Sunday, February 19, 2017

Do Judges Legislate from the Bench? What's Your Ruling?

Judge Neil Gorsuch, President Trump’s nominee to fill a vacant seat on the Supreme Court of the United States, will face a contentious vetting process in the U.S. Senate.  I expect the sausage-making process to be an opportunity for political grandstanding where bombastic bloviators will spew forth partisan pabulum.  Look for a senator, for example, to point out that the judge did not clean up after his dog when he was in the 7th grade.  “If we can’t trust you to clean up after Sparky, then how can we trust you to mind the Constitution?”

We read and hear about the scourge of judicial activism (JA), where judges invent laws rather than interpret existing law, as they are charged to do.  The antidote to judicial activism is judicial restraint (JR), when judges exercise modesty and base their rulings on the intent of the framers or on the words in the statute.  If, for example, the statute does not specify that “the puppies shall be saved”, then it is not for the judge, who may be a dog lover, to take on canine rescue as a ‘pet project’.

Let me define JA and JR more clearly for readers who do not wallow in the judicial universe.

Judicial Activism: A ruling that is disliked by various individuals and interests.
Judicial Restraint: A ruling that is celebrated by various individuals and interests.

If a judge rules for your cause, then he or she is a titan on the bench.  If however, you did not receive your desired judicial outcome, then the judge is an activist hack who is legislating from the bench.  I am generalizing, of course, but you get the point. 


A Den of Activism?

How has the judicial branch been performing?  A lot better than the other two branches, in my view.  Here’s some rough polling data.

      Approval Rating
Trump                            38%  (2017)
Congress                        28% ((2017 –  Surging -up 9 points in 1 month!)
Supreme Court             42% (2016)

Let’s not read more into this than the numbers merit.   Negative poll numbers do not mean that an individual or an institution is not performing well.  It simply means that the public is dissatisfied.  If Congress, for example, passes a law eliminating the deductibility of home mortgages, which may be a sound public policy measure, don’t look for an upward spike in poll numbers.

Hopefully, this blog, at least from time to time, polls well with readers.  What’s your ruling?  Of course, if I don’t like it, I will merely label you as an Activist Reader!

Sunday, February 12, 2017

Communication Between Doctors and Patients - Words Matter

Here’s a quote that readers will not readily recognize.

It is a pity that a doctor is precluded by his profession from being able sometimes to say what he really thinks.

I’ll share the origin of the quote at the post’s conclusion.  How’s that for a teaser?  I'll give you a hint below.

Author of the Quote as a Young Child

Physicians by training and experience are guarded with our words.  To begin, we are never entirely sure of anything, and we should make sure that we do not convey certainty when none exists.  This is why physicians rarely use phrases such as, I’m positive that..., I’m 100% sure…, there are no side-effects…

Because of the uncertainties of the medical universe, sometimes we sanitize our own concerns when we are advising patients and their families.  We may see an individual in the office with unexplained weight loss and a change in her bowel pattern.  While we may fear that a malignancy is lurking, we would be wise to keep our own counsel on this impression pending further study.  This patient, for example, may be suffering from a curable thyroid disorder. 

Words matter.  We all have heard how patients and families can dwell on one or two words uttered by a physician, who may have spoken at some length on a patient’s condition.  In these cases, the families may have inferred more serious news than the physician intended.  Doctors need to be mindful of this phenomenon when we are communicating.  Which of these messages would you prefer to receive on your voice mail?

“Please make an appointment to review your biopsy results.”

“Your biopsy results are benign.  Please make an appointment so we can discuss them further.”

On other occasions, physicians may opt to leave out certain words or suspicions.  Why unload anxiety on folks before the truth is known?  Additionally, not every patient wants the whole truth administered in a single dose.  These scenarios demonstrate the advantage that a physician has when he has an established rapport and relationship with his patient. 

Conversely, I don’t feel we are helping patients and their loved ones when we overly sanitize the medical situation in order to postpone an unpleasant physician task or to create hope that may not be realistic.  There’s a balance to be attempted, and I still struggle to achieve it. 

The quote that started this post was published 90 years ago, not by a doctor or a nurse.  I stumbled upon it when reading The Murder of Roger Ackroyd, one of the greatest works by the master of mystery, Dame Agatha Christie.


Sunday, February 5, 2017

Should Patients Order Their Own Lab Tests?

Knowledge is power.  Increasingly, patients are demanding and receiving access to levers in the medical machine that would have been unthinkable a generation ago.  I have already opined on this blog whether the informed consent process, which I support, can overwhelm ordinary patients and families with conflicting and bewildering options.  Television and the airwaves routinely advertise prescription drugs directly to the public.  Consider the strategy of direct-to-consumer drug marketing when millions of dollars are spent advertising a drug that viewers are not permitted to purchase themselves.  The public can now with a few clicks on a laptop, research individual physicians and hospitals to compare them to competitors.  The ‘Sunshine Act’, an Obamacare feature, publicizes payments to physicians and hospitals by pharmaceutical companies and other manufacturers.


"Sunlight is said to be the best disinfectant"
Every physician today has the experience of patients coming to the office presenting their internet search on their symptoms for the doctor’s consideration. “Yes, Mrs. Johnson, although it is true that malaria can cause an upset stomach, I just don’t think this should be our first priority.”
There are now laws that permit patients to order their own lab tests such as cholesterol or glucose.  Even registered nurses working in intensive care units are not permitted to order these tests without a physician's authorization.  Ordering diagnostic tests and medical treatments has always been under the purview of a physician or highly trained medical professionals.  Who interprets the results?  The patient?  The lab tech who drew the blood? The cashier at the retail health clinic?  A policeman?  A hospital custodian?
I had an office visit with my own physician to discuss how best to manage my own cholesterol level.  While this discussion did not have the drama of cardiac bypass surgery, it took time to consider the risks and benefits of various options along with my personal and family risk of cardiac disease.  My point is that even two medical professionals had to navigate through an issue that had more complexity than one might think.  Understanding the significance of a lab result takes nuance and medical judgment.
Patients already purchase all varieties of heartburn medicines over-the-counter, that years ago were out of reach.  Should we permit patients to buy antibiotics, blood pressure medicines, ‘statins’ for elevated cholesterol and anti-depressants? Why not?
Think of all the money the system would save.  A depressed individual, for example, doesn’t have to waste time and money with a psychiatrist.  He already knows he’s depressed. He can proceed directly to the Mood Aisle of the local drug store and get the pills he needs.  Wouldn’t it be easier and cheaper if patients could just buy antibiotics themselves for those pesky colds and flus?  No office visit or time off work for a doctor appointment. The fact that antibiotics don’t combat colds and other viruses never seemed to deter their use. 
Eventually, patients can order their own colonoscopies, stress tests, cardiac catheterizations and gallbladder removals.  Perhaps, we will see the creation of AmazonMEDPRIME.  Feeling a little chest tightness?  Just click the app, and the Cardiac Cath Mobile will be at your door in 30 minutes or less.    


Sunday, January 29, 2017

Probiotics Promote Digestive Health - Is There a Germ of Truth

Several times each week, I am asked about the value of probiotics.  Many of my patients are already on them, based on a personal recommendation or an advertisement.  As a gastroenterologist, I routinely treat patients with all varieties of diarrhea conditions, such as irritable bowel disease, ulcerative colitis, Crohn’s disease, lactose intolerance, celiac disease and the highly feared gluten sensitivity.  Many of them arrive in the office with a probiotic in hand waiting for me to pass judgment.  These patients look to me as a Digestive Supreme Court Justice as they sit on the edge of their chairs waiting for my ruling in the case of Probiotics vs Disease.  

First, let’s all be clear on what a probiotic is.  Probiotics are bacteria that provide health benefits when consumed.   Stop a moment and consider how bizarre this concept is.  Physicians have been fighting germs since the days of Louis Pasteur.  We have taught the public for generations how important personal hygiene is.  We are counseled not to eat under-cooked food from fear of contracting a food borne illness.  Every hospital in the country is stressing hand washing to all personnel to protect patients from infection.  Many of us won’t leave the house without a hand sanitizer bottle. 

In other words, germs are bad – unless they are probiotics!  In the latter case, billions of germs are deliberately ingested in order to relieve symptoms and treat diseases – an ironic shift in classic germ-fighting medical practice. 

Germs - Friend or Foe?

Are Our Intestines Germ-free?

Hardly. Our intestines are filled with zillions of bacteria.  Miraculously, during health these germs are not able to penetrate through the walls of intestines to reach internal organs which would cause a severe infection.  These strains of bacteria within the bowel all live together in balance providing health benefits to us.  They aid in digestion and immunity.  Some of these germs create vitamin K, which we use to maintain a healthy clotting system.  

When this bacterial neighborhood, which is called the intestinal biome, is disrupted, then disease can set in. For example, when we take antibiotics to attack ‘bad germs’, such as for a pneumonia or a urinary tract infection, the antibiotic also upsets the ‘good bacteria’ within our intestines.  In addition, many digestive diseases have an intestinal biome that is out of balance.   When the biome isn’t balanced, then the whole body is under a strain.

How Do Probiotics Work?

Here’s the theory in simplified form.  When the community of beneficial germs within our bowels is disrupted from antibiotics or disease, probiotics can get the biome back into balance.  Scientists are not entirely sure how this happens, but probiotic research is in high gear to understand how they work and who should receive them.  The theory is that bringing the biome back to its normal state restores health and relieves symptoms. 

What do I tell my patients with digestive conditions regarding probiotics?  I tell them the truth.  The supportive science is rather thin, but many of my patients feel better on a probiotic program.  We don’t know precisely which probiotic works best for a specific patient or disease, or how often to dose them.  Importantly, we believe that they are safe, but I would be very reluctant to recommend them to someone with compromised immunity.

If you have digestive symptoms and are contemplating a probiotic, here are 3 steps to consider.
  • Open the jar.
  • Open your mouth.
  • Open your mind to the belief that these germs can heal you.




Sunday, January 22, 2017

Repeal and Replace Obamacare - STAT!

Am I referring to Obamacare here or Obama himself?

I am glad that we have a new president.  Like most of the country, I was ripe for a change of direction and a new approach to foreign and domestic affairs – and we are certainly getting that.  New readers here might erroneously suspect that I voted for Trump.  I didn’t.  For the first time in my presidential voting history, I wrote in my choice for our top two office holders.

I have written multiple posts on my unfavorable views of Obamacare since it was jammed through congress without a single Republican vote.  (Do I sound slightly partisan here?)  Interested readers are invited to peruse posts on this blog within the Health Care Reform Quality category, if you dare.

There are two kinds of people who oppose Obamacare
  • Folks who believe it is wrong on policy grounds
  • Folks who wield it as a political cudgel to bash Obama.
Some opponents are a hybrid of both of the above.

I was also suspicious that the Affordable Care Act (ACA) was always an interim step preceding a full nationalization of our health care system.  Obama is on the record favoring such a policy during his 2008 campaign.  If Obama could have achieved this politically in one step, he would have.  The ACA represented the political upper limit that he could achieve, hoping that this would make a full would bring us within reach of a government takeover.   Some conspiratorial skeptics believe that the ACA was designed deliberately to fail so that private insurance companies would have to abandon it – as they have.  Then, the beneficient government would have to step in to rescue Americans who needed medical coverage STAT!  While I offer no opinion on this wild charge, there were many smart people who averred when the ACA was delivered to us, that the numbers would never add up. And they didn't.


Derailing the Obamacare Runaway Train

It is my belief that government is simply not equipped to assume control of the entire health care system and operate it at the highest level of quality possible, while controlling costs.  Remember how smoothly the healthcare.gov web site release was?  Do you think this would have happened if Google, or Facebook was in charge?  Which company do you have a higher opinion of in terms of quality and efficiency, the Bureau of Motor Vehicles or Amazon?  If folks want to have a government insurance plan like Medicare, I am fine with this.  But, give us access also to the free market.  I like choice because competition breeds excellence.  When FedEx came onto the scene, it forced the U.S. Postal Sevice to really step up, which they have. 

And, we all know that the plan’s proponents were somewhat less than truthful.  Feel free to GOOGLE Jonathan Gruber to become reacquainted with his 2014 comments which make reference to stupid American voters and other niceties.  How long did it take the Obamians to admit that the statement, “If you like your doctor, you can keep your doctor”, was known to be false from the outset?

Let’s face it.  The ACA promised us quality and cost control and in my view it has failed on both counts.  I do congratulate the president here, as I have previously, for taking on the challenge of health care reform.  Republicans over several presidential administrations failed to seriously confront this challenge.  And the plan does cover more Americans, which we all agree is a necessary goal.  But, the collateral damage of this achievement warrants a new direction, admitting that it may not be possible to uproot the entire tree.    

The replace part is going to be tougher than the repeal part.  Will the GOP take a lesson from their adversaries and jam it through without a single Democrat vote?

Sunday, January 15, 2017

Insurance Company Helps Patients Who Don't Speak English

When I was a kid, it was fun to get mail.  Now, not so much.  My mailbox at home is a receptacle for junk mail, various solicitations for services I will never need, and bills.  Office mail is not much more fun.  Each day I look through the stack and separate them into 3 categories.
  • Important stuff
  • Garbagio
  • Not sure

The latter category is the most vexing.  Some stuff is cleverly designed to appear important when, in reality it is drivel and nonsense.  We’ve all seen this stuff.  Sometimes, the envelope will include a teaser label, such as ‘Time Sensitive Material’, or ‘Signature Required’.   Once I have been duped to open up the envelope, I’ve lost the game.  Then, I am forced to scan the printed page as fast as my retinas can process the image with the hope that in a few nanoseconds I can send the page sailing into the waste bin.  Sometimes, however, even after reading the entire page, I simply can’t determine if the document merits calling an office meeting to discuss the contents or if it should be simply burned, with the ashes scattered over Lake Erie in a solemn ceremony.  One must choose wisely when facing these conundrums.  If a document is shredded instead of scanned into a patient’s chart, the potential consequences are simply too grisly for me to detail here on a blog that children can access.

I received a notification from a pharmaceutical company indicating that the heartburn medicine I prescribed so casually to an elderly patient was not the ‘preferred agent’.  These was a form letter which demonstrated the same level of warmth and human emotion that one expects when you call the Internal Revenue Service for assistance.  But, there was a 2nd page in the envelope, appears below.  Kindly note that I was able to technically reproduce the image here without the assistance of a 13-year-old child. 


This letter, sent to the patient, advises that customer service agents at WellCare are available to discuss the issue with the patient.  I am not certain if my patient intends to contact them, but my own experience is that making these phone calls is about as fun as undergoing oral surgery.  But, what struck me was all of the languages contained in the letter, many of which I could not recognize.  At the bottom of the letter is a Yiddish translation.  Yes, Yiddish.  Yes, the moribund language that many of our grandparents spoke.  I can’t speak it or read it, but I can recognize it.  Obviously, WellCare must include so many Yiddish speakers that they need to include this language in their correspondences.  My guess is that not a single Yiddish speaker is a WellCare customer.

Maybe, I am wrong and that Yiddish is roaring back.  Kudos to the linquists at WellCare for providing their customers with this essential service.  I may politely suggest that they include hieroglyphics on future mailings.  Why should these folks be left out?

So, was this letter worth saving?  Probably not, but I just couldn’t part with it. 


Sunday, January 8, 2017

Is Informed Consent Overrated?

Physicians now practice in the era of patient autonomy.  Most agree that the era of medical paternalism should not be resurrected.  During those days, doctors simply told patients what to do, and patients complied.  The informed consent process then was a shadow of what it should have been.  In general, physicians did not proffer medical options and alternatives for patients to ponder over.  They were told, ‘you need a hysterectomy’.
Sometimes, I think we physicians today have over-corrected for past arrogance.  Yes, I believe in informing patients, but I often wonder if many patients today really only want us to tell them which path they should pursue.  Even the most informed patients are not medical professionals who can grasp every medical nuance or ramification of a decision.  It can be vexing for them to choose among different medical options that are presented to them in an effort to meet our obligation to apprise patients of all reasonable treatment alternatives. 
Consider this scenario.
"You can proceed with surgery to treat your condition or try a new medication instead. The medication has risks and if doesn’t work, you can certainly have surgery.  Keep in mind that if surgery is delayed while you are trying the medication, it is less likely to be effective.  Additionally, the medical center downtown is doing experimental treatment for your condition.  Finally, some experts advise against any treatment, advocating watchful waiting instead.  What is your decision?" 
Not an easy labyrinth for a normal patient to navigate through.
Such a presentation is often followed by a patient asking, ‘what do you think I should do?’


What should I do?
I’m not advocating depriving patients of information they are entitled to in order to make rational health decisions.  I believe in informed consent and have written many essays supporting it on this blog and elsewhere.  However, I often believe that this process overwhelms patients and their families with competing choices that torture and confuse them.  As a statement of fact, many patients today are only seeking our best recommendation, even though physicians today go much further in an effort to meet our ethical obligation and to protect against a medical malpractice charge.  

I am very interested in what readers think on this issue.  Inform me, please.

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