Why Patients Avoid Colonoscopies - A Plea to Choose Wisely.

                                                            

Exercising good judgement can mean the difference between life or death.  Life can be unforgiving of the choices me make.  As we all know, many life events are beyond our control and understanding.  But, there is much we can do to shape our personal paths to a brighter destination.

Consider some of the choices listed below that many folks make every day.  Are any of them familiar to you?

• Texting while driving.
• Riding a motorcycle.
• Riding a motorcycle without a helmet.
• Lifting an object that we know is too heavy for us.
• Getting into a car when the driver has had one too many.
• Driving a car when we have had one too many.
• Giving your social security number to a caller who is promising you a tax refund.
• Responding to an email from Nigeria alerting you to a wad of cash waiting for you.
• Using your date of birth as your password for your on-line bank accounts.
• Rushing through a yellow light so we won’t be late for a movie.
• Eating street food in a foreign country that appears undercooked.
• Skipping a ‘flu shot’ and other recommended vaccines.
• Getting chest pain for the first time after shoveling snow and decided it was just heartburn.

Get the point?

All of the above activities can end tragically depending upon the choices we make.  But, they can easily end well for us.  Every day, we confront forks in the road when we must make choices.  Sometimes, we choose the wrong road.  Sometimes, we make no choice at all.  The point here is that we have a choice. 

A Velocycle - Safer than a Motorcycle

I see this issue in my gastroenterology practice.  I’ve done about 30,000 colonoscopies in my career, a number so large, that I can barely believe it myself.  Fortunately, the results of nearly all of them are normal or show benign findings.  Telling a patient and their family that all is well after the procedure is a pleasure that hasn’t changed over the years.

But, not every colonoscopy result is innocent.  As you might imagine, I have confronted a lot of colon cancer in my career.  When I discover one, I am aware that life for that person and his loved ones is about change profoundly.  Life changes in an instant.

While colon cancer affects the patient and his family most deeply, it’s a heavy day for the gastroenterologist also.  We are human beings.  What makes the day even darker for us is when the patient had faced a fork in the road, but made the wrong choice.  Consider the following examples which I have seen repeatedly in my practice.

• A patient turns 50 but chooses not to have a colonoscopy, against the advice of his doctor.
• A patient has rectal bleeding and ignores it.
• A patient was told of hemorrhoids years ago.  Rectal bleeding develops and he assumes that his hemorrhoids are active again.  He does not consult his physician.
• A patient’s bowel changes, but he decides that this must be a side-effect of new medication.
• A patient has a large colon polyp removed by his gastroenterologist.  He is advised to return in a year for another colonoscopy, but he does not do so.  He is too busy.

Colon cancer, unlike so many other cancers, is a preventable disease.  I am not suggesting that modern medicine can prevent every case of colon cancer.  It can’t.  I am stating that the majority of colon cancers that I have discovered were in people who did not choose wisely when they should have.  They ignored.  They denied.  They delayed. 

Time after time, I have seen intelligent people who have had rectal bleeding for months before they decided to see me. 

Every expert will attest that the earlier colon cancer is diagnosed, the better the prognosis will be.  But more importantly, timely colonoscopy can prevent the disease altogether.

I haven’t made perfect choices at every fork in the road that I’ve faced.  But, when I turned 50, I did the right thing.

We can’t control everything.  But, there is much that we can control.  For example, you have chosen to read this post.  How you decide to use it is your choice. 

                                                                                        

Charity Encourages Generous Donations - New Standard for the Industry?

This really happened.  The vignette I present now occurred 3 days before its posting on this site.  My good friend Bill invited me to a fundraising dinner to support a Jewish organization.  I declined the invitation, but told Bill that I would be pleased to make a donation to support a cause that was important to him.  I connected to the website which led visitors quickly to the Donate page.  Charitable enterprises want to make it as easy as possible for you express your generosity and separate you from your funds.  Haven’t you noticed that every museum visit leads to the gift shop? 

I quickly filled in the credit card information and then scrolled down and typed $50 in the Customized Donation window.  This box allowed donors to designate their own amount, bypassing the default listed uber high dollar amounts that appeared higher up on the page.  The entire process expended about 3 minutes and ended when I clicked on the Donate Now button.   It’s the same process that we all use to purchase items on line.

Immediately, I received an e-mail receipt, which I opened for no clear reason as I generally ignore these notifications.  At first glance, I noted a donation amount of $18,000 which, of course, was incorrect.  On closer inspection, as my pulse rate quickened, this is exactly what the receipt claimed was transacted. Most likely, I thought I must be suffering from some transient blurry vision from over-caffeination, a previously unknown complication. But, squinting failed to change the number.  I did not panic, because I am a medical professional, who is steeled to maintain my equipoise when unexpected turbulence confronts me.  This is when seasoned pros must let their training and muscle  memory kick in.  In other words, I panicked.  

At least they thanked me!

I called Visa, whom I regarded as culpable, or at least guilty of contributory negligence, by facilitating this fraudulent transaction.  After exposure to the highly personalized menu tree, and hitting the zero on the phone repeatedly until my index finger was nearly calloused, a human-sounding voice emerged that claimed to be emanating from an actual human.  I was grateful to have discovered an escape from the menu tree, a labyrinth that can keep clients and customers trapped for months or longer.  Most of these lost souls go mad simply from being forced to hear, ‘Please listen carefully as our options have changed’, at high volume and without pause.  Visa-man advised me that I had no recourse available with them; I needed to take it up with the charity.

A few nanoseconds later, I phoned the charity and immediately was greeted by a voice mail.  When would I hear back?  What if the call came while I was doing a colonoscopy?  Should I answer anyway?  (I was leaning 'yes' on this.) What if the religious charity didn’t consider my donation as a human error, but as a divine stroke for which I would be rewarded in the hereafter?  Would I risk selling my soul for a mere $18,000? (I was scared to lean yes on this one.)

In less time than it seemed, a rabbi called and promptly and courteously returned me to the status quo ante.  He made me whole.  How did this escapade happen?  He explained that the Donate page was defaulted to donate 18 grand, and unless this box is unchecked by the donor, this will be the amount transferred.   I congratulated the rabbi on having such an effective donation process, and he assured me with a laugh, that he would attend to the glitch. 

We have all clicked on the wrong box or sent a text message to an unintended recipient, which can result in amusing or serious consequences.   In this case, my ‘error’ wasn’t one of commission, but of omission.  I failed to ‘opt out’.

Physicians, at least honest ones, can relate to this anecdote.  In the electronic medical era, how many of us have placed an order on the wrong patient?  Wouldn’t it be a shame if a doctor ordered a colonoscopy on Bill by mistake?

Why Smart Doctors are not Enough

I’ve delved into the issue of medical judgment more than once on this blog.  I have argued that sound judgment is more important than medical knowledge.  If one has a knowledge deficit, assuming he is aware of this, it is easily remedied.  A judgment deficiency, per contra, is more difficult to fix.
 

For example, if a physician cannot recall if generalized itchiness can be a sign of serious liver disease, he can look this up.  If, however, a doctor is deciding if surgery for a patient is necessary, and when the operation should occur, this is not as easily determined or taught.  

Medical judgment is a murky issue and often creates controversies in patient care.  Competent physicians who are presented with the same set of medical facts may offer divergent recommendations because they judge the situation differently.  Each of their recommendations may be rationale and defensible, which can be bewildering for patients and their families.  This is one of the dangers of seeking a second opinion, as this opinion may not be superior to the first one.  Patients have a bias favoring second opinions as they pursue them because they harbor dissatisfaction, or at least skepticism, with the original medical advice.  If the second opinion differs from the original, it reinforces their belief that the first advice was inferior.  

Second Opinions Can Cause a Tug of War

Here are some scenarios which should be governed by medical judgment.

A 70-year-old woman with severe emphysema uses an oxygen tank.  She has never had a screening colonoscopy.  Professional guidelines suggest that screening begin at age 50.  Does a colonoscopy make sense for her considering her impaired health?

A 40-year-old man has had 1 week of stomach pain.  This started 10 days after he took daily ibuprofen for a sprained knee.  The physician suspects he might have an ulcer.  Should this patient undergo a scope examination to make a definite diagnosis?  Should the doctor prescribe anti-ulcer medication without determining if an ulcer is still present?  Should the ibuprofen be stopped if the patient states he has significant pain without it? 

An 80-year-old woman had some recent dizziness and nearly fainted.  The doctor sees her in the office two days later and questions her carefully.  He suspects that the patient was simply dehydrated.  Should the doctor simply reassure the patient or arrange for a neurologic evaluation to make sure that a more serious condition is lurking?  

Of course, you want your doctor to know a lot of stuff.  More importantly, you want a physician who can give you sound and sober advice.  Knowledge and scholarship are important physician attributes, but healing demands more.  At least, that’s my judgment. 

End of Life and the Medical Profession

Physicians and nurses deal with the deepest issues of the human condition – life and death.  Our profession brings new life into the world and does our best to bring comfort and peace at the journey’s end.  It is a profound and emotional experience for medical professionals to be with a patient and family when life ends.

There are other professions who routinely confront loss of life.  Law enforcement personnel, paramedics, firefighters and soldiers all are exposed to events that most of us would never wish to experience.

The medical profession and society is struggling to preserve our humanity in a 'cut & paste' world where one's worth is determined by the quantity of twitter followers.  

Hugging a child.  There's no 'app' for this.

On my very first day of medical internship in Pittsburgh, I was called by a nurse to pronounce a patient dead.   I had never seen the patient before.  The only deceased individual that I had any close contact with was the cadaver we studied in medical school.  I entered the room and did not know what I was supposed to do, never have been given any training or guidance on this responsibility.  I learned an important lesson then.  New interns know nothing.  Experienced nurses know a lot.  Ask for their help.  An arrogant intern will be permitted to sink.  The humble intern will be rescued.

This was an elderly patient from a nursing home and this outcome was anticipated.  The nurse patiently guided me through the requisite steps.  I performed this function multiple times throughout my internship and residency, but the only actual memory of these events is with that first patient on my very first day.  It imprinted upon me, much as the first day that I was introduced to the cadaver as a first year medical student in anatomy class. 

Being present with patients and families at profound moments is a privilege and a responsibility.  As we are all suffocating from dehumanizing technology in every sphere of our lives, there are experiences still that cry out for our humanity.   If you or someone you loved was facing difficult medical choices, who would you want in the room with you?  A physician, who might deliver wisdom and compassion or Alexa?

Musings on Religion

There is a confluence this weekend of holy days from two venerable monotheistic religions.  Today is Easter, which represents the anniversary of the resurrection of Jesus Christ, a foundational theological principle of Christianity.   Christians await the Second Coming, when they believe that Jesus will return to establish a world of peace and justice.

Passover, which began on Friday evening, celebrates the iconic and gripping tale, chronicled in the Book of Exodus, of the emancipation and liberation of the Jews who were enslaved under a cruel Egyptian regime.  The yearning for freedom and resistance against tyranny carefully documented in the Torah, is truly a universal template that is relevant to this very day. 

Jews Crossing the Red Sea Leaving Bondage Behind

The religions are so deeply intertwined.  While I am neither a Christian nor a scholar, I have taken some effort to study the New Testament so that I might gain some understanding of this ‘offshoot’ of my own religion.   Indeed, true scholars of Christianity teach that it is not possible to understand Christianity without having a deep understanding of Judaism.  When one considers that Jesus, his disciples, the pharisees, the priests and other figures highlighted in the New Testament were all Jews, it is obvious that understanding their birth religion is a prerequisite to understanding how and why Christianity developed and thrived. 

Consider some fascinating queries.  Did Jesus eat matzoh on the Passover?  Was the Last Supper a Passover meal?

I am not naïve and am well aware of the deep hostility that Jews have suffered from Christians both centuries ago and in recent times.   There has been a rapprochement, but the work is not finished.  And, my own house is not yet in order.    Many Jews and others are troubled by the principles and actions of the current Israeli government.  I presume these leaders, like Jews throughout the world, were at Passover meals, called Seders, this weekend, when they read about the plight of their subjugated ancestors. Did the ancient Exodus narrative offer them any perspective on current events?  In our own country, ignorance and prejudice against Islam has been used for malign purposes.

Many believe that religion has caused far more harm than good for humanity.  As we gaze around the world today, their argument is very plausible.  Where do we go from here?   Who will reach across rather than turn away?    Who will listen with an open mind and an open heart?  

Must we all wait for an apocalypse, described in Revelation, or a series of catastrophic plagues, as appeared in Exodus, for a peaceful world to emerge?   Is there anything we can do now?

Step Therapy - Pharmacy Benefit Managers are at it again!

Among the many tools that insurance companies wield to save money is a technique called ‘step therapy’.  This is a technique that exasperates patients and physicians.  Here’s how it works. 

A patients comes to his doctor with a medical issue.  The doctor, who presumably has a decent measure of medical training, experience and judgment, decides to prescribe a medication, in an effort to ameliorate the patient’s distress.  Let us call this magic elixir Pill A.  The doctor zaps this prescription to the pharmacy at the speed of light using the ever trustworthy electronic medical record.  The satisfied patient leaves with the mistaken impression that his cure is just around the corner.

Here’s where the fun begins.  Of course, the patient may receive the typical denial as Pill A is not on the formulary.  Keep in mind that an insurance company’s denial doesn’t mean the patient can’t fill the prescription.  Insurance companies would never interfere with a physician’s medical judgment.  The patient is still free to take the prescribed drug.  The fact that it costs $2,200 per month is but a trifle.   If Pill A costs a fortune and the insurance company’s alternative Pill B is cheap, then can we really argue that insurance companies are not practicing medicine?

Physicians in Asylum Driven Mad by Step Therapy

In the above example, usually Pill A and Pill B are medically equivalent, so the cheaper drug delivers the same benefit.  Sometimes, however, the doctor’s preference is medically superior.  Either way, the process burns up hundreds of hours per year for physicians and our staffs. 

Step therapy is when Pill A is denied because the doctor has not tried different types of medication first, which are not equivalent and are often inferior.  In order to get Pill A to be covered, the doctor must demonstrate that he has tried other medications first, and that they were not effective.  So, under this genius system, a patient receives drugs that cost money and likely won’t work.  After enduring this experiment, the  insurance company may ultimately cover the medicine that should have been prescribed in the first place.  Usually such approval is for a limited time guaranteeing that the physician can look forward to a sequel in the near term.  

Imagine if a patient suffered a serious side-effect from one of the step therapy drugs that the doctor knew was a waste of time.

I’ve argued on this blog on the need to reduce overutilization and to cut costs.  A fundamental premise of this blog is that less medical care can increase medical quality.  Step therapy managed to both increase costs while it cuts quality, not an easy feat.

We need to step up and step on step therapy.

Why I Fired Two Patients From My Practice

You're fired!  We've all heard this directive that was popularized by our current chief executive.

It is much more common for a patient to fire a physician than it is for a doctor to cut a patient loose.  Yet, I sent 2 of my patients termination letters in the month prior to my penning this post, which represents a firing surge on my part.  This has been a very rare event in my practice.  Since physicians are patient advocates by training and practice, we tend to extend leniencies to our patients, giving out 2^nd and 3^rd chances routinely.  But, the doctor-patient relationship is not unbreakable and both sides have responsibilities to maintain it. 

The Doctor-Patient Relationship Should be a Partnership - not a Duel.

Here are some reasons that patients have offered justifying seeking a new physician.  Keep in mind that these given reasons represent patients’ perceptions, which may not necessarily represent absolute truth.

• Poor or absent communication.
• Inattentive or rude staff.
• Unreturned phone calls.
• Habitual physician tardiness.
• Diagnostic delay or error.
• Dismissive attitude toward chronic medical complaints.
• Insurance coverage change - not a true 'firing' but a common reason to change horses.
• Suggestion that patient’s complaints stem from anxiety or depression.
• Refusal to order requested diagnostic testing.
• Rushed office visits.
• Arrogance toward complimentary and alternative medicine. 
• Unavailable timely appointments. 

Here’s why I sent two patient pink slips.

Patient 1:  I saw the patient in the office and scheduled her for diagnostic tests at our local community hospital.  This appointment time requires a commitment from me, the endoscopy department and the anesthesia personnel to be available at the appointed hour.  After the patient cancelled for the 3^rd time, we declared ‘no mas’.

Patient 2:  He is on a medication for colitis that suppresses the immune system.  This requires that he periodically check in with me for office visits and laboratory studies.  He missed his appointment and was due for his blood tests.  We called and wrote reminding him that I needed to see him.  He declined.  I wrote him a personal letter requesting that he make an appointment or I that would need to sever him from the practice.  When we didn’t hear from him, we followed through.  

It’s challenging enough to take care of sick patients who are playing by the rules.  When a patient decides to make his own rules, and can’t be coaxed back into reasonable compliance, then the doctor-patient relationship may traverse the point of no return. 

When a patient fires a doctor or a physician dismisses a patient, there is an opportunity for reflection and growth.  Just like in the business world, a person who is fired should want to know why the action was taken so that he can learn from the experience, rather than simply blame the boss.  Conversely, an experienced manager will want to understand why an employee has given notice.   

On those occasions when a patient has left my practice, I have tried to understand if I or we fell short.  Sometimes we have and we do our best to learn from the experience.