“It’s an old plane. Her name’s ‘Thumper,’” says pilot Mark Harris, as he revs the engine of the tiny 1957 Cessna 182. “Clear prop!”
It’s a 30 minute flight from our starting point in Eureka to the Hoopa Valley Native American reservation where Dr. Fratkin’s going to visit a man named Paul James. He’s dying of liver cancer.
“A good number of patients in my practice are cared for in communities that have no access to hospice services,” Fratkin says, shouting over the voices on the plane’s intercom.
Fratkin is a palliative medicine physician. He’s the guy who comes in when the cancer doctors first deliver a serious diagnosis.
“After the bad news, but before death, there’s a lot to be done,” he likes to say.
He manages medications to control symptoms like pain, nausea, breathlessness, but he also helps manage peoples’ fears about dying, and make choices about what treatments they’re willing -– and not willing -– to undergo. In rural Humboldt County, in the far northern reaches of California, he’s essentially the only doctor in a 120-mile stretch that does what he does.
“There’s very little sophisticated understanding for the kinds of skills that really matter for people at the very end,” he says.
The plane glides over the quiet Hoopa Valley, blanketed with trees and mist, and touches down on a narrow landing strip. A loose horse runs next to the plane as we taxi down the runway.
Fratkin is here to make a rare house call. He met Paul James -– his family calls him Pop -– and his wife, Cessie Abbott, at the hospital in Eureka where he’s on staff. But the four-hour round-trip is too much for them to make. So Fratkin came to them.
“You made it,” Paul says, as he struggles to sit up on the living room couch.
“I made it,” Fratkin replies.
It’s a visit Cessie, in particular, has been waiting for. She and her husband know he’s dying. But it’s hard for them to talk to each other about it.
“Dr. Fratkin has kind of been my angel to me, because he gets Pop to open up, where he don’t open up to me,” she says. “Then I get to hear how he feels when he doesn’t let me know, because he’s trying to be strong for us, I think.”
Fratkin sits on the coffee table across from Paul for the consultation. Cessie sits in a chair at the end of the couch. She tells Dr. Fratkin that the pain in Paul’s belly has been getting worse.
“He’s moaning in his sleep now,” she says.
“Have you ever taken morphine tablets?” Fratkin asks, raising his voice so Paul can hear. “Have you ever taken methodone?”
Fratkin breezes through the medical portion of the consult. He’s most interested in talking to Paul about his emotional experience, the human experience. Fratkin firmly believes there should be a spiritual component of these conversations.
“Yeah, Paul, there’s more to you than this body of yours, isn’t there?” he says, a refrain he repeats with almost all of his patients.
“Oh yeah,” says Paul, then goes quiet. He’s a full-blooded Yurok, and talks about how happy he is when he’s in the mountains, hunting with his grandsons.
Cessie says she can hear him praying when he’s alone in the bathroom.
So Fratkin asks Paul to light some Indian root and say a prayer now. After a few more requests, Paul agrees.
“Great spirit, that created this earth,” he begins, his eyes clenched shut.
By the time Fratkin leaves the Hoopa Valley, he’s spent half a day with one patient. This is something the hospital in Eureka just can’t afford for him to do.
Fratkin says he’s under constant pressure to see patient after patient to meet the hospital’s billing quotas.
“It’s very hard for one doctor to manage the complexity of each individual patient and to crank it out in any way that generates productive revenue,” he says.
Fratkin’s convinced he can’t do the kind of work he wants to do within the health care system. He feels overworked and underappreciated. So he quit.
Instead, he’s going to launch a start-up.
“I had to sort out an out-of-the-box solution,” he says.
He calls his new company ResolutionCare. There will be no office, no clinic. He wants to save money on rent and upkeep and put those resources into hiring a team of people who can do home visits. When time is stretched, he plans to use video conferencing – or telemedicine – to consult with patients, from a provider’s laptop to the patient’s home computer.
Telemedicine is a rarity in palliative medicine and end-of-life care, says Robert Moore, chief medical officer for Partnership HealthPlan of California, a managed care plan for Medi-Cal, the state’s insurance plan for the poor, which covers nearly 30 percent of people who live in Humboldt County.
“There’s a vast underuse of telemedicine in general,” Moore says.
Studies are mixed on how receptive older patients are to telemedicine. Some patients are put off by the screens or challenged by the technology, others simply forget that it’s there.
Moore says Fratkin might run into trouble getting paid for home visits or video conferencing. Medicare and Medi-Cal only pay for face-to-face visits. Insurance plans that do reimburse for these services don’t reimburse very well.
That’s why Fratkin has cooked up a multi-tiered business plan to finance the venture. He’s cultivating private donors and is looking for foundation grants. He’s arranged an independent contract to sell his services back to the hospital he’s leaving. And, the requisite piece of any new start-up, he launched a crowdfunding campaign to back training he’d like to do for other palliative medicine doctors who practice in rural areas.
With only a week to go before the fundraising campaign closes, it has stalled at less than 50 percent of the $100,000 goal.
Down the line, Fratkin is even thinking of asking some of his more well-off patients to pay out-of-pocket for his services.
“Yeah, yeah, I think I would,” says Mary Maloney, a retired nurse who is dying of esophageal cancer. She tried radiation and chemo for a while, but both made her feel awful –- she had terrible abdominal pain, nausea, and esophageal spasms. Dr. Fratkin was the one who told her it was okay to stop treatment.
“I mean, I love life. I don’t want to let it go,” Maloney says from the recliner in her home in Blue Lake. “But I don’t know if I’m willing enough to put myself through all the things I’d have to put myself through. Because it just makes you so sick.”
Instead, she’s been reading to her granddaughters and taking her dog to compete in the agility trials.
“These last months, almost a year, I’ve had such an amazing trip,” she says. “It’s been great.”
Fratkin says he’s cared for more than a thousand people in Humboldt County at the end of their lives. He admits not everyone likes his approach. Some find him off-putting or abrupt.
“I wish I could say my batting average was a thousand,” he says. “But there are some people who aren’t welcoming of a clear and direct acknowledgement of the seriousness of terminal illness.”
But there are people like Cessie Abbott and Paul James and Mary Maloney who love him. Fratkin hopes enough satisfied patients will step forward to help get the start-up off the ground.