Hardeep Phull, MD is an oncologist, but he is also a patient advocate. When conventional forms of immunotherapy and chemotherapy are not effective for a cancer patient, Dr. Phull will advocate for his patients to position them for a clinical trial, if they meet the criteria to qualify for the trial.
Dr. Phull says patient advocacy needs to start with the patient, but there are instances in which the patient’s doctor can advocate, such as working with an insurance company to make sure it covers a necessary procedure. Another way a doctor can advocate for his or her patient is through empathy and empowerment. Dr. Phull says he has seen patients go from “non-compliant” to cooperative, thanks to empathy.
Dr. Phull says in some instances a patient will want to change doctors, which these days is quite understandable as an increasing number of cancer doctors are specializing in one or two types of cancer. He says if a patient wants to be treated by a doctor more specialized in their type of cancer than he is, he will try to connect the patient with such a specialist.
Three primary forms of cancer treatment are immunotherapy, genomic testing and chemotherapy. Dr. Phull says a combination of the three can be prescribed, in some cases along with a clinical trial. He says at one time genomic testing cost tens of thousands of dollars; now the same procedure has a co-pay of less than one hundred dollars.
Dr. Phull says clinical trials combine the standard of care with a newer sort of therapy, and the explosion of clinical trials will lead to an increase in good patient outcomes. He adds whatever science has achieved as of today will be far greater ten years from now.
However, in order for a patient to qualify for a clinical trial, he or she must meet a long line of criteria. And before the clinical trial may begin, a certain amount of time must elapse after the completion of a more convention treatment regimen, such as chemotherapy, to get the chemotherapy out of the patient’s system. This is called a washout.
Dr. Hardeep Phull says insurance companies will often deny coverage of a necessary procedure because it saves money. That results in he and the nurses on his staff expending untold hours with the reviewers from the insurance companies to make a case for the patient. Dr. Phull says it is frustrating to deal with a reviewer who is often reading from a script when articulating the company’s coverage denial. He says many times the patient is angry and many times in this situation, the doctor or nurse is angry; but Dr. Phull says he has changed his approach to one of empathy for the reviewer who he suspects deals with angry callers all day. He has found that an empathetic approach often gets the reviewer to take a closer look at the appeal, which often leads to coverage.
Additional Resources:
Websites:
Hardeep Phull, MD on LinkedIn: https://www.linkedin.com
TRANSCRIPTION
Bruce Morton: This is the Cancer Interviews podcast and I’m your host, Bruce Morton. The topic of patient advocacy comes up frequently on our interviews. On this episode, we are going to address this important topic, but through the eyes of a doctor. He is Hardeep Phull, MD, of San Diego, California. What he has to say may surprise, but it will definitely inform you. So, here he is, and Hardeep, welcome to Cancer Interviews.
Hardeep Phull: Hey, Bruce, it is such a pleasure to be here with you this morning to address this important topic.
BM: We would like to start off by learning a bit more about you, so if you would, Hardeep, tell us a bit about your background in medicine.
HP: Absolutely. I started my journey early when I was growing up in Arizona. I was doing a lot of research in neurology and neurological cancers. I eventually went to medical school in Cleveland at the Cleveland Clinic. Back then, I aspired to be a surgeon, but I eventually found my passion in medicine, specifically oncology. My mother was an oncology nurse at the VA hospital where I volunteered. I get hours from my service for my pre-med applications. I still have a very big heart for the VA and that population. But it was a full circle, and I am back in oncology and have been since 2011, basically. Practicing in San Diego, I am a general hematologist oncologist, so I see a wide variety of cancers now.
BM: In a broad-brush sort of way, how might patient advocacy appear differently through the eyes of an MD as opposed to a patient?
HP: First of all, he encourages patients to advocate for themselves and to be their own advocate. As physicians, we are supposed to help the patient advocate, in other words, be their advocate. The most common scenario there is to be there on their behalf for insurance companies, especially when we are trying to get important studies done or be their advocate for other things. Let’s say a patient is trying to quit smoking or another habit, like alcoholism. By being their support system and advocating for them, and helping them, showing them that we have their back, we greatly encourage our patients to take control of their lives again.
BM: Again, speaking in a general sort of way, are there red flags a patient should notice, thus necessitating patient advocacy?
HP: I would say red flags pertain to a patient that is struggling to get things done. Often, we label these patients as ‘non-compliant.’ Sometimes we will say to the patient, ‘why didn’t you get your scan on time,’ or ‘why didn’t you show up for your appointment,’ stuff like that. These are signs the patient is struggling to understand the diagnosis, the logistics, the treatment or having financial or food insecurity. I had a patient just the other day that I saw who was sitting in the lobby. Some food was brought in and all he could do was sit and eat sandwiches and watch the TV screen. We concluded that to him right now, nutrition is more important to him than cancer and if we don’t feed his soul and give him energy, he is not ready and prepared to talk about chemotherapy. So, for him, every time he came in for an appointment, we actually had some sort of food or treat for him, and he started looking forward to these appointments. Then he opened up more. Nobody likes to admit when they are checking into an office that they are suffering from food insecurity that they are on food stamps. But when you empower people that way, when you help them, then they open up more and you see the person behind the illness.
BM: We’re confident you’ll be able to learn some tips and tools to help you through your personal cancer journey, but first we’d like to invite you to please give us a ‘like,’ leave a comment or review below and share this story with your friends, Kindly click on the Subscribe button below and click on the bell icon. That way you will know the next time we post a cancer interview. And if you or a loved one are facing a cancer diagnosis, please click on the link in the Description and Show Notes below to check out our free guide, “The Top Ten Things I Wish I Knew When I First Got Cancer.” Finally, we want to remind you that Cancer Interviews is not a purveyor of medical advice. If you seek medical advice, please contact a licensed healthcare professional, like our guest Hardeep Phull, MD.
Now, Hardeep, I want to take this a step farther, and ask are there certain situations in which they go a step farther and rise to the level that the patient should consider switching doctors?
HP: It does happen. It happens frequently. It could be that the patient needs more specialized care than say, I, can provide. Nowadays cancer is getting so complicated. Even when I started training, yes, there were rare cancers and common ones, but in general there were published treatments, there were likely one or two. If the first one didn’t work, then you would try the second one. Now it is like every cancer is its own subspecialty and people do subtraining and subfellowships and specializations. So, some doctors may do only one or two cancers. That’s all they specialize in. They won’t see anyone else. Of course, they are going to be more specialized and better trained than I am, as I try to keep up with that specific field. Now with so many trials and drugs being approved, many of the tools we have are being combined in very interesting combinations. For example, previously we had targeted treatments like immunotherapy and chemotherapy, as the main three options. Now we can combine them sometimes all three of those at once and hit the cancer hard up front and then still have backup options later on while we test other patients’ DNA mutations. When I started training, doing genomic sequencing, getting this procedure done cost tens of thousands of dollars. Now that’s a co-pay of less than a hundred dollars. Talk about advocacy, we can advocate for them if they can’t afford it and in some cases, the patient can get the procedure for free. So, what an amazing time to be targeted and intelligent about the precision treatments that are out there. But, going back to your original question, are there times when I don’t have enough information a patient desires more expertise, absolutely. My ego is not so bad that I think I am the end-all, be-all. I sometimes encourage a second opinion from the beginning, just for some reassurance even though I know that another doctor’s opinion is going to be there same as mine. It helps a patient to understand. I see the reason the patients want that. I highly encourage that and then the last thing is about clinical trials. There are certain trials that are only available at certain academic centers, some patients have to drive a hundred miles or more if they are living in a rural area, but if it is the right fit and there are no other options or it is a better option than the standard of care, despite the transportation burden for some of our patients, it is actually good to do clinical trials. Patients are not guinea pigs. Clinical trials combine the standard of care with a newer sort of therapy and that’s how we innovate cancer care. Clinical trials are the way we find cures and new treatments. So, for the right patient, especially the patient who has not responded to conventional treatment, I highly recommend trials, and I have no problem referring such a patient to other doctors who perform clinical trials.
BM: And Hardeep, we want to get into the whole notion of clinical trials in a little bit more detail a little bit later. The same for doctors advocating for insurance coverage of certain procedures, I want to get into that as well. In a previous professional life, I worked in the hospitality business and learned that guests love to complain. To get back on topic, can patients sometimes hamper the treatment process by making outsized complaints?
HP: You know, when patients come into our office, not all patients have a serious cancer. Some have a benign blood condition, but in many instances, the referral form says “oncology,” and of course, the patient’s mind goes racing, wondering how could this be, how did doctors miss this, why is it now, I have had this cough for months but nobody paid attention and now it’s cancer, it is very easy for people to go into that phase. They regret, guilt and sometimes blame. I think everything is a process. People go through phases of coping with news, whether it is bad news or unexpected news. My goal when I meet a patient like that, when they are not having their best day, whether they are complaining or not, is just to have empathy and to realize that person is extremely scared. I walk into the room with a smile, tell them what is going on, I give them the facts. I tell them what is okay and what isn’t. I tell them what is serious and when something just needs to be watched. I think just having that knowledge and empowerment helps patients overcome that blame game, but sometimes the blame is warranted. There are sometimes when physicians are running behind. I have seen that happen and when it does, what can you say, except the front office can be trained to say we’re sorry, the doctor is running behind and there are other patients. I think as patients come in and they see less fortunate souls in the waiting room, most people have goodness in their hearts and empathy, and they understand why the doctor is running late. The bottom line, Bruce, is that yes, there are going to be complaints and sometimes it is unwarranted. For my part, I will not call them out. I will ask why they are feeling that way and what can we do better?
BM: Now, in terms of the kind of patients you encounter, I want to go in the opposite direction. We recently had a guest who said he wanted to be the best patient he could be. He closely monitored his diet and exercise. He showed up on time for his appointments. Regarding his medications, he followed instructions to the letter. To what degree can a patient being a good patient aid and abet the treatment process?
HP: I celebrate all patients’ efforts to take control of their lives, whether it is diet, exercise or something related to mental health. By the way, I also tell my patients this, that they should be balanced and not go to any extreme. The worst thing patients can do on the heels of a new diagnosis is punish themselves. They start eating things their body has never been used to. I call it the ‘kale diet.’ It can include foods that are really hard to digest, high fiber, great things, I am glad you are eating them, but feed your soul. You are going through a very difficult time. The body responds wonderfully to taste and smell and comfort. Comfort foods are that for a reason. On chemotherapy, your tastebuds change, your taste, your smell, what you like, so feed your soul. Yes, be compliant, try to eat in a healthy way, be active, but there are days in which you won’t want to be active; but that over-compliant patient who is trying to do everything right, I say take it easy, take a few breaks. Don’t set such a high bar because that can lead to problems when you lose control and there is an unexpected outcome. The bottom line is we encourage all these healthy habits, but we want to keep people sustainable for a long term journey, rather than a short term sprint when one in fact is on a marathon.
BM: Hardeep, I want to get into this two-part area. We have already addressed it to some degree, but I want to go into a little more detail, if we can. First of all, the notion of clinical trials. Is this for which doctors can advocate in every case, or must this be handled on a case-by-case basis and some cases are stronger than others?
HP: It depends upon the type of cancer, the staging, how rare it is, whether the patient is failing first-line treatment or if they are on their last legs and they have tried multiple conventional things are they are failing. The wonderful thing today with this genomic testing I was alluding to earlier, many of these uncover new mutations we have never heard of or things that there are trials for. They often have reports on the back of what trials would match a patient’s specific mutations. So, that’s one way a patient can quickly learn about what’s going on. The other way is that there are websites, like https://www.clinicaltrials.gov, where patients can learn what is being studied. The key is to tell every patient you have to meet these eligibility criteria. If you are running a clinical trial and accept all comers, your clinical trial will fail. You have to have a very specific question and scope. In other words, this type of patient, this age group, this type of cancer, etc. If you don’t meet those criteria, it is not like you have failed. Something else will come along, but you have to be an appropriate candidate, and the doctor must equip the patient to realize he or she doesn’t just show up to this clinical trial center and you get the trial drug. There are an incredible number of safety precautions for patients. We don’t want to give patients drugs without their consent without their understanding the risks, the benefits, the alternatives, and the intent of the trial, understanding what the trial is, what the mechanism is. The patient shouldn’t just be told, “Here is a miracle drug and you might get placebo.” The message should be, “Here is the drug, here are the potential side effects,” and explaining the trial. Most trials require what we call ‘washout.’ In other words, if they had prior chemotherapy, there is a certain amount of time the chemo has to be out of the body before you start a new drug, or the patient requires a new type of blood testing or certain scans. Of course, we want patients to have all the knowledge and accessibility to trials, but I often equip patients with all of this knowledge so they understand it is not a simple matter of showing up and getting your trial done. It is you’ll show up, you’ll be screened for a trial and you are a candidate you will go on it. I am a big advocate of trials because I know today’s treatment is amazing, but in ten years it will be even better. There is no way to accomplish that without trials.
BM: Now I want to talk about another phase of patient advocacy that crosses the line over to the exam room and the doctor that occupies that exam room, and that’s insurance coverage of a certain procedure. We have heard from time to time from patients who feel that when coverage is denied, that their doctor can be do a better job of running point on obtaining coverage than can the patient. Your thoughts on that?
HP: My favorite topic. It always appalls me when I get these denials or rejections, especially the wording of it. It is often not worded in the most compassionate way. They send a letter to the doctor and the patient. You can imagine what a patient feels like when I have spent hours telling the patient what the right treatment is and what the right steps are, and not to worry. Three weeks later, none of it is done because the insurance carrier denied coverage. Sometimes the denial can be addressed with a simple appeal, but even that consumes a great deal of time for me or my nurses. Sometimes beyond that it is denial for the sake of denial. It is mind-boggling for me that some denials happen because they can happen. It is easier to deny and hope someone doesn’t fight it than to approve everything. It saves the company money to deny coverage. I don’t mind that health care is somewhat of a business, but I don’t like the fact that a sub-specialist saw a patient, they followed guidelines, their notes say it all, everything is published nowadays, but the company wants to make it hard. It all comes down to what is called a peer-to-peer, where a physician like myself has to get on the phone, usually a doctor working remotely, usually not an oncologist, sometimes a nurse practitioner, and these people usually have a script on the other side that they are reading that says coverage is being denied because of ‘this and this.’ I used to go into those calls extremely angry and worked up, but I have changed that because it wasn’t working. I now take a much more light hearted, compassionate approach, and demonstrate empathy for the reviewer who is denying the claim. Think of the reviewer. They are working from home and probably having to deal with really angry people all day long, but I just approach it differently and I have had 100 percent approval rate. I hope they don’t watch this and hear this! I am not faking it. I am just using a different approach, but that is the advocacy a doctor needs to do for patients. A patient can talk to an insurance company, but a doctor can put up a better argument after talking to other physicians. As much as I hate that process, that it even exists, and that it is like a rubber stamp of denial rather than a well thought out one, until Congress makes some changes, I have to deal with this, and ask myself what I can do to advocate for this person? The best thing I can do is be nice on the phone, then vent later to my staff rather than the reviewer who holds my patient’s life in their hands.
BM: Hardeep, we are going to wrap up now, but before we wrap up is provide an opportunity for anybody listening if they would like to get any more of your expertise, is there a place they can go on the web to avail themselves of your expertise?
HP: I am very active on LinkedIn. You can find me on LinkedIn. I am under my name, Hardeep Phull. That’s where I post a ot of empowering content, but I also share a lot of other people’s wonderful content, mostly examples of empathy or success, sometimes examples of failure that we learn from other industries. So, I have a wonderful following on there. I really like LinkedIn because you can have a conversation about something rather than just a ‘like’ or a viral video. It’s more like, ‘let’s have a conversation.’ I like the professional interactions on there. Happy to hear from anyone who would want to reach out on LinkedIn.
BM: Excellent. Our guest has been Hardeep Phull, MD of San Diego, Caifornia, and Hardeep, thanks very much. You have shared a wealth of information that can be of benefit to patients of all types. Thanks for being with us on Cancer Interviews.
HP: Thank you, Bruce. This has been amazing. Thanks for having me.
BM: And we want to remind you that if you or a loved one are on a cancer journey, you are not alone. There are people like Hardeep Phull, MD who have words of wisdom that can aid your cancer journey. So, until next time, we’ll see you on down the road.
Additional Resources:
Websites:
Hardeep Phull, MD on LinkedIn: https://www.linkedin.com
SHOW NOTES
TITLE: Hardeep Phull, MD, Oncologist & Patient Advocate – San Diego, California, USA
Cancer patients are often urged to be fierce advocates for themselves as they go through a cancer journey; but members of their care team can also serve as advocates. In this interview, Hardeep Phull, MD discusses how one’s doctor can advocate for his or her patients, with advocacy addressing insurance coverage for a needed procedure and assistance in getting a patient to qualify for a clinical trial.
Additional Resources:
Time Stamps:
01:45 How patient advocacy appears to a doctor
04:57 Under what circumstances should a patient consider switching doctors?
08:29 Clinical trials lead the way to new cancer cures.
10:06 Hardeep admits that from bad news can come from patient complaints.
13:04 Advise for those who zealously seek to be a good patient.
15:48 Hardeep explains how a patient can qualify for a clinical trial.
21:20 How a doctor can advocate for insurance coverage of a procedure.
24:56 Hardeep explains why a doctor can do a better job of fighting for insurance coverage than a patient.
KEYWORDS (tags):
immunotherapy
chemotherapy
hardeep phull
clinical trials
genomic testing
washout
bruce morton
Comments