Intern Burnout – Part 1

Adys Mendizabal, MD

PGY 1 Neurology Prelim Pennsylvania Hospital/Hospital of the University of Pennsylvania

Lewis Katz School of Medicine Alumnus, Class of 2016

The results of the recent presidential election have been troubling for many Americans, and have left the medical community with a great deal of uncertainty. What will happen with the Affordable Care Act? Will it be repealed altogether? How will this affect our patients? What of insurance coverage? And how about medication coverage?—Now, this last question I find to be the most provocative of all.

I’m a first year internal medicine resident/neurology preliminary intern, but my experiences with healthcare systems started from a young age back in Cuba, where my dad practiced as a physician.  In those days, common medications such as antibiotics or blood pressure medications were relatively easy to find and free of cost; however, the downside of a communist system is that the not-so-common medications were simply not available anywhere on the island. So yes, medications were free of cost…as long as you could find them.

We later moved the United States, the Mecca of healthcare advancements, latest medical discoveries, and the creation of novelty pharmaceuticals to treat some of the most disabling conditions. Yet, in this same Mecca, the price of such groundbreaking pharmaceuticals is prohibitive to the average and even the not-so-average American. Oh, and these high prices are not only for “novelty” or “designer” medications, but also for some of the most common and life saving medications. Here are a few examples of medication costs and some anecdotes I’ve gathered through my training:

Albuterol Inhaler ($58-65):  Rescue medication during an asthma exacerbation.

I was diagnosed with exertional asthma during the first year of medical school. One day I was going up a flight of stairs and I felt short of breath. Later that evening, I was walking around a free health clinic during orientation and I simply couldn’t stay standing for long because of the shortness of breath.  Subsequently, I was diagnosed with asthma, and I was prescribed an albuterol inhaler. When I went to my local Rite Aid to pick up my prescription, I found that, even with the school’s health insurance (which was about $220/month), my prescription was not covered; instead, I had to pay the $60 out of pocket. Sure, that may be pocket change for many. But for the average family in North Philadelphia, $60 for asthma treatment might be $60 they can’t afford.

How about foregoing the inhaler and just taking my chances? Well, a severe asthma exacerbation, not treated with an inhaler, will lead to an ED visit (best case scenario), an intubation, or hypoxic event leading to cardiopulmonary arrest, aka death.

Lantus ($200):  Long-acting insulin for management of diabetes. Administered at night in order to achieve good glycemic control first thing in the morning (which is the main goal in the management of diabetes).

Here I am during my third month as a “newly-minted” doctor. It’s my sixth week in a general medicine inpatient service. One of my patients came in with complications of a newly diagnosed autoimmune vasculitis, which required high doses of steroids. Steroids cause your blood sugar to skyrocket, so this patient also suffered steroid-induced hyperglycemia, which requires insulin use. As I’m finalizing the discharge paperwork, I give him a script for Lantus (9 Units, a very low dose), a drug that many of our patients with diabetes are prescribed in the hospital.  The following day, as I’m running around on a typical stressful day on the general medicine ward, I get a call from the patient’s wife, saying that WalMart was charging them $200 for insulin. My jaw dropped. I have ordered Lantus nearly every day in the hospital setting, and yet I had no idea that such a commonly prescribed medication cost my patients so much.

“I have ordered nearly every day in the hospital setting, and yet I had no idea that such a commonly prescribed medication cost my patients so much”

I spoke with one of our pharmacists who recommended NPH, an intermediate-acting insulin, typically covered under the “$4 plan” at Walmart (which actually costs about $20-$30).  Furthermore, this replacement medication comes in a vial, so the patient needs to have access to needles in order to even take his medicine. Needless to say, the patient’s “diabetes education” training only showed him how to use an insulin pen, not the vial, and the patient’s wife understandably felt very uncomfortable drawing insulin from the vial since she had never been educated on the procedure. After speaking with the pharmacist, I was able to contact our hospital’s outpatient pharmacy, which could sell my patient insulin pens for Levemir (another long-acting insulin) for $60.

In case you’re wondering how insurance factors into all of this, this patient was on Medicare, but without the Part D coverage, so his medications were not covered.

Tenofovir($1000-1142 for a 30-day supply):  Antiviral medication used for treatment of HIV and to prevent Hepatitis B re-activation.

It’s often said that autoimmune conditions are like “birds of a feather” in that, if a patient has one autoimmune condition, he/she will likely have another.  Take for example, the above patient, who not only had an autoimmune vasculitis, but had also developed hemolytic anemia that was likely of autoimmune etiology.  When he saw a hematologist about his hemolytic anemia, he was told to try taking Rituxan, an immunosuppressant.  While Rituxan would help keep this patient’s immune system in check, and hopefully treat his anemia and vasculitis, the dampened immune response could allow Hepatitis B reactivation in a patient with a previous Hepatitis B infection. Since this patient was going to receive six weeks of Rituxan (one cycle, once a week for six weeks), we also placed him on Tenofovir in order to prevent Hepatitis B reactivation. In this scenario, the patient only needed one pill, once a week, for a grand total of 6 pills over the course of his treatment.  Yet, when the patient’s wife went to fill his prescription, she found that they were being charged $1000 for Tenofovir.  I contacted Walmart, where they were filling the prescription, and their pharmacy explained that they are unable to break the bottle (30 pills), so the patient would have to buy an extra 24 pills for $1000. Once again, the hospital’s outpatient pharmacy came to the rescue.  They offered to sell the pills individually, as the inpatient pharmacy often had to break the bottle and dispense Tenofovir in smaller quantities.  Even then, when the patient filled his prescription at the hospital’s outpatient pharmacy, he paid $40/pill for the 6 pills, amounting to $240.

Keep in mind, this is a retired family living in the suburbs of Southern New Jersey.  Not the poorest of the poor, just your typical middle class patient.

Zonisamide ($14-60):  Medication for treatment of epilepsy. Well-tolerated, with minimal side effects.

In the neurology clinic, I saw a 24 year-old female patient with a history of migraines, seizures, and bipolar disorder. Previously, she had tried two seizure medications, one which sent her into severe depression and suicidality requiring her hospitalization.  At the time of her visit with me, she was on Depakote, a highly teratogenic medication that we try to avoid in women of reproductive age, because of its risk of causing neural tube defects during pregnancy.   Therefore, we wanted to start her on Zonisamide this time around because it not only had the potential to help with both her migraines and seizures, but also it’s a well-tolerated medication, with minimal side effects.

The next day I got a call from the patient saying her insurance did not cover Zonisamide. I looked into it and found that Walmart sells Zonisamide for $14, so is there really a good reason for her insurance company to not cover it?

I tried contacting her listed insurance company, which replied that the patient wasn’t enrolled with them, but was instead enrolled in a different health insurance plan.  Now, our records showed that the patient hadn’t been with that second company in a year, and lo and behold, when I contacted said company they verified that the patient was not enrolled with them.

Now there are two practical issues in this scenario.  On one end you might say, “well, call the current health insurance and ask them to cover it,” but at this point, I had spent one hour on the phone with not only multiple health insurance representatives, but also the patient who said “I’m currently working, I don’t have time to try to sort this out right now.” I was able to find the medication at Walmart and with a coupon it would be $14 for a 60-day supply which the patient agreed to pay. But in the practical, very busy world of an intern, that one hour on the phone felt like an eternity, and it was immensely frustrating. On the other hand, why would the insurance company be unable to cover a $14 medication? And if I had a difficult time sorting out coverage for the patient, imagine the patient herself, a working mother, trying to navigate the healthcare system to advocate for the coverage of her own medications.

___________________________________________________

When we say “medical residents are burned out and jaded,” there are numerous causes for that, but for me, I can tell you the biggest culprit for my burn out in the last six months has been medication costs, lack of insurance coverage of medications, and wholesale retailers and commercial pharmacies overcharging for the medications my patients need. I feel frustrated, stressed, and angry every time I need to spend an hour calling insurance companies, contacting pharmacists to discuss alternate medications, and faxing prior authorization forms because guess what, that’s not what we signed up for when we applied to medical school. That hour is an hour that I could have spent providing direct patient care, such as spending an extra 5 minutes to get to know my patients better, properly educate them on their medical conditions, and treatment plans. It’s also frustrating to know that the medication that will best treat my patients’ condition will be a medication that they can’t afford.  Finally, it’s especially frustrating when my patients can’t actualize their right to be healthy because of big pharmaceutical companies overcharging for medications and health insurances refusing to cover life-changing medications.  

doctor-burnout-329_0

Medication costs taken from: www.goodrx.com

Images taken from:  http://www.health.harvard.edu/blog/why-many-generic-drugs-are-becoming-so-expensive-201510228480, http://www.shape.com/blogs/shape-your-life/your-doctor-burned-out

 

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