Sunday, November 22, 2015

Is E-mailing with Patients a Good Idea?

Physicians speak with patients every day on the phone for a variety of reasons.   Our practice now uses a portal system, giving patients access to some of their medical data and to us.  Although I was resistant to having e-mail communications with patients, I have come to appreciate the advantages.

  • It relieves our ever congested phone lines
  • It relieves patients from a state of suspended animation as they hope and pray that a living breathing human being will return to the line after being placed on hold
  • It saves our staff time who no longer have to triage calls as the patient directly reaches the doctor

While this streamlined cyber communication system is useful, it does have limitations.  It can’t solve every problem.  Indeed, some issues are not appropriate for either a phone call or an e-mail.

Calling his doctor?

Consider the following scenarios.  Which can be appropriately handled on the phone and which merit a face to face encounter with a physician?

  • I was in the emergency room yesterday and they told me to call you for pain medicine.
  • My diverticulitis is acting up and I need an antibiotic.
  • My breathing is worse.  I think it’s a side-effect of the new heart medicine I started last week.
  • What can I take for constipation?
  • My cousin had the same symptoms and it ended of being her gallbladder.  Can you give me the name of a surgeon?
  • I’m dizzy and my hemorrhoids have been bleeding for a week.  What can I take?
  • I have hepatitis C.  Is is okay if my grandchildren visit?
  • I had some chest pain yesterday when I was shoveling snow.  Should I double my Nexium?

The practice of  medicine is not fully wireless, at least not yet.  Sure, e-mail is convenient for everyone, but if used too casually it can become quicksand.  Often, the patient feels an e-mail is sufficient, but the physician may not be comfortable, depending upon the medical facts and how well the doctor knows this patient.  When you are face to face with your doctor, the medical history will be more detailed, there may be a physical examination, and there will be a dialogue and review of treatment options.  It’s a lot easier for us to assess your pain, for example, when you are in front of us.  Moreover, when you return to see us for a follow-up visit, we have a baseline to use as a comparison.

What are your thoughts on all this?   Feel free to e-mail me, but I’d prefer if you came to see me
face to face.

Sunday, November 15, 2015

Gadzooks! There's Gluten in my Cheerios!

Gluten is in the news again.  Gluten and probiotics are among the two dietary issues that most consume my patients.  I am asked for my opinion on them several times each week.  Although my opinion is solicited, these patients have largely already made up their own minds as they are often avoiding gluten and swallowing zillions of ‘good bacteria’ with zeal and enthusiasm.

Why do they do this in the absence of corroborating medical evidence?  Why do millions of voters support Donald Trump’s mantra that he will ‘make America great again’?  Both of these groups do so on faith.  When our need to believe something is overpowering, our demand for proof recedes.  Many of us need to believe that gluten is the agent responsible for our vague medical complaints that have stymied our doctors.  Similarly, our frustration with so many aspects of our society and conventional candidates makes us believe that Trump will turn the nation into yellow brick roads leading to Emerald Cities everywhere.

Wheat Attacks General Mills

I take care of patients with true celiac disease who need to avoid gluten.  Most of my gluten-avoiding customers are not celiacs, but feel better on their self-prescribed diet.  When these folks see me and relate their clinical improvement, I support their decision.  Why do I do so after I just mocked the gluten-free zealots?
  • Just because there is no medical evidence, doesn’t mean it’s not true.
  • There is scientific basis of true ‘gluten intolerance’ in folks who do not have celiac disease.
  • Never talk a patient out of anything that seems to be helping him. 
Recently, General Mills recalled nearly 2 million boxes of gluten-free Cheerios and Honey Nut Cheerios, because these boxes were contaminated with wheat, which contains gluten.  The company voluntarily and properly undertook this recall.  If a product is represented to be ‘gluten-free’, then it should be.   Folks who have life threatening allergies to peanuts, for example, depend upon true labeling for their very lives.  However, not every manufacturing goof will result in such a dire risk for consumers. Yet, the Cheerios recall is labeled a Class 1 recall which means that there is a reasonable probability that it will cause serious health consequences or death.  Give me a break.  The phrasing states will cause, not even may cause.  Gluten is not botulism.   If a celiac patients ingests some gluten by error – which every one of them does throughout their lives – they live to see another day.  This FDA’s Class 1 designation is over-the-top hyperbole of the first order, if you will forgive my redundancy.  We would expect a Class 1 recall to be invoked for a faulty pacemaker, for example. 

Who makes up these definitions?  Obviously, the FDA wasn’t thinking clearly when they did so.   They were probably on a sugar high after wolfing down too many bowls of Fruit Loops.  

Sunday, November 8, 2015

How to Increase Medical School Enrollment

Lawyers and physicians have so much in common, despite some benign grievances that occasionally reach the level of homicidal rage.  Just kidding.  Calm down, juris doctors.  Consider the similarities.  Both professions serve a public who needs help.  Both wield professional advice and judgment that must be tailored to an individual’s unique circumstances.  Neither professional is ever 100% certain of anything, and an outcome cannot be guaranteed.  Both are charged to put their clients' and patients' interests above their own.  (Snickering permitted here.)
Let's see what our legal brethren are up to.  Law schools in America are having a serious problem that they are struggling to remedy.   They need more students.  Of course, they could fill their classrooms by recruiting qualified candidates to apply to their institutions.  This strategy apparently couldn't fill the seats, assuming that it was even considered.  So, here is their plan, brilliant in its simplicity.  I will state it here in boldface italic type.
Lower admission standards!
Dozens of law schools are deliberately lowering admission standards to increase their class sizes, as reported by The New York Times.  Of course, these students will face a high bar of passing the bar, assuming that they make it to graduation.  Apparently, generating highly qualified legal professionals is not the objective. The true objective appears below.

The Objective
My blog's readers are among the sharpest in the blogosphere.  Let me post some queries, which I hope will stimulate some insightful responses.
  • You don’t think law schools are accepting unqualified applicants just for the money, do you?
  • Will the exorbitant debt they will incur benefit them and society?
  • When these struggling students fail the bar exam, have they still enjoyed a valuable life experience?
  • Should we support lowering the admission standards to conform to the emerging norm that excellence is overrated and every competitor should go home with a trophy?
  • Should we encourage this process as society desperately needs more lawyers, particularly underqualified professionals?
What's next?  Lowering the passing rate for the bar exam?

Maybe there's a lesson here for the medical profession.  We all hear that many areas of the country are medically underserved.  Surely, there is some way we can recruit more doctors?

Any ideas?

Sunday, November 1, 2015

When Should a Doctor Lose His License?

This afternoon, as I write this, a professional football player was ejected from a game for committing the transgression of unnecessary roughness.  This infraction should be taken seriously in a game where violence is not only legal, but desirable.  I’ll leave it to the reader to imagine how unnecessary the roughness was if it resulted in an ejection. 

It is self-evident to any thinking person that the human body is not designed to withstand the punishment of this game.  Keep in mind that most of us are only seeing the actual games, and not the hundreds of hours of brutal practicing.  I take care of an octogenarian who played for the Cleveland Browns decades ago.  While this profession lifted him out of a Pennsylvania steel town, it is challenging for him to identify a part of his body that is working properly.   The National Football League (NFL), which showed us all last year how they fumbled their domestic violence issues, has belated admitted what most first graders would readily recognize.  Getting smashed in the head hundreds of times per season over many years is not good for the human brain. One must wonder about engaging in an activity that requires a helmet and body armor for protection.

Legalized violence

There are rules to govern this mayhem, and sometimes a player is kicked out.

Are errant physicians kicked out of the medical profession?  Yes, it does happen, but these are rare events.  Some have argued that there is a ‘white coat wall of silence’ that protects physicians who need to be sanctioned or sidelined.  A few times a year, I receive a list of Ohio physicians who have been disciplined by the State Medical Board of Ohio.  Most of these offenses involve personal substance abuse.  ‘Pill mill’ doctors are also targeted.  Physicians who engaged in improper and inappropriate behavior with patients are on the list, as they should be.

Losing a medical license is the most serious professional sanction that a physician can receive.  Such a penalty should be implemented only for a egregious act, or a pattern of wrongdoing, provided that the physician has been afforded due process. 

When do readers think that a doctor should be tanked?  I’ll offer a few hypothetical scenarios below.  Let me know if the physician is salvageable or should be cut loose.
  • A gastroenterologist misses a diagnosis of colon cancer three years in a row.
  • A surgeon refuses to repair a patient’s hernia because the patient has no insurance and cannot afford the operation.
  • A physician is a recovering alcoholic and is now found guilty of a DUI.
  • A review of a psychiatrist’s medical records confirm that 10 patients committed suicide in the past 36 months.
  • An internist is found guilty of domestic violence.  No drugs or alcohol are involved.
  • An investigative reporter discovers that an orthopedist was paid $250,000 last year to promote a medical device to colleagues across the country, and never disclosed this relationship.
  • A physician is discovered to be double billing Medicare over the past year.
  • A physician persists in asking one of his patients to date him.
Do these offenses merit surrendering a license?  Would this be unnecessary roughness?  

Sunday, October 25, 2015

Hear Ye, Hear Ye, Probiotics Cure All!

A probiotic rep came to our office bearing lunch and billions of bacteria.  Who on their staff, I queried, counts the bacteria verifying that each packet has 3 billion disease-busting germs?  I suspect that these quantities are only estimates and that consumers may be unwittingly subjected to either an inadequate dosage or a toxic amount.   Caveat emptor!

I surmise that plaintiff law firms are hiring germ counting experts hoping to establish with clear and convincing evidence that the product's label is false and misleading.  Soon, we can expect to see TV commercials when we will hear an authoritative announcer asks, "If you or someone you love took probiotics and developed fatigue, joint pains, weight loss, weight gain, nightmares, daydreaming, lack of energy, excess energy, loss of a sense of humor, extreme frivolity, lackluster performance reviews at work, basement flooding or any other adverse life outcome, then you may be entitled to compensation.  Call 1=800 GETCASH.  Operators are ready to speak with you in 9 languages.   

After the announcer states his message, scary music plays and we see black and white footage of suffering zombies.

Probiotics, unlike conventional prescription drugs, are not subjected to Food and Drug Administration (FDA) approval.  Hence, the germ guru who brought deep fried food to our office is free to discuss all possible uses of the agent despite the absence of any scientific basis underlying his claims.  Drug reps detailing prescription medicines do not enjoy a similar level of free speech.  In fact, they are securely gagged and are prohibited from discussing off label use of their products, even if we ask them about it.  If these guys and gals stray off message, not only will they be summarily terminated, but their companies may be heavily fined, as many have learned.

Drug Reps Cuffed by the FDA

Does this make sense?  Prescription drug reps, whose products have been rigorously tested and are used off label routinely, can't even whisper or use hand signals to communicate important but unofficial information to doctors.  In contrast, a purveyor of probiotics, whose products are unregulated and unproven, can sing like a canary extolling the benefits of billions of germs that we're told can fight all kinds of illness, foreign and domestic.

I've always felt that the FDA is too strict in restricting the content of conversations between drug reps and doctors.  This is an overreaction from pharmaceutical industry abuses with aggressive marketing of off label use to physicians.  As a result of this hyper response, physicians are deprived of an important information resource from reps whom have a very deep knowledge of a narrow subject.  Who wins here?

Who needs prescription drugs anyway, now that I know that probiotics are the panaceas that can cure all.   

Sunday, October 18, 2015

The Daraprim Debacle - The Smell Test Sniffs Out Price Gouging.

You don’t need to be an ear, nose & throat doctor to be conversant with the ‘smell test’.   We use this technique in everyday life.  This diagnostic test is used to determine if a situation is an egregious deviation from established norms.  The beauty of the smell test is that one need not be encumbered by facts and data.  It relies upon emotion and instinct, which greatly simplifies its use.  Let me illstrate.

Situation When Smell Test Does Not Apply

  • Grading the SAT Examination.  Sniffing and smelling just won’t work here.

Situation When Smell Test Applies
  • A city mayor hires his brother in a no-bid contract as a consultant. 

Are you catching on here?

The Mother of All Smell Testers

I surmise that my erudite and insightful readers would sniff deeply through flared nostrils if they confronted the following situations.
  • “A double dip ice cream cone, which yesterday cost $4.25 is now $57.85.  A severe shortage of sugar cones developed last night.”
  • “The Sunday New York Times is now priced at $82.  Middle East turmoil has caused the price of newsprint to skyrocket!”
  • “Your overnight Fed Ex envelope will cost $325.  We haven’t had a price increase in 4 months and will use this revenue to serve you better.”
  • “Yes, I can reschedule your airline ticket with a keystroke for only $150.”
  • “Call this number and I will send you absolutely free my fool proof system to make millions in real estate without any money or experience!”
  • “One fat-burning pill a day will melt the pounds away without changing your diet or exercising!”

 No explanation, even when delivered by an authoritative  PR pro can make the bad smell go away.

Recently, Turing Pharmaceuticals acquired the drug Daraprim, which is used to combat toxoplasmosis, a potent parasite.   The new company decided that a slight price adjustment was necessary.  So, the price per pill was increased from $13.50 to $750.  No typo here.  Feel free to use your preferred search engine to seek out the company’s explanation for their mega-gouging.  While I always try to remain open to opposing views, can any explanation exist that would justify this increase?

This is an example of corporate excess that will boomerang right back to strike the perpetrator.  Wanton greed and arrogance will surely provoke anger and bring a hammer of reform crashing down.  Ask your doctor.  Physicians understand what happens when a profession refuses to heal itself. 

Sunday, October 11, 2015

Is More Gun Control the Right Prescription?

Guns are in the news again.  Here are some incontrovertible facts.
  • Mass murders committed by young males have become a new phenomenon in American life.
  • Individuals who should not be permitted to own a firearm can legally purchase one.
  • Many other advanced nations have much lower incidences of mass killings.
  • There is no political solution to this issue in sight.
I remain skeptical  that restricting guns will make us safer.  I doubt that further legal restrictions against buying guns would apply to criminals who by definition are law breakers.  I concede that we should consider additional barriers to keeping guns away from those who are mentally unstable.  I challenge any reader here to offer a template on how we might accomplish this.  There are tens of millions of Americans with mental illness or a history of mental disease.  What about creepy people or folks who seem angrier than they should be?  Loners? Assuming we could identify these millions of citizens, how would we use this information in the event that some of them wanted to buy a gun? Tell me how you would do this because I haven't a clue here.

Consider these facts.
  •  The vast majority of mentally ill Americans will never commit violence.
  • Medical ethics and privacy regulations do not permit identifying mentally ill people. 
  • New or existing laws would not have prevented most or all of these mass killings.
  • We have no reliable method to predict a person’s violent potential.
Even if we could eliminate these horrible paroxysms of violence – a worthy and necessary societal objective – we should realize that most of the hundreds of thousands of yearly deaths by gun are not mass murders.

Is this the enemy?

An overall reduction of violence will not be solved by incarceration or gathering up guns.  The solution that continues to evade us will be as much from economic social, and educational policies as from our legal response.  I am not ‘blaming society’ for the actions of criminals.  But, I do believe that the solution will be of societal origin. 

I know many gun owners.  I understand their passion in protecting their constitutional right to own a firearm.  They recoil when gun control advocates pose questions such as, ‘why does one person need so many guns?’  They believe that unfettered gun ownership is their right and it is not for others to limit it.  Many of us use the same argument with regard to free speech.  Ugly speech and provocative art are protected.  Haven't we heard protests against offensive art by those who argue 'why should a museum display this filth'?   

Like everyone, I am angry, vexed and ashamed.  As physicians understand, making the diagnosis is often the easy part.

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