Sunday, October 26, 2014

Governors Mandate Ebola Quarantine

Who says that bipartisanship is dead?  Just recently, Governors Cuomo and Christie – a Democrat and a Republican – were shoulder to shoulder as they announced a new and improved Ebola policy to protect their voters,  I mean citizens.  Now, every individual who was arriving at Newark and Kennedy International Airports from Liberia, Guinea and Sierra Leone who had direct contact with an Ebola patient, would face a mandatory 21 day quarantine. 

This policy exceeds restrictions advocated by the Center for Disease Control and Doctors Without Borders, two organizations who presumably are better qualified in infection control than politicians are.
Might this policy discourage our health experts from traveling to West Africa to help to control the Ebola epidemic as they would face a 3 week quarantine upon their return home?

Might some folks who are returning home who don’t agree with this new policy lie about their Ebola contacts?

What if travelers returning home from West Africa didn’t touch down in New York or Newark?  Don't the other 48 states deserve to be safe?

Does this policy seem more political than medical?

Future CDC Director?

Future NIH Director?

Maybe the governors’ new edict doesn’t go far enough?  I'm surprised they did not consider the following scenarios.
  • If an Ebola patient in Sierra Leone sends an email to a New Yorker, should the American be required to take his temperature twice a day?
  • If a Rutgers University student looks up Ebola information on an iPad, and used the touch screen without two sets of surgical gloves, should the student be quarantined and the iPad confiscated?
  • If a Manhattan commuter enters a cab driven by a Liberian…
Why stop at Ebola?  Why not force returning passengers who have been exposed to influenza, which unlike Ebola, is extremely contagious via air, to be quarantined?   

There is a reason that politicians should not make health care policy.  Let them do what it is that they do best – saying and doing anything to get elected.  Will other governors now compete to establish the strictest guidelines?   

Scientists are testing an Ebola vaccine. We pray for their success.  I hope that the NIH is working on a vaccine against hysteria.  I know two politicians who need it desperately.  

Sunday, October 19, 2014

Ebola Virus Outbreak Goes Viral!

While I haven’t devoted significant space on this blog to the news media, it is not because I do not have strong opinions on the current state of journalism.  Indeed, I could write an entire blog on the subject, and many have.

News acquisition and analysis have always been important facets of my adult life.  I spend many hours every week reading various newspapers and other materials to gain new perspectives on the issues of the day.  Nearly every morning, I send items of interest to a close circle of friends and family.  I read news and opinion, although sometimes it’s hard to tell one from the other.  I am always drawn to opinions that differ from my own. While there is excellent journalism today, the profession is deeply flawed by a blow-dried approach that appeals to our tabloid lust and their desire for increased ratings. 

Just because it’s above the fold on Page 1, doesn’t mean it truly deserves this prime real estate.  Pick up your own newspaper and see what the leading articles are.  It’s likely to be some local crime outbreak, while news that really matters is either a small item pages later, or may not appear at all.

TV News - If It Bleeds, It Leads!

Turn on CNN.   Set your stopwatch to measure how many minutes it will take before the bright banner of BREAKING NEWS flashes across the screen.  All that’s left is for Wolf Blitzer to announce:

BREAKING NEWS! 
 HERE’S A COMMERCIAL THAT YOU CAN'T MISS!!

How has the media performed with the Ebola issue?  Poorly, in my judgment.  First, the coverage has been absolutely suffocating on major TV stations and has been on Page 1 of newspapers for days now.  Is this an important issue?  Of course.  Are there public health ramifications?  Definitely.  Has the media heightened public fear beyond the science?  Without question.

When the media, particularly television, sinks their fangs into an issue, they will feed upon it until either the ratings start to ebb or some new fresh meat draws them away.  Remember how CNN covered the Malaysian airplane disappearance?  

While Ebola is clearly newsworthy, the number of infections and fatalities that have occurred here in the U.S. can be counted on one hand, with a few fingers to spare.  My point is that the coverage has been disproportionate to other issues that have been sidelined, as the media routinely does.
  • 30,000 Americans will die of flu this year
  • 11,000 expected U.S. deaths by firearms this year.
  • About 100 U.S. highway fatalities daily with a yearly estimate of 30,000 victims
Where’s the proportionality?   While every life is sacred, why are big stories buried and much smaller ones sensationalized?   Last night, I came home and declared that my domicile would be an Ebola-free zone for the evening.   This meant there would be no TV news for us.  I feared that even turning on a random TV channel could violate my edict as Ebola coverage is omnipresent.  To make sure that we were in compliance, we pursued a safe entertainment alternative.  Netflix!

Ebola, a deadly virus, has gone viral in the press.  The media, as always, perpetuates journalistic contagion.  Maybe they should be quarantined?

Sunday, October 12, 2014

Is Hepatitis C Treatment Cost-effective?

One catch phrase in health care reform is cost-effectiveness.  To paraphrase, this label means that a medical treatment is worth the price.  For example, influenza vaccine, or ‘flu shot’, is effective in reducing the risk of influenza infection.  If the price of each vaccine were $1,000, it would still be medically effective, but it would no longer be cost-effective considering that over 100 million Americans need the vaccine.  Society could not bear this cost as it would drain too many resources from other worthy health endeavors.  Economists argue as to which price point determines cost-effectiveness for specific medical treatments.  As you might expect, insurance companies and pharmaceutical companies might reach different conclusions when the each perform a cost-benefit analysis. 

Remember, it’s not just cost we’re focusing on here, but also effectiveness.  If a medicine is dirt cheap, but it doesn’t work, it’s not cost-effective.  Get it?

Pharmaceutical companies who are launching extremely expensive medicines often boast about the medical benefits while they ignore the cost factor entirely.  We see this phenomenon regularly when the pharm reps come to our office or we are listening to a paid speaker.

Understandably, when expensive medical care is being paid for by a third party, patients and their families are not considering cost-effectiveness.  They are focused on their own health and welfare.  If the doctor advises that our mom needs chemo, we’re not wondering if the cost would be a fair allocation of societal resources. 

A new hepatitis C (HCV) drug, Sovaldi, has recently been launched.  The 12 week course of treatment costs $84,000, or $1,000 a pill.  This bargain doesn’t include the costs of other drugs that are taken with Sovaldi as part of the treatment program.   The cost of curing HCV, a worthy objective, approaches $200,000 including the costs of medicines, physician services and laboratory and radiology testing.  Assuming that there are over 3 million Americans who are infected with HCV, the costs for curing them all approaches $300 billion.   That’s billion with a ‘B’.

Electron Micrograph of HCV

Consider these facts before deciding if hepatitis C treatment is cost-effective.
  • Most patients with HCV feel well.
  • Most patients with HCV are not aware that they are infected.
  • The majority of patients with HCV will not develop cirrhosis or other serious complications of the disease.
  • Many HCV patients who are ‘cured’ of the virus would never have developed any health issues.  They were silently infected.
Here’s what’s needed.
  • Identifying HCV patients who are destined to develop severe complications.
  • Proof that treating these patients changes the course of their disease.
  • HCV treatment that is cost-effective.
TV or print ads about HCV treatment suggest that you ‘talk with your doctor to see if the drug is right for you’,   When you do so, ask for the evidence that the treatment will allow you to live longer or live better.  Clearing your body of HCV sounds like a triumph and is marketed as such, but this might not change your life at all.

Information is power.  I wish there was some way this post could go viral.



Sunday, October 5, 2014

Why I Won't Refill Your Prescription

Giving prescription refills is not quite as fun as it used to be.  Years ago, we doctors would whip out our prescription pads – often sooner than we should have – and we’d scribble some coded language that pharmacists were trained to decipher.  I’m surprised there were not more errors owing to doctors’ horrendous penmanship.  On occasion, the Food and Drug Administration (FDA) would require a pharmaceutical company to change the name of a drug so it wouldn’t be confused with another medicine with a similar name.   The name of the heartburn drug Losec was too similar to congestive heart failure drug Lasix, so the former drug name was changed to the familiar Prilosec. 

Pharmacists Used the Rosetta Stone to Decode Prescriptions

Nowadays, we physicians refill medicines with point and click techniques within our electronic medical record (EMR) system.  When this works, it’s a breeze.  Three clicks and the refill has been transmitted to the patient’s pharmacy. Alerts notify the physician of any potential drug interactions with a patient’s other medicines.   A record of all prescriptions and refills becomes a part of the EMR system for all time.

Often, the drug interaction alerts are too sensitive.  More than once, an alert has appeared warning me that if I hit the ‘prescribe’ button, that my patient will suffer the same fate as did the Wicked Witch of the West when Dorothy doused her with water.  When I can’t verify this doomsday scenario using old fashioned techniques, I call the pharmacist directly who may reassure me that the drug is safe to use.  So, I prescribe the drug knowing that my EMR system will document that I have been duly warned and have chosen to cavalierly override the admonition.  Guess which profession likes this EMR function?

Patients contact us nearly every day for prescription refills.  Of course, we beg them to do so when they are in the office, but life doesn’t work this way and I understand this.   Here are some instances when I will not refill the requested medicine.

  • One of my partner’s patients calls after hours for a refill on narcotics
  • A patient wants a refill beyond my expertise.  I won’t be refilling your cardiac medicines as this should be done by the prescribing physician for several self-evident reasons.
  • I haven’t seen the patient recently.

It is a common scenario for a patient whom I have not seen for a year or two to request a refill on their GERD or heartburn medicine.  When this occurs, I politely request that the patient see me in the office first.   The patient may not grasp any urgency as he is feeling well and only wants another year’s worth of acid-busting pills.  However, the moment I refill it, I am in effect accepting responsibility for this action and any resultant consequences.  Here are some pitfalls with refilling a patient’s heartburn medicine who has been AWOL.
  • Does this specific drug still make sense?
  • Can the dosage be lowered?
  • Have any new symptoms developed that might require diagnostic investigation?  Suppose the patient has been losing weight, for example?  What if the ‘hearturn’ has worsened and a new disease is responsible?
  • Is the patient experiencing side-effects from the medicine that he or his primary care physician might not appreciate?
  • Could the heartburn medicine interfere with new drugs that the patient is now taking?
  • Is the patient up to date on other issues within a gastroenterologist’s responsibility such as colon cancer screening?

Refilling routine medicines may not be routine and should be done with care and caution.   The patient from 2 years back who has GERD might think he needs Nexium for his 'heartburn'.  What if his symptom is actually angina?  Get my point?


So, when we ask you to stop in for a brief visit, it’s not because we delight in hassling you or are hungry for your copay.  We’re trying to protect you and to keep you well.   Doesn’t this seem like the right prescription?

Sunday, September 28, 2014

Which Medical Specialty Should Medical Students Choose?

A medical student recently asked my advice on her decision to pursue a career in dermatology.  It was about 25 years ago when my own parents encouraged me to pursue this specialty.   What was their deal?  Perhaps, they anticipated future developments in the field and were hoping for free Botox treatments?   As readers know, I rejected the rarefied world of pustules and itchy skin rashes for the glamor of hemorrhoids, diarrhea and vomit. 

My parents were making a lifestyle recommendation.     Dermatologists are doctors who sleep through the night.  Spying one in a hospital is a rarer sighting than spotting a liberal Democrat at a Michelle Bachmann rally (unless a planted heckler).  Nocturnal acne medical emergencies are uncommon.   And anyone who has had cosmetic work done understands painfully that this is a cash business.

Diagram of Skin
Luckily, the Whistleblower is thick-skinned

Here’s where some readers or Dermophiles will accuse me of skin envy.  Not true.  Some dermatologists may be a tad thin-skinned over this assertion, but facts are facts.  These docs have a soft lifestyle and earn much more money than most physicians do.   Sure, these guys and gals see some serious stuff, but the nature of their specialty is less intense and frenetic than that of other colleagues.  

Many professions push back when it is suggested that they are afforded unique and soft perks that most of us don’t have.  Teachers, for example, never state out loud that having every Federal holiday off, enjoying school vacations every few months and having 10 weeks off in the summer are unbelievable soft padding that no one else has.  We know you work hard under difficult circumstances and we respect you and your profession.  But just admit that you have some unbelievable professional cushions.  This won’t diminish your self-worth or contributions to society. 

Many medical interns and residents don’t consider lifestyle when they are making their career choice, and they should.  Obstetrics is thrilling when you are 30 years old.  Fifteen years later when you are overworked, tired and have your own kids, it may be slightly less thrilling to bring new life into this peaceful world in the middle of the night on a regular basis. 

For me, leaving my own bed at an ungodly hour to haul out to the hospital is an unwelcome activity.  I do not relish being awakened with phone calls or having to attend to an individual in the emergency room when the rest of Cleveland is soundly snoring.   While gastroenterology is a more taxing specialty than the skin gig, it is still uncommon for me to have leave for the hospital during the black of night.   Since we are in the era of medical hospitalists who are on staff around the clock, there is only a rare need for me to make a personal appearance.   On most nights, my scope rests securely in its holster. 

Do I think that medical students should consider lifestyle as they are contemplating their future?   Absolutely.   Indeed, the emerging culture of the medical profession has morphed from the prior culture when doctors worked 24/7 and interns were proudly on-call every other night.   Medical doctors today are increasingly employed by institutions, work shifts and delegate the hassles of hospital life to hospitalists. Doctors are self-prescribing R & R.  

Leisure, relaxation, avocations and personal time for reflection are not evil pursuits.  They are the fuel that cultivates and sustains our humanity.   Who wouldn’t welcome a little more humanity in the medical profession?



Sunday, September 21, 2014

Medical Complications Torture Doctors Too

If you are a physician like me who performs procedures, then rarely you will cause a medical complication.  This is a reality of medical life.  If perforation of the colon with colonoscopy occurs at a rate of 1 in 1500, and you do 3000 colonoscopies each year, then you can do the math.

Remember that a complication is a blameless event, in contrast to a negligent act when the physician is culpable.  These days, for many reasons, an actual complication is confused or misconstrued as an error.
Some complications are more difficult on physicians than others.  For example, if I prescribe a medication and the patient develops a severe rash, I do not feel personally responsible.  It’s the drug’s fault.  However, when I perforate someone’s colon as a medical complication, I feel responsible even if this act was a blameless event which will occur at a very low but finite rate.  (Of course, there are perforations of the colon which result from medical negligence, but I am leaving these aside to make my point here.)  

I Didn't Cause This Rash.  The Drug Did It!

I feel responsible because my hand was on the instrument that caused harm.   I can’t as easily blame the scope, as I blamed the rash-causing drug.   I’m sure that surgeons feel the same painful emotions when they perform a routine operation and serious bleeding results that requires additional surgery and complicates what should have been an uneventful recovery.

When your hand is on the colonoscope or the scalpel, and the unexpected happens, it’s an awful experience for the doctor even if we have performed according to proper medical standards.
Of course, serious medical complications are much more difficult for the patients and families involved than they are for us.  But, we physicians suffer greatly when a patient is harmed from a procedure that we recommend and perform.    You can imagine how we torture ourselves with second-guessing when these events occur.

Complications are inevitable.  The only gastroenterologist who hasn’t had a perforation of the colon is one who is brand new.   So, if you are drawn to a gastroenterologist because he has a 0% perforation rate, caveat emptor!   Paradoxically, the most experienced colonoscopists have accumulated many more complications over their career because of a much higher volume of cases or that they are referred very challenging cases by virtue of their skill and experience. 

A medical complication is an especially difficult event when it occurs in what was expected to be a routine outpatient examination.   Patients who come to our office for a screening colonoscopy understandably expect to be home 2 hours later.  So do we.  On those rare occasions, when this recovery path is altered, we must have a very serious, sober and unexpected conversation with the patient and the family.  Our plan is always to tell the truth and reassure all involved that we will do all that we can to make it right. 

Medicine is not a simple or predictable endeavor.  Sometimes, it can be rather complicated.

Sunday, September 14, 2014

Should You Trust Your Doctor's Advice?

Is your doctor a hammer and you're a nail?  Here's some insider's advice coaxing patients to be more wary and skeptical of medical advice.  Should you trust your doctor?  Absolutely.  But you need to serve as a spirited advocate for your own health or bring one with you.  Ask your physician for the evidence.  Sometimes, his medical advice may result more from judgement and experience as there may not be available medical evidence to guide him.  Make sure you have realistic expectations of the medical out me.  And most importantly, try as best you can to verify that the proposed solution is targeted to your problem.

Is Your Doctor a Hammer?

Consider a few hypothetical scenarios.

A 66-year-old patient has chronic right lower back pain.  Physical therapy has not been helpful.  Radiological studies show a moderate amount of hip arthritis.  A hip replacement is flawlessly performed.  The orthopedist discharges the patient from his practice.  The pain is unchanged.

A 60-year-old patient has chest pains that are not typical for angina.  Her internist arranges a stress test and the results are equivocal.  A cardiologist performs a cardiac catheterization and a moderate narrowing is found in an artery.  A stent is successfully placed in the proper location.  The patient is reassured that her cardiac pipes are all wide open.  She returns to see him a month later wondering why the pains have continued.

A 50-year-old patient sees his gastroenterologist for stomach pain.  An ultrasound confirms the presence of gallstones.  The patient accepts the specialists advice to have his gallbladder removed.  The operation proceeds smoothly.  You can guess the rest.

This is not meant to serve as an indictment of the medical profession.  The examples above have been highly simplified to make a point.  First, making accurate diagnoses are complex undertakings that can frustrate even seasoned diagnosticians.  Patients' medical histories are often vague and evolving.  Many diseases and conditions have clever mimics that can lead doctors astray.  Every doctor can regale you with anecdotes detailing episodes when they have been fooled.  There isn't a medical doctor alive who hasn't fumbled over a case of chest pain. 

Just because medical advice doesn't lead to the desired outcome, doesn't mean that the advice was wrong.   I concede, of course, that bad medical advice can cause adverse outcomes, a self-evident statement. 

Despite the vagaries and uncertainties in the medical arena, physicians try as best we can to propose a remedy that is directed to your symptom, rather than serve as a fix for something that is not ailing you.  My advice to patients is that when your doctor is raising the healing hammer, is to try not to get nailed. 

Make sure this inquiry is in your tool box.  "Doctor, can you please explain why the treatment will cure the symptom that brought me to you in the first place?

Maybe a hammer is the right tool for you.  Without doubt, the time to have this conversation is in advance of pulling the treatment trigger. Having realistic expectations can prevent future frustration when a treatment doesn't bring you to the end zone. 

So, next time your physician proposes a plan of action, hammer away.




  

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