Time Stamps

  • 3:03 Demographics of AMA Discharges
  • 5:59 Clinician/System Related Factors of AMA Discharges
  • 10:30 Strategies for Mitigating AMA Discharges
  • 15:59 Do we have to sign the AMA form?
  • 18:27 Do Insurances Deny Payment for Patients who Leave AMA?
  • 23:09 Take Away Points

Show Notes

Statistics on AMA Discharges

Understanding Patient Motivation to AMA

  • Financial/Employment
  • Caring for Dependents 
  • Undermanaged Drug Withdrawal, Pain, or Other Symptoms 
  • Perception of Stigmitization/Discrimination by Healthcare Practioner
  • Unclear Expectations (e.g., timing of procedures, NPO status, overall care plan)
  • Disagreements with Discharge Planning

Strategies for Mitigating AMA Discharges

  • Clarifying Expectations (early in the hospital stay)
  • Appreciating health as only one patient priority amongst others
  • Cognitive Re-Framing:  threat of AMA as an opportunity for patient connection
  • Mindfulness of personal anger/frustration before entering AMA conversations
  • Offering Control (e.g., with timing of labs, vital signs)
  • Shared Decision Making, Harm Reduction, and willingness to compromise around inpatient care plan with planned follow up

Questioning the Value of AMA Discharges

  • Real possibility of harm (later stigmatization through appearance in the chart)
  • AMA forms likely to antagonize patients during a moment of critical discussion

Transcript

Margot:  I wanted to start off this episode by telling you about the very first patient that I discharged against medical advice. This was a young man who had been admitted overnight. He had a history of IV drug use, heroin specifically, and came in looking really lousy – febrile, shaking. They drew blood cultures in the ER and started him on broad spectrum antibiotics, and I met him first thing in the morning. I saw him first for two reasons: One was that I was paged by the micro lab that he was growing 4/4 bottles with a gram positive bacteria, and second because I had also gotten paged by the nurse, who was telling me that the patient was dressed and ready to go. I walked into his room and explained my concerns – I was worried that he might have endocarditis, might have bacteria in his bloodstream that was seeding his heart valves. But he told me quit calmly that he had to go. I asked why, and he said that his mother had gotten into some legal trouble and he needed to go take care of her. But I kind of suspected from the yawning, from the piloerection, that he was withdrawing from heroin. I offered him methadone to try to see if that would convince him to stay, but he declined my offer. He left against medical advice, and I don’t know what happened to him.

Margot: Welcome back to “At the Bedside”, the segment of CoreIM that discusses common ethical issues in clinical care, and questions that fall outside the traditional realm of evidence-based medicine.

Margot:  I’m Margot, a 3rd year internal medicine resident at NYU

Jafar:  I’m Jafar, a hematology/oncology fellow at UCLA

Tamar:  And I’m Tamar, currently pursuing research in bioethics

Jafar:   On today’s episode, we’re gonna discuss a topic that comes up frequently in our practice: discharges against medical advice, or A-M-A.  Many of you listening have had to discharge a patient against medical advice and, like us, you’ve probably come away from those conversations with some moral discomfort–or at least frustration.

Tamar: And we wanted to quickly acknowledge here that questions of capacity often weigh heavily on if and how a patient leaves the hospital against medical advice. Recognizing that it’s a sometimes complicated topic, we’re hoping to dedicate an upcoming episode to discussing capacity assessment. For today’s discussion, we’ll focus on patients who have demonstrated capacity in making their own decisions. So we’re speaking with Dr. David Alfandre, whose research largely  focuses on AMA discharges. He is an associate professor at NYU’s departments of medicine and public health, and a health care ethicist with the VA’s National Center for Ethics in Healthcare. We’ll talk to him about different approaches in these situations, and then discuss some truths and myths about discharges against medical advice. 

Let’s begin with some of the statistics. AMA discharges only make up about 1-2% of all hospital discharges, but these patients are particularly likely to be from more vulnerable populations.

Dr. Alfandre:  Right, so um, one interesting study suggested that the same factors that are associated with AMA discharge are associated with people having difficulty accessing care. So, um, you know, we see patients who were poor, who are uninsured. Um, those factors are a risk factor for, for being discharged AMA, but it’s also a risk factor for actually being able to engage in care and be able to access care on a regular basis.

Jafar:  Yea, exactly.  As I was reviewing this topic I found a great paper, it was a retrospective study of over 300,000 discharges from 2002-2011 found that AMA discharges were highest among patients who were young, male, had Medicare or Medicaid, or who were uninsured, and also specifically people being admitted to the hospital for reasons relating to mental health or substance use disorder.

And this is, for me, this is such a large part of the frustration with AMA discharges.  By definition, these are the patients that I don’t want to walk out the door. It’s really not surprising, then, that they do in fact end up with worse outcomes.  You know, they are less likely to attend follow-up appointments, and studies show that their 30-day readmission and mortality rates can be twice as high as patients who stay in the hospital.  It’s easy to make a lot of generalizations when I hear this kind of demographic information, but I always wonder, how do these statistics apply to the patient in front of me?

Dr. Alfandre: What an individual patient is going to be interested in as far as needing to leave the hospital, you really have to individualize. So you have to talk to the patient. For some patients it might be that there’s a social service payment, but others, there may be a pet in the home, there may be competing priorities that they have. And that could be anything. It could be a child in the home, it could be an older parent in the home, whatever it is, it’s a competing priority. And so that’s really what you’re trying to uncover when you talk to patients is what else is going on that’s competing for their need to be in the hospital.

Tamar: So thinking about some of the groups mentioned in that study — for example, let’s take people in their 30s and 40s, who have higher rates of AMA discharges than other age groups. It makes sense – these are ages where people are very likely to have important obligations to others in their lives: children, a parent, a partner. So they choose to prioritize these obligations over the hospitalization.

Similarly, unfair stigmatization or biases are applied to people admitted for reasons relating to mental health or substance abuse. Sometimes these patients have faced difficult interactions with clinicians in the past. This is all really important context when we consider why someone may then be more likely to decide to leave the hospital early.

Margot: Ok, so we’ve got a pretty clear sense of why these statistics are important to talk about. Understanding which patients leave AMA helps us understand why they leave AMA, and hopefully down the line that will help us find ways to address the needs of these more vulnerable populations. But there’s a whole other category that I also want to make sure we touch on. It’s not just patient-specific factors that are causing AMA discharges; we work within a complex healthcare system. 

Alfandre:  We’re, we’re starting to gather more information about that, but what we’re finding is, is urban hospitals, hospitals that are nonteaching hospitals.   Those tend to have more AMA discharges, which is an important point when you think about that it’s not simply related just to patient factors. But there are other, what we call sort of non-patient health system/provider factors that may contribute to the AMA discharge.

Margot:  So we, as the clinicians, have a large role in this too. 

Alfandre:  That’s important information to consider, right? Is it the gender of the healthcare provider, the age of the healthcare provider, the number of years out of practice, the specialty? I mean, there’s a lot of things that may be, again, just associated with it, but those are important questions to ask because if there are related to healthcare providers, then that’s where we intervene. Right? We talked about the patient related  factors that are associated, but what if there are healthcare provider factors that are associated? Because those would be important to find out about and intervene to try to mitigate the adverse outcomes. 

Margot:  These factors are really interesting to consider, and again, it’s a topic that we don’t think about as often. There’s a bit of a gap in the literature here, but there are a few small qualitative studies on the topic. One of these studies in 2010 reached out to patients who left the hospital AMA and talked with them about their reasons for leaving. For some it was a  breakdown in communication, which has absolutely happened with some of the patients I’ve taken care of: the intern tells the patient one thing, and the consultant comes by and says something else, then by the time the attending rounds, the whole plan has changed again. Other patients felt dissatisfied with their doctor’s bedside manner, felt that their pain was under-treated, or felt stigmatized because they had a history of drug use. Again, all these reasons really resonate with my experience.

A study in 2016 that Dr. Alfandre was a part of also found that patients often wanted to leave AMA because they disagreed with the discharge plan; they didn’t want to be discharged to a skilled nursing facility, for example. Other patients left AMA because they were frustrated by certain aspects of their medical care, like being kept NPO for a procedure or being kept in a contact or isolation room. 

Tamar:  Yeah, Margot, all these situations you’re describing sound super familiar to me as well. And I guess this highlights another reason why it’s so important to communicate clearly with our patients. And I do know that’s a silly thing to say, I mean we all try to be clear, but it is interesting to think of this as kind of a small possible intervention for making AMA discharges a bit less uneasy. It of course won’t come close to solving every difficulty, but for some patients if I push myself to be more clear or maybe explicit about why I’m doing what I’m doing in the medical plan, maybe I can prevent even just a few misunderstandings and the premature discharges they would lead to. 

Jafar:  Yeah absolutely. And with that in mind, we need to figure out how to move forward towards a good – or at least better – way to have a conversation with our patients in these situations.  I feel like we just have to start by admitting that it can be exceptionally frustrating when a patient insists on leaving AMA.

Alfandre:  Remember there’s the socially sanctioned role of a physician is to provide care for patients, you know, regardless, um, unconditionally, right. So, um, you know, AMA discharges sort of push up against that. It’s, it’s not uncommon to find practitioners frustrated, sometimes even angry with patients that choose to leave the hospital over the recommendation of the provider. 

Tamar:  So then, how else do you think about this?

Alfandre:  I mean, I think most of the time patients just want to be heard. They want to have a conversation with their healthcare provider. They want to have their concerns or their needs addressed. Um, and sometimes, sometimes that’s the only way for them to have that conversation is to, is to assert that they’re leaving the hospital. So it’s, it can be inconvenient for healthcare providers, but I often say that it’s an opportunity.  

Often when I say that, how my trainees often sort of roll their eyes and say, oh great, another opportunity to have a conversation about AMA discharges. But that’s really what it is, right? The patient in the only way they know how is trying to say I have something really important that I need to do or I have something really important to tell my healthcare provider and this is how I’m saying it. So one sort of cognitive restructuring that can help house officers is to think about when a patient is asking to leave AMA, it’s an opportunity to better connect with the patient about their, their needs, what’s important to them, and often to convince them to stay. Because that’s often the case.

Margot:  That’s a really helpful way of thinking about it. Here we’ve got a conflict, but that conflict ends up being a way for both sides to talk about what really matters to them.  It ends up being a way for both sides to understand each other better, and hopefully improve care. 

Alfandre: I really enjoy these conversations. I truly see them as opportunities. I really find the ability to work with patients who are, um,  frustrated and concerned and wishing to decline recommended care. I find those interesting, a clinical challenges. And I hope I can convince other physicians that if they see it that way as well, they, it may be just like an interesting EKG or an interesting chest x ray, easier to sort of engage with the process.

Tamar: So where do we start these conversations?

Alfandre:  Really it comes down to having that shared decision making conversation with the patient. And that means finding out what’s important to them, what their competing priorities are, what else they’re concerned about in their life. And that means quite honestly, just empathizing with the position that they’re in. It’s not easy to understand necessarily the financial and social and emotional pressures that some patients are undergoing. Um, but that’s really what this process requires. Um, it’s about sitting down with the patient and finding out what is of concern that’s interfering with their ability to make decisions that are gonna promote their health. 

So, you know, when, when, um, you know, if it’s a, if it’s a beginning medical student, they’ll say, “Yeah, I understand AMA discharges, patients have the right to make bad decisions,” and I’ll say, well, that’s not quite how I would describe that. They – the competent patients – have the right to decline recommended treatment and sometimes that means not promoting their health, um, but it’s not bad necessarily because it’s meeting some other need that they have and the more open you are and nonjudgmental to what those needs might be, first of all, the more likely you’re already hear it from the patient, the more likely they are to trust you and be able to confide in you about what those concerns are. Um, and then the more likely you are able to identify resources that are directed towards meeting those needs.

Jafar:  You know, the way he describes it — it sounds wonderful, but I feel like it is so much easier said than done. 

Alfandre:  If you go in and you’re angry and frustrated and overworked, um, at least the last two variables probably accurately described most night floats, right? They’re getting paged, you know, every couple of minutes they’re running around, they’re caring for a lot of patients, um, and it’s easy to feel overwhelmed in those situations. So it’s hard to have these conversations and um, take the time to make sure that they’re getting the information they need from patients. Um, but often, you know, a short amount of time invested at the beginning will save a lot of time later on in the course of the patient’s care by developing that relationship, creating a treatment alliance, developing trust and getting good information from the patients so that you can develop a care plan that actually meets their needs. I think one interesting study from, oh, probably 30 or 40 years ago showed that the more likely clinicians were to established expectations early in the hospitalization, the lower the likelihood of AMA discharge. 

Jafar:  So this totally  gets back into what we were talking about earlier. The critical role of communication, of being connected and transparent with our patients.  But honestly, I know that when I get busy or frustrated – and being an intern on night float was a perfect example of that – when I’m frustrated and busy — all I wanted them to say is “I know I can die” and sign a piece a paper, so I can move on to my, you know, next minor crisis of the night.

Alfandre:  When I come on service, I go over very clearly that really our primary ethical, legal and obligation is to ensure that the patient is making an informed refusal of care. Right? Or there’s an informed consent discussion about the patient choosing to decline recommended treatment. Um, and that’s all they need to do. Um, once they do that, then they need to document that process within the record. But as soon as I tell house officers that, they uniformly sort of their shoulders relax a little bit and they nod in agreement and they say, oh, okay, that’s really easy. I say, you don’t need to have them fill out the AMA discharge form.  As a matter of fact, that’s probably just going to antagonize the patient. It’s extra work for you. It’s never been shown to actually promote higher quality risk communication. Um, and often patients feel like the process is more stigmatized when there’s an AMA discharge form. So there’s another holdover from a more paternalistic era, um, but we see it in lots of different health systems.

Jafar:  Ah, and that’s so important to remember: It’s really not about the form at all, it’s not some golden document that keeps me out of jail.  You just do your best, you know, you have a real talk, and document it somewhere.  

Margot: Let’s take a second here to talk about the form, because I know at least for me that piece of paper feels like the symbol of an AMA discharge. Dr Alfandre outlines our ethical obligations to the patient, which is a thorough and empathetic informed-consent discussion. The AMA form addresses the legal  aspects of the case. It’s essentially an attempt to make sure the discussion includes the information the clinician would need to protect themselves legally if the case ever goes to court. AMA forms are different in every hospital, but generally include three parts:

The first part says that the patient has demonstrated capacity to leave AMA. The second part records the key pieces of the informed consent discussion, which is what Dr Alfandre has been walking us through: the clinician needs to communicate her concerns, the intended workup and potential treatments, and all the potential risks of leaving, and the patient needs to understand what was explained. The third part of an AMA is that discussion is documented in the chart, which for many people means the AMA form itself, but Dr Alfandre is discussing the alternative, which is documenting in the EMR.

The form can be helpful: a study of emergency room physicians found that introducing  an AMA form improved the quality of physician documentation of AMA discharges. But the form isn’t a “get out of jail free” card – it can’t replace the conversation. There was a lawsuit about this in 1991 called Battenfeld v. Gregory, in which a patient sued 2 doctors for delay in treatment for her ruptured appendix. Essentially, the patient had just given birth, and had a fever, elevated heart-rate, and a high white blood cell count concerning for an infection. But she wanted to return home to her family, and was advised that while they recommended staying until she defervesced,  she could go home if she signed an AMA form. The jury argued against the doctors involved, saying that the doctors hadn’t really explained the risks the patient was taking by leaving early – the form wasn’t enough. 

At the end of the day, both ethically and legally, the conversation is key – as for whether you document that with the AMA form or a note in the patient’s chart, check your local hospital’s policy.

Tamar:  So, again, like so many other parts of the treatment plan, it’s all about the conversation and shared decision making. Still, when a patient leaves the hospital AMA, why does it often feel uncomfortable or difficult?

Dr. Alfandre:  I think the concept of harm reduction is sometimes challenging to accept. I hear from a lot of providers, well, if I don’t discharge the patient AMA, they’re not getting the right message. They’re getting the message that it’s okay to use drugs or it’s okay to forego their health. Um, and that’s not really the primary philosophy behind harm reduction. Patients can get really frustrated in the hospital. But when you sort of think about the arc of their provision of care, the goal is to keep them engaged with the healthcare system. And so if they choose to leave the hospital now, that doesn’t mean that they won’t come back sooner. And so your goal is to give them as best care that you can and care that they’re willing to accept.

Tamar: This was really helpful to hear. It makes me think of when I come up with what feels like the perfect discharge plan medically: This patient will finish her IV antibiotics and then leave the hospital on Tuesday to a skilled nursing facility.  But if that plan doesn’t work in her life, then I was misunderstanding what would be perfect. Instead, I need to find some sort of compromise between what the patient needs medically and what fits with her motivations and priorities. 

Jafar:  So it’s not a failure or a breakdown, it’s helping someone get to a goal that works for them.  We don’t have to throw the baby out with the bathwater on this, just keep them engaged and this person has a chance to pick up where they left off on that hospitalization.  We’ll get ‘em next time.

And to that end, just because someone is leaving AMA doesn’t mean we should forgo making some kind of discharge plan for them.  For example, we may want them to stay on IV antibiotics for four weeks, but if they’re not willing to do that, we’re obligated to find kind of some oral regimen that can help treat their condition — even if we don’t think it’s ideal — and give them follow up appointments with primary care and infectious disease specialists.  Just because they’re not conforming the best medical evidence doesn’t mean we turn our back on them, and you know, to the extent that we do that, we should be careful to look at how we actually might be trying to punish that patient for not agreeing with our plans. Of course, we always need to think about the safety of our compromised discharge plans – for instance, I wouldn’t be willing to give benzos or barbiturates to someone leaving AMA during alcohol withdrawal, just given the risk of combining substance abuse with continued drinking – but it’s still our ethical obligation to try and offer what we can, where we can.  One of the most dangerous pitfalls is when we let AMA designation itself get in the way of this, and use it as an easy excuse for not working with that patient to find other solutions.

Alfandre:  The general premise of the argument is, is that we’re finding that AMA discharges don’t, haven’t been demonstrated to advance a patient’s care in any evidence based way, and we know that there’s evidence of stigmatization and reduced access to care for these patients. So from an ethics perspective, there’s really minimal benefit, um, or no identified benefit, and there’s emerging evidence of harm. 

Tamar:  So these situations don’t need to put a stop to our trying to provide the best possible care, it’s just redefining it and asking “what’s now the next best way to take care of this patient?”

Margot:  Right, and that also leads us to addressing an important myth about AMA discharges.  I’ve heard this, and I know my colleagues have as well: is it true that if a patient leaves AMA, his insurance will not cover the hospitalization?  It’s sometimes used as the rationale for convincing someone to remain inpatient.

We dug into the data on this, and there’s a great study from 2012 that combed through the records of over 46,000 admissions. About 1% of those admissions ended in AMA discharges, and when they looked through those records, they found a total of 453 patients who left AMA who had some form of health insurance. While some of the claims ended up being rejected for administrative reasons, such as submitting the bill too late, not a single one was rejected because the patient left AMA.  

Jafar: Wow I’ve been lying to people about this for a long time… and to be honest, I’ve tried to leverage it to keep people in the hospital.  I almost WANT IT to be true, but you know that’s me trying to financially bully the patient into doing what I want them to do with their hospitalization.   But that’s a really helpful myth for us to debunk, I think that gets thrown around a lot, so I really look forward to sounding smart the next time this comes up.

Tamar:  So Dr. Alfandre took us through trying to reframe discharges against medical advice as opportunities to discuss our patients’ competing priorities, and a way to focus on shared decision making and harm reduction. We then hopefully debunked a couple of the larger myths that loom over AMA discharges. With that, we’ll turn it back Dr. Alfandre for some take-home points on the strategies for doing all this effectively. 

Dr. Alfandre:  Hopefully I can provide sort of a general framework to think about the problem again, given some of the values that we’ve talked about or promoting shared decision making and harm reducing alternatives. So like you said the first thing I divide them up into behavioral and cognitive strategies.  The first thing is from a behavioral standpoint is involve others, right? And that means the patient’s family, the patient’s friends, the patient’s healthcare provider, patient’s primary care doctor. Involve other people who the patient knows and trusts. Because if you’re the, if this is the first time you’re meeting the patient, they’re unlikely to trust you or necessarily want to agree with what you’re saying.

The second thing is to maximize the amount of decisions the patient can control. Um, I had an interesting conversation with a psychiatrist about this and he talked about making the unconscious “no” conscious.  So patients may be just saying no because I want to hear, they haven’t thought through the consequences of the case you described. They haven’t thought through all the alternatives. They’re just like, I’m done with being here.  I’ve spent X number of nights not sleeping, getting woken up every couple of hours. The person in my room is screaming, I’m uncomfortable. Right? They’re not necessarily thinking through all the risks associated with leaving, they’re just thinking I’ll be more comfortable at home.  Um, and so you want to slow down that process, but also help the patient control whatever they can within the hospital environment. So sometimes when you go to the bedside and the patient says, I’m ready to leave, you find out what’s on their mind, what their concerns are, and you find out that they don’t want to get their vitals checked at two in the morning.  So you, you give them that opportunity to control that about their healthcare environment. So you maximize anything you can about the patient’s experience in the hospital. 

The third I think we’ve talked about is empathizing, and that requires practice.  So as you’re walking into the room, yes, you’re getting, you have four pages backed up and now you’re running to the bedside to talk to this patient.  Remind yourself, alright I’m not going to argue with the patient. Patients want to be heard, right? They don’t necessarily want to be right, they just want to be heard. 

And so if you remind yourself, and I’m going to empathize with this patient, I’m not going to argue, you’ll often find out what’s going on with the patient, what the patient is concerned about. It will also calm you down a little bit. You won’t feel as activated and antagonistic. Um, so that’s, that’s the third point. 

The last one is, as we’ve said before, rely on trusted legal advice. Um, so if you don’t know, ask your attending, Hey, what are my legal obligations here? And once you know what those are, it’s easier to relax. It’s easier to focus on the care of the patient.

And then the cognitive strategies.  The first is conflict as opportunity, which we talked about, seeing a patient’s desire to leave AMA is an opportunity to have a conversation about what’s important to the patient, what’s on the patient’s mind, what’s concerning to the patient, right? I mean, much of the work of interacting and aligning with patients is finding out what’s important to them. And sometimes that’s how I’m, that’s how they tell us. They tell us that they’re ready to leave. So see that again as an opportunity rather than as a challenge to your authority. 

The second is understanding and accepting patients with substance use disorder.  I bring that up specifically because so many more patients with substance use disorders are likely to leave against medical advice.  So the more training you have, the more comfort you have in caring for patients like this, the easier it is for you to provide high quality care and focus on their needs. 

And then the last part is decide for yourself whether or not you want to discharge the patient AMA. That’s a choice that I leave to the individual healthcare provider.  I’m not here to say you should never discharge a patient AMA. I’m simply saying think about whether or not it’s going to advance the patient’s care. Think about the harms associated with the designation.  Again, this isn’t, this is about the designation of the discharge, both in the record and discussing with the patient. I always tell trainees and other physicians, this isn’t about not recommending that the patient remain hospitalized.  This is about letting them know their options, letting them know the risks, the benefits, and if so recommending that they stay in the hospital because that would promote their health. But taking it that next step further and formalizing the decision, document into the record, using an AMA discharge form, those have never been shown to advance a patient’s care.  So think, consider for yourself, like other high value care decisions is what I’m doing actually advancing the patient’s care or is it actually harming the patient potentially? So those are the main strategies

Margot:  Thanks to Dr Alfandre for those take-home points. We’ve covered a lot in this episode – our ethical and legal obligations to our patients, some strategies for meeting them halfway, and a framework for structuring a conversation that can help mitigate some of the conflicts that often come up when a patient has one foot out the door. We’re planning an episode to explore an issue that many of us find challenging: the capacity assessment. It’s such a nuanced topic that it really needed a whole episode to itself, so stay tuned. We also wanted to acknowledge that even in the best of circumstances, AMA discussions don’t always go according to plan. We think that the framework outlined in this episode is really helpful, and has the potential to improve the therapeutic relationship, or safety of an AMA discharge, or even convince a patient to stay, but sometimes, in the face of it all, you’re going to strike out. While I was researching and recording this episode, I had several patients leave, which was pretty humbling. Clinical medicine can be challenging and wonderful in all these difficult ways, and at the end of the day – just keep on trying your best.

So I wanted to close out with a few last words.  I wanted to echo what Tamar said at the beginning, which is that this is a really wonderful framework, but one that applies for patients who have demonstrated the capacity to leave the hospital against medical advice.  And there, there’s a few big issues that we weren’t able to tackle in this episode. One of them is the capacity assessment, which deserves an episode unto itself, and that’s an episode that we’re hoping to do in the future.  And a few other things that still leave me unsettled, like what happens when, after a really full and productive conversation, you and the patient just cannot settle on the same answer. Um, and I’m sure there are a lot of issues that you as our listeners have probably come across that we weren’t able to fully address in this episode.   So I wanted to say that because I know that I feel personally insufficient when I am not able to solve a clinical problem or a clinical situation, and I just want to just acknowledge that clinical medicine is really difficult, and, um, challenging, and really wonderful in difficult ways, and just keep on trying your best.

Thank you to:

Audio Editor: Julia Skubisz

Illustration: Dr. Michael Shen

Endless Technical Support: Harit Shah

Music composer: Peter Mark Kendall and Gabriel Stern of Hickory Collective from Hickory Collective 

References