a deficit that American taxpayers would have to help cover.[4]

If the moral argument that every human being deserves the pursuit of a better life doesn’t work for you, then let the economic one suffice. A 2016 study by the National Academies of Science, Engineering, and Medicine concluded “immigration has an overall positive impact on long-run economic growth in the United States” and “immigration is integral to the nation’s economic growth.”[5]

Whether you are an immigrant or were born in the US, we all have a responsibility to vocalize dissent against the Department of Homeland Security’s morally and fiscally-flawed anti-immigrant proposal. Vote, attend town-hall meetings, write to your representatives, conduct personal research, engage in constructive dialogue, and comment below to get the conversation started. Remember, the Statue of Liberty reads: “give me your poor, your tired, your huddled masses.” If we match xenophobia and ignorance with empathy and facts, we can ensure that America remains a beacon of hope for future immigrants, just as it was for me in 1982.






Wallet X-Ray

Have you ever heard the term ‘wallet biopsy?’

A wallet biopsy is what occurs in U.S. health care when you or a loved one show up with a medical complaint to seek treatment.

From the emergency department to the inpatient hospital, to the doctor’s office or the procedure suite—at any location where an American might receive health care, you’re subject to a wallet biopsy.

Health care is a business. An expensive one. And the beast has to be fed—not only to keep the lights on, but also to buy the latest equipment and pay the folks that provide the care.

In a recent piece for Kaiser Health News, journalist Phil Galewitz updates us on how the U.S. practice of wallet biopsy has morphed into wallet x-ray.

The idea is longstanding: grateful patients (with financial means) have always looked for ways to share their good fortune with the medical establishments (and professionals) that have treated them.

Galewitz’ piece suggests that the practice of seeking out potential donors has ramped up in intensity: large health care enterprises (often university-based or affiliated) are performing financial background checks on patients they deem to be potential donors—and then aggressively wooing them.

There’s nothing necessarily wrong with this—it just smells a bit fishy. And it implies that if you’re not a grateful patient, or in financial position to be one, that you may wind up getting a bit less…er, attention? Fewer amenities? Less TLC?

Check out the article, which also ran in the NY Times, and let us know what you think of the specialty of wallet radiology.

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