Finding ways to say YES

Being a human being, is a privilege and a joy.

But so much of our lives seems to be about drama.

Someone gets their feelings hurt, lashes out, hurts someone else's feelings, then before you know it we're making ourselves even more miserable. We cut ourselves off from others. Enemies are made. Then we don't feel safe, because now the universe isn't benevolent any more.

And the joy of being human is lost.

This is the Hindu idea of Karma. Negativity begets negativity.

The answer is to break the downward spiral by not reacting to the negativity of others with more negativity.

Sometimes we create negativity needlessly. Such as when we say no, when we could just as easily say yes.

As a health care provider, I say no many times each day. Some of these no's are appropriate. Others are not. It's those inappropriate no's which are a measure of my personal limitations. Finding a way to say yes to people who come to one in need is a great way to work on one's humanity.

After all, being in a position where people come to you for help is a privilege in itself.

Why are Europeans thin?

I just returned from my first-ever trip to France. Spent a week in Lyon. Had a great time.

During the entire week I spent in France, I probably saw about 5 overweight people. Can you believe it?

I often advise my overweight patients to avoid bread and sweets, but the French eat bread and sweets often.

I'm convinced that the reason they're thin over there is that they don't eat as much at every meal as we do.

If you go to a French cafe, the people are sitting around talking, drinking tea or beer or wine, and snacking on a croissant or something. They're not eating sweet rolls, and they're not eating huge meals.

Yesterday I went to Olive Garden and ordered linguini with meat balls, and a salad. I got a bowl of salad with about 4 servings of salad in it, from which I served myself a bowl of salad, followed by a second and a third. There was still salad left in the big bowl when my linguini came. I realized right then that I was already full, but since I'd ordered it I ate about half the linguini.

So essentially, in one meal, I ate about 2 complete meals--and still left half the linguini uneaten.

In Europe I would have been served a single small salad and about half the linguini that I was served at Olive Garden.

So now I have this theory that we in the U.S. are fat because we eat too much. Go figure.

Getting Younger

It seems to me that getting healthier is the same thing as getting younger.

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If a patient is 25# overweight, has pre-diabetes and hypertension, then loses 25#, no longer needs BP meds, and gets a 2-hour glucose tolerance test and discovers that the pre-diabetes has resolved, isn't it reasonable to say that s/he has gotten younger? I think so!

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After all, if your health improves, then you'll live longer.

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So let's all get younger (instead of older)!

Universal Healthcare is Inexpensive

I think President Obama has it right when he says we need to revise our nation's healthcare system to reduce costs.

According to the World Health Organization, France has the highest-quality healthcare in the world. Yet they spend less per capita on healthcare than we do here in the U.S. Here is a list of selected countries' healthcare costs as a percent of GDP as of 2006:

U.S. 15%
France 11%
Germany 11%
Canada 10%
U.K 8%
Japan 8%

Yet these countries have universal healthcare, and we don't!

So it is possible for every single person in our country to have health insurance, and actually spend less money on healthcare than we do now.

The reasons for this are complex, but among other things are explained by 2 facts:

1. Emergency Room care is expensive. A patient can go to the ER and spend $1500 easily, whereas comparable service in my office would be about $130. Patients who have no health insurance go to the ER.

2. People without health insurance delay going to the doctor until they are very ill. From then on, you're playing catch-up--trying to get their diabetes controlled, dealing with the heart disease resulting from untreated hypertension, dealing with kidney failure, etc. These are expensive diseases to treat. If these people had health insurance, they'd find a primary care physician and be diagnosed much earlier. They might even avoid these medical conditions in the first place, by appropriate preventive medicine measures.

So three cheers for Barak Obama and his efforts to reform our healthcare system.

I'm Everybody's Friend

My new motto is "I'm everybody's friend".

The idea is to have every patient who comes to see me have a positive experience.

Some co-workers have told me that this is an unrealistic expectation, because patients sometimes need to hear things they don't want to hear, and sometimes patients wants things they shouldn't have.

But I think there's a tactful way of saying no.

The bottom line is: The patient is the boss of his or her own health care.

What got me thinking about this is, I noticed that I always go out of my way with little children to make them have a positive experience--blowing up balloons, etc. So why don't I do the same thing with adults? Not blow up balloons, but make them have a positive experience.

So that's what I've been doing this week, and for the most part I've succeeded.

We'll see whether I can keep it going.

The start of a typical day

8:00 Ms. B arrives early for her 8:15 appt.
8:14 Mr. A arrives 14 mins late for his 8:00 appt, is shown into a room.
8:15 Ms. B complains to receptionist that Mr. A got to go in first. Receptionist explains that Mr. A's appt was before Ms. B's appt.
8:15 On way to room to see Mr. A, Dr is told that Mr. X is on phone with chest pain.
8:20 Ms. B is shown into a room.
8:25 On finishing phone call with Mr. X regarding his CP, Dr goes to Mr. A's exam room. Mr. A has list of 5 problems he wants addressed.
8:30 Mr. C arrives on time for his 8:30 appt.
8:40 After addressing first 3 items on list, Dr tells Mr. A that he'll need to do the other 2 on his next visit. Mr. A is displeased, says that if his disability form isn't completed today he'll lose his job. Dr says he should have brought that item up first, now regrettably there's no time to address it. Mr. A goes up front to complain to office manager.
8:45 Dr goes into room to see Ms. B, now 45 minutes behind. Ms. B is visibly angry. Dr apologizes for keeping her waiting. Ms. B says she doesn't know why she's there, was told she had to come in. Doesn't see why she should have to come to the doctor when she feels fine. Dr explains that all patients with diabetes need to see the doctor every 3 months. Ms. B asks why. Dr explains. Dr reviews pt's labs, notices that cholesterol is high despite dietary changes, suggests a medication. Pt says she doesn't like to take medicines. Dr explains that a high cholesterol causes heart attacks, suggests pt cut back on meat, dairy products and eggs. Pt says she hardly eats any of those. Dr says, "Then medication is the only other option". Pt reiterates she doesn't like to take medicines. Dr refills patient's prescriptions. Pt is displeased that the doctor doesn't put 3 refills on each 90-day Rx. Asks why. Dr explains that if he put 3 refills on the Rx's, pt would not return for a year, and needs to be seen every 3 months. Ms B accepts the prescriptions and walks out in disgust.
9:15 Dr goes into room to see Mr. C, still 45 minutes behind. Apologizes for keeping him waiting. Mr. C says, "Hey, don't worry about it, Doc, I know you're busy." Dr smiles and shakes Mr. C's hand, grateful for the nice patients.

You can't please everybody

The patient tells me about a problem. I type what he says into his chart, asking appropriate questions. While I'm typing, he's thinking, "Hm, well, he's not saying anything, what am I supposed to do? Well, I guess I'll tell him about another problem." So he tells me about another problem. I'm still typing up the previous problem, but I don't want to tell him to wait because people don't like that. So I keep typing up the previous problem, and simultaneously try to remember what he's saying about the second problem. I make appropriate sounds of acknowledging what he's saying. Then the patient thinks, "Well, he's not saying anything, so I guess I'll tell him about another problem." But I'm still typing up the first problem. So now I'm trying to hold the fact of 3 problems in my head. Then I just have to say, "Hold on there, dude, you're 3 problems ahead of me, give me a second to catch up, okay?" But this makes the patient upset, and he thinks I don't care about him, that I'm not a nice doctor, etc.

Here's another scenario: The patient tells me all her symptoms. I'm now typing into the computer, thinking about her symptoms, trying to figure out how to approach the problem, trying to figure out what the causes of her symptoms might be, what tests to order, etc. Since I'm not saying anything, she thinks, "Hm, he's not saying anything sympathetic, I wonder if he cares? I wonder if he really understands how serious this problem is." So she starts to tell me how terrible the problem is, how it's destroying her life. Then she tells me all the terrible stressors in her life, and how in addition to all those stressors this medical problem is just making things worse. I'm now listening to a terrible tale of woe, and getting more and more distressed all the time. This is getting really painful, and meanwhile I'm unable to think about her medical problem because I'm so sympathetic to her suffering. So I say, "Okay, give me a minute to think about what to do about this," but that just makes her irritated and impatient. She's thinking, "He doesn't care about me."

The common denominators in these 2 scnarios are my silence while I'm thinking or typing, and the presence of the computer in the room. When I'm thinking, the patient thinks I'm not doing anything. When I'm typing into the computer, the patient thinks I'm ignoring him.

Unfortunately, there's no good solution to this problem. I have to think. While I'm thinking, I can't talk. To think effectively, I have to not listen either. But I know from experience that when the patient speaks I have to listen, or I might miss something really important. So for me to think effectively about the patient's problem, there has to be silence.

Also, I have to type into the computer. The computer is the patient's chart. It's also where I go to look up recent test results, to read what consultants have reported, to see what I did on the patient's last visit, to see what medicines the patient is taking, etc.

Some patients understand that when I'm paying attention to the computer I'm paying attention to them, since I'm looking at their chart and thinking about their case.

Some patients understand that when I'm not talking I'm thinking, and they're not uncomfortable with silence.

Fortunately, I'm more committed to the health of my patients than I am to making them happy. If that weren't the case, I'd listen sympathetically, make a lot of eye contact, not type into the computer at all. Patients would love me, but I wouldn't be solving their medical problems. I wouldn't be a very good doctor.

But I want to make everyone happy. It hurts me when patients are unhappy with me. So I'm a good doctor who helps a lot of people, but daily has to deal with the disapproval of the people he's trying to help.

Actually, I'm not unique. This is the dilemma that all doctors go through, for one reason or another. It's not always the computer that's the problem, or the doctor's silence. There are lots of things that patients can be displeased with which have nothing to do with the doctor's competence. And a sensitive doctor will be taken aback by the patient's displeasure and to a certain extent be less able to do the job he needs to do to help the patient as a result.

On the other hand, should a patient never express displeasure with the doctor? That's no solution either. Sometimes, I learn some of the most important things about the patient's problem when the patient gets upset with me. And patients should always feel free to communicate with their doctor. This is also the time when I can learn how to be a better doctor and a better person.

So I try to let people know I care about them, and at the same time ask them politely to slow down, or give me a second to think about their problem, and just hope that I'm not offending them. And when they're offended anyway, I try to just realize that that's what being a doctor involves, and you can't please everybody.

Only patients who want to be healthy need apply

What are your medical goals? Do you want to get healthier than you are? If so, how much are you willing to do? Are you willing to:

• See the doctor regularly
• Lose weight
• Stop smoking
• Take medication
• Exercise
• Be on time to doctor visits
• Keep all appointments with doctors
• Eat a healthy diet

I have many patients who are not willing to do some or all of the above.

I believe that patients are the bosses of their own medical care. A patient who doesn't want to do certain things is okay with me. But I don't necessarily have to be that person's doctor, either.

The problem is that health care involves a lot of work. If the patient is not willing to do anything, then the doctor has to do more. This puts a strain on the doctor's resources. In effect, the patient is saying, "I don't want to do anything, Doctor, so you need to do more."

It may seem that the doctor should be willing to do more, since he's being paid for his time. But it doesn't work like that. Here are some examples:

• The patient doesn't want to go to the doctor more often than once a year. She brings with her a long list of complaints. The doctor now has an unpleasant choice to make: either tell the patient she needs to return for another appointment to address some of her issues, or take more time with the patient and keep his other patients waiting.

• Under Medicare's new Pay for Performance program, doctors incur financial penalties from Medicare for not keeping their patients healthy. A diabetic who isn't willing to stop eating sweets, for example, will cost the doctor money.

• The patient who only wants the doctor to write prescriptions for a sore throat, and doesn't want to take care of himself, still has to listen to the doctor's suggestions to lose weight, get blood tests, stop smoking, etc, and has to say no to each of the doctor's suggestions. This is unpleasant for the patient, so the patient gets irritated with the doctor. The doctor's feelings are hurt because the patient doesn't seem to like him. The doctor doesn't have the option of not making those suggestions, since if he did not make them he wouldn't be a good doctor. The patient thinks the doctor is unpleasant, the doctor thinks the patient is unpleasant, and the whole interaction is unsatisfying for both parties.

So I've decided to not see patients who are not willing to take care of themselves.

Helping people get and stay healthy is a wonderful experience. I thoroughly enjoy helping people all day long. There's no better job in the world. But there are so many patients out there who would like to be healthier, who are willing to do whatever it takes, that I don't need to waste my time on patients who aren't. It's as simple as that.

Moving from Helpee to Helper

One way to see whether you're getting healthier is to ask yourself: "Am I a helper or a helpee?"

If you are healthy, you can help others in your life. If you are extremely unhealthy, you will be spending all of your time seeking help from others.

Some patients I see are healthy enough to help others, but are for some reason committed to being helpless. Some patients I see are very unhealthy, but still manage to focus on helping others.

So it's partly one's attitude.

Patients who want to be healthier might want to examine their lives to see whether they are primarily a helper or a helpee. No matter where you are on the continuum, you will benefit from moving closer to the helper end of the spectrum.

Poor Customer Service

I had a bad customer service experience at my car dealership this weekend. When I arrived (for my 5000-mile maintenance appt) there were people standing around waiting expectantly for one of the attendants to notice them. There was no organized way of figuring out who was next in line, so all of us customers were eyeing each other with suspicion. The attendants didn't seem to care about us. Finally, one approached me with a list of appts. I told him my name, but I wasn't listed. Apparently my appt had been forgotten. I waited around for 10 more minutes, then left in disgust.

This is not much different from the experience some of my patients have at my office. They arrive on time, only to find that the doctor is 45 minutes behind schedule. Talking to other people in the waiting room, they discover that 2 other patients have appts at the same time they do. Sometimes they get fed up and leave in disgust. When they do wait it out, they sometimes find me to be distracted, in a hurry, or paying more attention to my computer than to them. Or I help them with 2 problems but tell them I don't have time for a third.

My experience at the car dealership has caused me to be more sympathetic to disgruntled patients, and to resolve to make my patients' experience at their doctor's office rewarding rather than frustrating.

This is something that I feel is well within my capabilities. Some doctors would not agree. They would say that, with the state of modern managed care, a doctor cannot survive financially without seeing at least 4 patients per hour. This means 3 problems will never be addressed in one visit. Also, since patients will come in with emergencies, there's no way you can avoid keeping patients waiting sometimes.

However, even when a patient has to wait, I can be gracious enough to apologize for the delay when I walk in the room, and listen sympathetically to every problem. Most patients are willing to tolerate occasional delays, if after their wait they are greeted by a sympathetic doctor who really is interested in them and wants to help them.

Since I started working on my manner with patients, I have been pleasantly surprised to find that, when you make an effort to make the other person's experience more rewarding, you make your own experience more rewarding as well.

You may wonder, "Well gee, after 10 years in practice, why didn't he learn this years ago? Why don't they teach doctors to be sympathetic to patients' complaints right from the beginning?"

It's true that there is very little if any training in bedside manner. This is one problem. Medical schools and residency programs really should start training future doctors in how to make patients' experiences with health care providers more positive.

However, there really is a huge problem staying financially viable when you are a primary care doctor these days. You simply cannot take adequate time with each patient and still stay in business. So your doctor is sitting there trying to be sympathetic to your problem, while at the same time he's thinking about the 3 patients who are already in rooms impatiently awaiting his arrival. He cannot book 2 patients per hour and spend 30 minutes with each patient, because then he wouldn't be able to pay his office staff, pay his rent, etc.

Finally, the doctor's first allegiance HAS to be to the patient's health. There are many doctors out there whose first allegiance is to the patient having a positive experience, who are loved by their patients, but who don't keep their patients healthy. A doctor who is always nagging you to lose weight, to stop smoking, etc is a better doctor than one who always tells you what you want to hear.

It's taken me 10 years of practice to find a way to have all 3: financial viability, optimal health care, and happy patients. I don't achieve this goal with every patient encounter--far from it--but I think I've figured out how to achieve it now. Each day my skills improve. And with each satisfied patient, my job becomes more enjoyable and rewarding.

It's difficult to be nice all the time

A doctor should be nice to patients at all times.

Unfortunately, this is easier said than done.

Because I want everyone to be happy with me, when a patient shows displeasure with me I tend to get upset. Sometimes I deal with this by confronting the patient about the problem (which has the advantage of being direct but can put people on the defensive). Sometimes I deal with it by closing down emotionally (which leads the patient to conclude that I don't care about him or her).
And sometimes, despite the best of intentions, I'm actually rude.

Patients' reasons for showing displeasure for the doctor vary widely. Here are just a few:

• The patient was already having a bad day before arriving at the doctor's office.


• The receptionist was rude to the patient.


• The patient had to wait a very long time for the doctor.


• The patient just doesn't like doctors in general.


• The patient is upset about something the doctor did in the past.


• The patient thinks the doctor is incompetent.


• The patient is dissatisfied with the care being received from the doctor.


• The patient thinks that showing displeasure with people is the best way to get them to help.


• The doctor pays more attention to his computer than to the patient.

I would love to be able to make everyone happy, give the best possible health care, and keep the practice financially solvent, all at the same time. Unfortunately, these 3 goals are sometimes incompatible. For example:

• The patient wants me to address 4 problems on a visit and there's only time for 2. Spending extra time with one patient would make other patients wait (they'd then be unhappy).


• The patient wants me to prescribe narcotics despite a history of narcotics abuse. This would endanger my medical license, and then I wouldn't be able to care for anybody's health.


• The patient wants me to be on time, even though doing so would mean not addressing emergencies as they arise during the day. People would die.


• The patient wants me to declare her to be disabled even though I don't think she is. This would be unethical. I would make the patient happy, but my integrity would be sacrificed.


• The patient wants me to fill out a disability form but not charge for the service. The practice would go out of business if free services were routinely provided.


• The patient wants me to prescribe a medication over the phone without seeing him. In most cases this would not result in the best medical care, and in some cases would endanger the patient's life.


• The patient wants me to have reviewed her entire chart before every visit, so that I never have to look anything up. This would make a 15-minute visit take 30 minutes, and the practice would go out of business.


• The patient wants me to spend the whole visit making full eye contact, devoting all my attention to her, and not entering anything into the computer. I would then have to spend 15 minutes after the visit entering everything into the computer, making a 15-minute visit take up 30 minutes of my time. The practice would go out of business.

Recently I cut way back on my schedule. I'm now seeing about 30 patients less per week than I used to. That way, I can spend more time with the patients who need extra time, and not make people wait so long.

I'm also making a concerted effort to be nice to every single patient, no matter how displeased with me the patient gets. Some days I succeed in this endeavor, some days I do not. Each time I am not nice to a patient I feel bad about it, and resolve to do better next time. If any of the readers of this blog has any suggestions on how to keep one's cool in the face of displeased customers, I'm open to hearing them!

One Secret to Enjoying Life

In our modern world, one source of stress is having to live by the clock.

It's helped me a great deal to eliminate insofar as is possible the need to hurry.

Allow enough time for each of your tasks. Try to set it up so that you can take extra time if you want.

Just having an unlimited set of time laid out before you which you can fill any way you want is quite relaxing and rejuvenating. I think this is one reason why we enjoy weekends and vacations so much.

The person who is at a very high level of self-actualization enjoys each and every minute of the day, concentrates fully on each and every task. It's impossible to be in the here and now if you're worrying about what you have to do next.

Know Your Medical Conditions

In your medical chart, the doctor can see your

• Medical Conditions


• Medications


• Allergies to Medications


• Surgical History


• Family History

I am often surprised to find that a patient does not know what his or her medical conditions are, and does not know the names of his or her medications.

If you do not know these things about yourself, then just ask your doctor to print out a copy of your medical conditions, medications and allergies.

In any case, I suggest you go online and set up a Personal Health Record. For example, you can do this inside of Google at https://www.google.com/health/p/.

Interrupting Patients

Recently a very nice patient of mine complained to my office manager that I interrupt too much.

As a result of getting this valuable feedback, I decided to go a whole day without interrupting anybody--as an experiment. By midday, I had discovered that I was interrupting everybody constantly. It was a much bigger problem than I had imagined.

Since then I have made a point of not interrupting people--either patients or anyone else. I still slip up from time to time.

As a result, I have found that people enjoy my company more, and I enjoy their company more. My job--which I already enjoyed thoroughly--has become even more rewarding. Instead of just getting along with patients, I'm actually having quite positive interactions, and even feel that some of my patients are my friends as well as my clients.

Artificial Sweeteners Cause Weight Gain

WASHINGTON — Want to lose weight? It might help to pour that diet soda down the drain. Researchers have laboratory evidence that the widespread use of no-calorie sweeteners may actually make it harder for people to control their intake and body weight. The findings appear in the February issue of Behavioral Neuroscience, which is published by the American Psychological Association (APA).

Psychologists at Purdue University’s Ingestive Behavior Research Center reported that relative to rats that ate yogurt sweetened with glucose (a simple sugar with 15 calories/teaspoon, the same as table sugar), rats given yogurt sweetened with zero-calorie saccharin later consumed more calories, gained more weight, put on more body fat, and didn’t make up for it by cutting back later, all at levels of statistical significance.

Source: http://www.futurepundit.com/archives/004997.html

Clean the Gunk out of your Carburetor

Many patients think that statins are unsafe. Statins are drugs used to lower cholesterol. Examples include Lipitor, Crestor, and Zocor. (The generic name always ends in "statin"--Lovastatin, Atorvastatin, Pravastasin, etc.) Such drugs have 2 significant side effects--muscle cramps and elevated liver enzymes. The muscle cramps aren't so scary, but the elevated liver enzymes tend to put some patients off. Which is a shame, because if your cholesterol is high, then taking a statin is one of the best things you could do for yourself. I take one myself every day.

The liver has the job of breaking down poisons that you ingest. The body considers any medication to be poison. Thus, the liver breaks down medications. Some medications are harder for the liver to break down than others. Statins are an example of this. That's why we do blood tests periodically to check the liver enzymes on any patient who is taking a statin. If the liver enzymes start to rise, we stop the statin. The liver enzymes come back down to normal. There's no danger in the small amount of liver enzyme elevation we commonly see on statins.

I liken statins to STP, the stuff you pour in the carburetor of your car to clean the gunk out of the engine. Cholesterol is the gunk in the body's engine. Gunk (cholesterol) clogs the works (arteries), so that your engine (heart) can't get enough gasoline (blood) when it needs it the most. This results in heart attacks. Clean out the gunk and you'll live longer. It's as simple as that.

Discharging Patients

Sometimes it becomes necessary to discharge a patient from my practice.

Here are some reasons this can occur:

• The patient is discontented with the services I provide.
• The patient upsets a member of my staff.
• The patient doesn't pay his or her bill.
• The patient fails to show up for appointments at my office.

Not every doctor is right for every patient. The same qualities in me which are so appealing to many of my patients are irritating to other patients. Examples are:

• My commitment to optimizing my patients' health. Not everybody wants to get well.
• My use of computers. Many patients find my use of a computer distracting.
• Bringing patients back for frequent doctor visits. Many patients don't want to go to the doctor any more often than absolutely necessary.

Fortunately, there are many primary care doctors in my community. Patients who are not a good fit for my practice style still have plenty of other doctors to choose from.

Take a Quiz

Go to http://123facts.com/ and take a quiz on any trivia topic of interest. Several of the quizzes there were written by me. This is one of my favorite web sites, and one which you might find amusing. Some of the quizzes are on medical topics.

Nice Patients

Some patients make my day. These are the patients who have a positive attitude, treat other people with respect, and are genuinely interested in becoming healthier.

Some patients are less enjoyable to treat, though I care for them just as thoroughly. Some people seem to think it's a crime to smile. Some seem to be resentful about having to be at the doctor's office to begin with. Some are distrustful of doctors; apparently they think doctors are out to get them or something (rather than help them live long and healthy lives).

When I first meet a patient who seems distrustful, hostile or downright impolite, and after patient communication and evaluation, discussion of options, etc, the patient begins to open up to me, and relaxes, it's very rewarding for me as a doctor. I figure such patients have had bad experiences with doctors in the past.

Some people are just grumpy, though, and there's nothing I can do to change them. Someone was joking that we should allocate one day a week dedicated to grumpy patients, see them all on the same day. It would have to be a Friday though, because I'd need a couple days to recover!

Why do patients sometimes sabotage their own healthcare?

Some patients don't get the best healthcare they could from their physicians because they put up roadblocks to their treatment. Here are some examples:

• "I don't want to take cholesterol medicines because they can damage the liver." (This is a misconception.)
• "I don't like to take medicines." (I've never understood this one, perhaps someone can explain it to me.)
• "I don't like to go to the doctor."
• "I don't want to take that medicine because my friend had a bad experience with it."
• "I don't want to take a medicine every day. I just want something I can take when I have symptoms." (But the medications you take as needed are often more dangerous than the ones you take every day.)
• "I'm not willing to lose weight."
• "I'm not willing to quit smoking."
• "I'm not willing to stop eating sugar, even though I have diabetes."
• "I want to lose weight, but I'm not willing to eat less. I barely eat anything now."
• "I don't need a colonoscopy. I don't have any symptoms." (But cancer in its early stages has no symptoms, and a colonoscopy can prevent colon cancer.)
• "I stopped taking all my medicines. I was taking too many pills."

As a result of these roadblocks to care, I am unable to help some patients as much as I help the others.