Sunday, December 10, 2017

Reducing the Federal Deficit - A Monumental Approach

This past week President Trump reversed protection for millions of acres in two national monuments in Utah.  Bears Ears National Monument and Grand Staircase Escalante will be halved as a result of the major surgery just performed by the Chief Executive.  These moves will likely result in job security for scores of environmental lawyers.

Teddy Roosevelt is growling in his grave.

As expected, there were howls from the left, most of whom have probably never visited the sites.  How many people are against opening up the Arctic National Wildlife Refuge for drilling who have never been to Alaska?  Keep in mind that the folks who actually live in Utah, and the legislators who represent them, argue that they should have control over their own lands.  Shouldn’t they have the right to determine the fate of their own state and to resist federal encroachment?   Should the feds compensate states for the economic losses that they suffer when lands are deemed to be federal monuments? When do the feds have the right to ‘trump’ states’ rights?

I was shocked to learn that the vast majority of Utah land is controlled by the feds. 

Imagine the reaction if the location that Amazon chooses for its 2nd headquarters were suddenly designated as national monument.  Do you think that state would welcome this federal intrusion?  More likely, would be rioters with pitchforks in the street.


Let's cash in from Old Faithful at Yellowstone Nat'l Park!

Now I admit, I am uncomfortable opening up monuments to development and energy exploration.  Parks and monuments are finite and I fear inexorable mission creep if we have a permissive stance in reducing their size.  But I admit, that my misgivings do not constitute a legal argument.  Keep in mind that Utah is not forced to develop these newly released lands.  If they wish to keep them unmolested, they are free to do so.

Perhaps, we should be looking to generate revenue from governmental protected sites?  This could amass cash that could be used for social programs, conservation efforts or even to provide Americans with tax relief.

As a pilot program, I suggest that the Bright Angel and South Kaibab Trails that descend to the base of the Grand Canyon be monetized.   At each mile marker, hungry and thirsty hikers would encounter Starbucks, Five Guys, a Home Depot Annex, Verizon Customer Service, a Lemonade and Smoothie Stand, Sushi Bar, an Army Recruiting Station, FedEx and Whole Foods.   Of course, these goods and services would not in any way detract from the hiking adventure.  If a visitor does not wish to engage in a commercial transaction, then he can simply walk on by.   But, should we deprive a hiker who wants to satisfy an urge for a Frappacino?

This strategy truly gets airborne when it is applied to all of our national parks and monuments.  If Teddy Roosevelt knew of this plan, would he call out ‘Bully!’ or just ‘Bull’!?

Sunday, December 3, 2017

Does Patient Autonomy Improve Health?

It used to be that doctors knew best.  We told you what to do and you obediently complied.  The world has changed and the paternalistic system of yore has given way to the shared decision model where patient autonomy is respected.  

The Old Way:  “Well, I’ll be setting you up for surgery soon.”

The New & Improved Way: “Let’s discuss all of the reasonable options with their respective advantages and drawbacks.  Then, you make the call.”

To paraphrase the mantra of Fox News:  Doctors Report – You decide!

Has our current fidelity to patient autonomy improved medical outcomes?  I have no idea.  It has certainly changed patient’s (and our) experience, but I do not know if it has improved patients’ health.   I wonder if doctors and patients who have experienced both systems believe that the current system have improved medical outcomes.


Has anyone measured if the new system is better?

Not every patient wants this level of authority.  I cannot count how often patients have asked me over the years to make the medical decision for them – which I do.  There is an argument that the professional is better equipped to make the right medical choice; but the question is who has the right to make that choice. 

My point is not for us to return to our prior paternalistic pattern, but only to pause and consider if patients have benefited under current norms as much as many believe.

I am certain that attorneys and various consultants can relate to this issue very well.  Lawyers today, for example, generally don’t dictate an edict, but present clients with a range of options depending upon cost, risk and tolerance of legal exposure and the facts.

Why not extrapolate to the next level?   Let the patient make any medical choice he desires despite our medical misgivings.  If a patient, for example, wants a colonoscopy, antibiotics, a heart catheterization or removal of the gallbladder – and they are fully informed of the risks and benefits – why should medical professionals obstruct them?  Doesn’t the patient come first?   

Isn't this how the marketplace works?  Customers buy what they want, not necessarily what they need.   Should I be prevented from buying a premium vacuum cleaner if my current one is adequate?  If I want a contractor to do some remodeling which makes no aesthetic or functional sense, should he turn the job down?  

Yes, you might argue that medical care is different than buying an appliance.   But, if we doctors can refuse an informed patient's request, then aren't we returning to the Era of Paternalism that we claim to have abandoned?





Sunday, November 26, 2017

Thanksgiving 2017




The nation pauses to give thanks for health and family and freedom.  As during any holiday or celebration, some of us are in the valley or have been there.  There is always a way forward, even if the pathway is obscured. 


We gather together.

The First Thanksgiving


We converse amiably.

'I'll kill you!'


We dine.

Blessed with bounty...



We talk turkey.

Pardon me?


Saturday, November 18, 2017

When Electronic Medical Records Crash

The computerized era has introduced all of us to a genre of errors that never existed during the archaic pen and paper era.   The paper medical chart I used during most of my career never ‘crashed’.  Now, when our electronic medical records (EMR) freezes, malfunctions, or simply goes on strike, our office is paralyzed.  Although I appear to the patients as a breathing and willing medical practitioner, I might as well be a storefront mannequin who appears lifelike, but cannot function.  We cannot access the patients’ records, write a prescription or enter a new office visit. 


Mannequins appear lifelife but don't function well.


Of course, like any business who faces this crisis, we expect instantaneous rescue from our IT professionals, as if we are their only client and they are permanently stationed in our waiting room just waiting for us to sound the alarm.

This is among one of the most frustrating aspects of EMR for medical professionals.   We simply don’t have the time or psychic reserve to absorb unexpected loss of computer service.  We are not playing computer games (although sometimes it feels as if we are.)  We have a live patient facing us as we face a blank screen.  It is frustrating and awkward.   The patients understand this reality as they undoubtedly have endured similar frustrations in their own lives.  

Yes, we resort to writing a note in longhand and scanning it into the EMR later, but this is problematic.  First, a scanned document cannot be ‘read’ by our EMR as this document is not ‘part of the EMR family’.  It can’t be tracked, as we do routinely with laboratory and x-ray data.  More importantly, I will be offering medical advice without any access to the prior medical record, which may span years.  If the patient has a complex, chronic condition with a history of extensive testing and medication changes, moving blindly could lead me into a blind alley or through a trap door.

I propose no solution to all of this.  No technological system can perform perfectly.  It’s another example of our ever increasing reliance and dependency on technology – more than we really need, in my view.  I have no choice but to accept EMR in my professional life.  But, there are opportunities when we can stand up and push technology back.

Do we really need Alexa to turn on our lights?

Sunday, November 12, 2017

Why Curbside Consults are Dangerous

One of the skills and stresses about being a doctor, is giving advice to or about patients we have never seen.  If readers think these are rare events, it happens nearly every day.  Often during weekend or evening hours when I am on call, my partners’ patients will call with questions on their condition or about their medications.  Radiology departments contact me during off hours with abnormal CAT scan results of patients I do not know.  Or, a doctor may call me during the day for some informal advice about one of his patients.  These physician-to-physician inquiries are called ‘curbside consults’, which are appropriate for simple questions that do not require a formal face to face consultations.

Physicians must be cautious when providing a curbside opinion on a patient he has not seen as even informal advice could result in legal exposure if the patient later files a medical malpractice claim.  Consider this hypothetical example.

An internist contacts a gastroenterologist for a curbside opinion on an elderly patient who had some mild rectal bleeding.  The internist suspects hemorrhoids and doesn’t want to refer the patient for a colonoscopy as the patient had one 3 years ago at which time hemorrhoids were discovered.  The gastroenterologist reassures the physician that the bleeding is probably from hemorrhoids, which is a very rationale conjecture.  But, it may be wrong.  The bleeding now may be from a colon cancer that was either missed on the last colonoscopy or has developed since.  The cancer won’t be discovered for another year.  Is the 'curbside' gastroenterologist responsible here?

I think so because, even though he hasn’t seen the patient, he has rendered medical advice directed toward a specific patient, rather than simply offer generic comments.  Indeed, the internist may have told the patient and his family that the 'curbside' gastroenterologist agreed that no testing was necessary.  Had the gastroenterologist pushed back against the internist and insisted on arranging for a colonoscopy or seeing the patient in the office, then the outcome may have been different.

Had I been asked for a curbside opinion regarding above inquiry, I would have been much more circumspect with my response, and ideally, I would have entered a chart note in my electronic medical records.  Memories of physicians and patients can fade over time.  I would feel more secure if my chart note recorded that I recommended that the patient be sent to me for an office consultation.

Some questions should never be answered ‘from the curb’.  I would not, for example, give informal advice to an internist about changing his patient’s medications for Crohn’s disease.

If I have any discomfort in responding to an inquiry on the phone, then I recommend an office visit when I can provide a thoughtful and informed opinion. 

Some inquiries are so innocuous that I respond readily even without entering a chart note.  These generic questions do not directly connect me to an actual patient.  To clarify, I will list a few examples.

What’s the proper schedule for the hepatitis B vaccine?
Is the generic for Nexium equally effective?
Are ulcers caused by stress?

There’s a skill set physicians need when we are advising strangers.  Sometimes, the skill is knowing when to remain silent or when to push back.  If you're not careful, it's easy to trip over the curb.

Sunday, November 5, 2017

Polypharmacy in the Elderly: Who's Responsible?

There's a common affliction that's rampant in my practice, but it's not a gastrointestinal condition.  It's called polypharmacy, and it refers to patients who are receiving a pile of prescription and other medications.  I see this daily in the office and in the hospital.   It's common enough to see patients who are receiving 10 or more medications, usually from 3 or 4 medical specialists. 

Of course, every doctor feels that he is prescribing only what is truly necessary.  If an individual has an internist, a cardiologist, a gastroenterologist, a urologist and a dermatologist which is not unusual - and each prescribes only 2 or 3 essential medicines, then polypharmacy is created.  Each day, the patient swallows a chemistry set.

First of all, I don't know how these patients, who are often elderly, manage the logistics of taking various medicines throughout the day and evening, before meals, after meals and at bedtime.  Who can keep track of this?  Nurses in the hospital can barely manage this overwhelming schedule.  This has to negatively affect one's quality of life as the daily calendar of events is predominantly pill popping events.  

Keep in mind that the drugs we doctors prescribe are not that smart.  Does the Nexium I prescribe to hundreds of patients only act on just the right amount of stomach acid to relieve the patient's reflux?  Doesn't the drug reach every organ of the body having potentially deleterious effects that we might not be aware of?  Could Nexium be interacting with other medicines in an unfavorable manner?  While we are quick to demonize stomach acid as an enemy of mankind, isn't the acid that Nexium is reducing there for a reason?  Are we smarter than a few million years of natural selection?

I'm betting on Darwin's theory.

Extrapolate the Nexium example above to a situation when 10 or 12 drugs are cruising throughout the body on a Fantastic Voyage journey, colliding with each other and smashing into organs far away from the drugs' intended targets.  

We also function in a culture where every symptom demands a pharmaceutical response.  While depression, hyperactivity and insomnia are real illnesses, can anyone dispute that the medical community is over prescribing medicines for these conditions?

I wonder how many folks who are suffering from unexplained nausea, balance issues, confusion, dizziness, falls, bowel disturbances and abdominal pain are actually getting a taste of their own medicine.   When they present these symptoms to their doctor, they may end up with yet another prescription thrown onto the pile, when the solution is to diminish the pile which is causing side-effects.

Challenge your internist and your specialists to verify that every drug is truly needed. Insist on the lowest dose that will accomplish the mission.  Are the doctors on your team communicating adequately with each other?  Is someone in charge? 

In my experience, the biggest risk factor for polypharmacy is polydoctor.   More medicines and more physicians aren't better medicine.  Primum non nocere, first do no harm, still deserves to be the mantra of the medical profession.  In medicine, less is more.  On your next visit, ask your doctor to please do less for you. 

Sunday, October 29, 2017

Patient Navigators Climb Your Mountain of Medical Bills

To accomplish certain tasks, we need a little help from our friends.  No one can do it all, although many of us are more resourceful than others.  Some folks are adventurous and dive into a new arena with excitement.  They may be tinkerers who aren’t afraid to play with new gadgets.  Sure, they might break some china, but they are apt to widen their skill set and enrich their lives.  Others, eschew this dive bomb approach and prefer to wade cautiously into new experiences.  Their comfort zones are narrower.  They never break the china, but their personal growth is likely more stultified. 

For some activities, we should simply call upon the professionals straight away.  Here are some examples of jobs that we should pay others to do for us.
  • Cut down a huge dead tree on our front yard.         
  • Replace damaged roof shingles.
  • Investigate why smoke is seeping out of the hood of our car.
  • Prepare our last will and testament from www.DIEWITHCASH.com or some similar website.

I realize that not everyone may agree with my examples above.  Many folks, for example, would have no hesitation to scamper up to the roof with a tool belt strapped on to do some reshingling.  Have at it.  If you ever spot a man on my roof, trust me, it’s not me.

If a job needs this tool, then keep your fingers and hire a pro.

There are some activities that we pay others to do, but we shouldn’t have to.  It’s not our fault.  Certain systems are so complex and byzantine that a normal individual simply isn’t equipped.  Why should most of us have to pay someone to figure out how much we owe the government in taxes?  I realize that this absurdity is employment security for the accounting and legal professions, but it indicates to me that the system is broken.  The system should be simple enough that we can calculate our obligations ourselves.

Similarly, shouldn’t understanding and paying medical bills be a simple process, similar to paying all of our other bills?  When I receive a plumber’s bill, leaving aside that his hourly rate might be higher than mine, I can easily understand the itemized services and how the total charge was calculated.  Not so with medical bills.  I’m a practicing physician and I cannot reliably understand my own medical bills. Medical bills occupy a unique universe, which is not governed by reason or logic.  I will assume that every reader has had similar experiences.

We need a modern day Rosetta Stone to decipher our encrypted medical bills.  Of course, we can always call our insurance company directly, which is guaranteed to be as relaxing and fun as undergoing a rigid sigmoidoscopy.  Also, don’t you love the musical phrase, “please listen carefully as our options have changed”?

Enter the new profession of Patient Navigators, an emerging occupation that helps the confused citizenry understand their medical bills.  We all know of many patients who have stacks of bills awaiting payment from physicians, hospitals, radiologists, pathologists, laboratories, emergency rooms, etc.,that would overwhelm the most rugged among us.  Grappling with medical billing is to tread onto a treacherous pool of quicksand with no bottom. Leaving aside the Herculean task of sorting through the morass, there is an inhumanity to expect sick or recovering patients to be forced into this maze of madness.

The existence and growth of the Patient Navigator profession is Exhibit A that medical billing needs to be reformed.  With all of the nonsensical ‘reforms’ that have been forced onto the medical profession, Obamacare missed a target that was overripe for real reform. 





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