Sunday, June 26, 2016

Lebron James and Medical Ethics - Let Me Explain.

Medical ethical issues confront physicians daily.  Most of us contemplate ponderous ethical dilemmas, such as end-of-life care care, allocation of the limited supply of organs for transplant or our unequal access to health care.  Many ethical decision points are rather quotidian, not situations that would serve as content for bioethical conferences.

Here are some examples of everyday ethical issues that physicians deal with.
  • A patient asks his doctor to support a claim for disability that is not warranted.
  • A patient asks his gastroenterologist to change his constipation diagnosis after the fact so that his colonoscopy is covered more fully by the insurance company. 
  • An employee in a doctor’s office, whose own doctor is booked solid, requests an antibiotic prescription for a urinary tract infection from her physician boss.
  • A physician falsely claims to an insurance company that he has tried certain medicines on a patient in order to gain approval of a desired medication.
  • A doctor tries to limit diagnostic testing of a patient with no insurance in order to save the patient money.
This past week, I had a request from a patient under very unique circumstances.  I performed a colonoscopy on a young man this past Tuesday.  Prior to the procedure he remarked “that he needs a really big favor from me.”  Such phrasing portends an improper request.   Would he be asking for pain medicines or to sign off that he needed light duty for the rest of the week?  He wanted me to give him a medical excuse for Wednesday, the day after his procedure. 

From time to time, we have requests from patients for work excuses on the day prior to or following their procedure.  Nearly all of these requests are politely, but summarily denied 

The Curse is Broken!

Wednesday, 6/23/16, was not an ordinary day in Cleveland.  There was going to be a once in a lifetime celebration downtown for the triumphant Cleveland Cavaliers, who bested the Golden State Warriors in an epochal championship series.   Contemplate the narrative.  A poor kid from Akron is raised by a single mom under very challenging circumstances.  His talent leads him to the Cleveland Cavaliers where he brings hope to a city that has been cursed with sports failures.   He leaves Cleveland in a clumsy, arrogant and ‘cavalier’ manner for the Miami Heat where he picked up some rings.  The poster boy became a Cleveland doormat.   He returns home to keep a promise.  We lose to the Warriors last year.  Now, we win against them by a whisker in game 7.   Cleveland hasn’t had sports championship team in over half a century.  We have suffered under a curse.

Even folks like me who are not sports fanatics have been swept up into this movement.  We are so proud of our amazing team and the fans who, like Moses, had been permitted to look upon the Promised Land, but not to enter it, until now.

How should I have responded to my patient’s request?

Sunday, June 19, 2016

Appreciating the Gifts of Life

The value of anything becomes apparent when it is taken away from you.  Nothing profound here about one of life’s central truths.  It is an ongoing challenge not to take life’s gifts for granted.  I have never known hunger or lived without shelter. I have never been unemployed or suffered a serious illness. I pay my bills.  I have 5 children who enjoy excellent health and are forging pathways toward their dreams.  I love the people I work with.  I have found new love in the 6th decade of life.  And, I have ice cream every day of my life.

It would be shameful to have been bestowed so much and then to complain about some of life’s trivialities.  But, I am human.

The Mother of All Gifts

Consider the following list of events.  Has any of them ever dampened your mood, made you angry or resulted in an outburst of coarse language? 
  • You find yourself in a traffic jam which delays your arrival to a meeting by 20 minutes.
  • Your lengthy and detailed e-mail to a client suddenly disappears.
  • The concert of your favorite performer is sold out.
  • You have gained 10 lbs.
  • The women ahead of you in the cashier’s line at the supermarket is digging around in her purse for coins.
  • Your cell phone reception disappears.
  • The airline informs that you may change your ticket reservation for $200.
  • You have a flat tire.
  • Your doctor is running an hour behind schedule, again.
  • A driver cuts in front of on the road.
  • A police officer issues you a ticket for speeding because you were speeding.
  • Your dog has made your new Persian rug her toilet.
  • Your check bounces higher than a kangaroo in heat.
A man came to my office, accompanied by his wife, for his colonoscopy.  He was younger than I.  I had never met him before.  He was alert and in good spirits.  I was pleased that I could inform them both after the procedure that his colon was in excellent health.  Sadly, the health of his colon was more robust than his mind was.  He had dementia and couldn’t recall that he was taking prescription medicines.  How sad and unfair that he and his family were losing a gift.  After my day was over and I was driving home, how important would a traffic jam really be?

When I am headed out to see a patient in the emergency room at an ungodly hour, I remind myself that the patient has it worse than I.  He’s the sick person and I will be returning home to sleep in my own bed.

I want to be more grateful and appreciate for all that I have, but I am flawed human specimen.  The struggle continues. 

Sunday, June 12, 2016

Medical Statistics - The Art of Deception

“There are three kinds of lies: lies, damned lies and statistics.”   There is much truth in this quotation of uncertain provenance.  We see this phenomenon regularly in the medical profession.  We see it in medical journals when statistics are presented in a manner that exaggerates the benefit of a treatment or a diagnostic test.  Massaging numbers is raised to an art form by the pharmaceutical companies who will engage in numerical gymnastics to shine a favorable light on their product.   It’s massaging, not outright mendacity.   The promotional material that pharmaceutical representatives present to doctors is riddled with soft deception.

A favorite from their bag of tricks is to rely upon relative value rather than absolute value.  Here’s how this works in this hypothetical example.

A drug named Profitsoar is tested to determine if it can reduce the risk of a heart attack.  Two thousand patients are participating in the study.  Each patients receives either Profitsoar or a placebo at  random.  Here are the results.

                                1000 Profitsoar Patients      1000 Placebo Patients

# Heart Attacks                                                               6

As is evident,  only 2 patients were spared a heart attack by the drug.   This is a trivial benefit as only 6 of 1000 patients in the placebo group suffered a heart attack.  This means that taking the drug provides no meaningful protection for an individual patient.  However, the drug companies will highlight the results in relative terms to package the results differently.   They will claim that Profitsoar reduced heart attack rates by 33%, which would lure many patients, and a few doctors to drink the Kool Aid. 

Check out this promotional piece below which was recently mailed to me about Uceris, a steroid that I use at times for colitis patients.

See how low the actual remission rates are for the drug.  Only 18% of patients responded to the drug, a small minority, and the placebo rate was 6%.  No worries.   Just brag that Uceris is 3 times more effective than placbo!

Is this a lie?  Not exactly.  Is it the truth?  Technically yes.  

Most physicians are tuned into this deception.  I know from my own patients that the public is easily seduced by this slick presentation of data.  The next time you see a TV ad for a medication, which will be about 5 minutes after you turn on the TV, see if you can spot the illusion.  You'll have to watch quickly and repeatedly.  Like all skilled magicians, these guys are expert at distraction and sleight of hand.  Hint: Whenever you hear the word 'percent', as in "35% of patients responded...", you should pay particular attention.  

When we used to see a woman sawed in half on stage, we knew it was a trick even if we couldn't explain how it was done.  I've taken you behind the curtain here.  Let's make it a fair fight between us and illusionists.

Sunday, June 5, 2016

Is Same Day Colonoscopy Right for You?

Like nearly every gastroenterologist, we have an open access endoscopy system.  This means that patients can be referred, or refer themselves, directly to our office for a a procedure without an office visit in advance.

Why do we do this?  We offer it as a convenience so patients do not need to make two visits to see us when it is clear that a procedure is necessary.  For example, a referring physician doesn't need our consultative advice for his 50-year-old patient with rectal bleeding.  He just needs us to do a colonoscopy.  We have a strict screening process in place to verify that these patients are appropriate for our one-stop colonoscopy program.  If we have concerns about medical issues or potential informed consent capability, then we arrange for these patients to see us in advance.

However, no screening process is perfect.  On occasion, someone shows up whom we might have preferred to see in our office first. How should we handle these situations?  We don't automatically cancel the test, particularly after the patient and his driver have taken time off  work and the patient has already swallowed the delectable and satisfying colonoscopy prep.

No Appointment Needed!

We are meeting many of these folks for the first time, and they are often nervous.  We get this.  First, they are at a physician's office for an intrusive medical test, always a relaxing activity.  The doctor may be a stranger to him, another calming feature of the event.  They become victims of intravenous needle assault, always a pleasure even from our ICU nursing veterans.  They have been fasting and may have enjoyed the pleasure and delight of our colonoscopy cleansing cocktail.  They are naked except for a gown that by design covers about 40% of their body's surface area.  Ready to sign up?

Open access endoscopy also raises potential ethical issues.  On occasion, a patient arrives for a procedure that we may not feel he truly needs or needs now.  Or, the patient is sent for one of our procedures, which may not be the best choice to address the patient's symptoms.   These are delicate issues and I don't have an idealized response to offer here.  In the open access arena, we regard ourselves more as technicians than consultants.  This is similar to when a doctor sends a patient for a CAT scan, the study gets done regardless if it is medically appropriate, or the patient has had half a dozen of them over the past year.  Radiologists don't question the appropriateness of what we order. While patient care would be better served if radiologists offered their advice in advance, this is not how the game works.   Of course, they are happy to have these conversations about our patients, but their default system is open access.

How would you handle this scenario?  One of your best referring physicians sends a patient for an open access colonoscopy.  We interview him and realize he is 2 years early. He is prepped and took a day off of work.  He has a driver with him.  Do we tell the patient that he is 2 years early?  Do we send the patient home?  Do we say nothing?    Do we contact the referring physician and point out his error?

As you craft your response to the above hypothetical scenario, remember that this is not an ethics seminar, but is the real world.  Real life is not as neat and tidy as we would like.

Sunday, May 29, 2016

Memorial Day 2016 - We Remember

I am in coffee shops several times per week.  I prefer independent establishments with atmosphere and authenticity.  For that reason, it is rare to spot me in a retail coffee outlet whose HQ is in Seattle, Washington.  This past week, as I was carrying my cafĂ© mocha to my table, I spied some board games stacked up on a table.  On top was the game pictured below.

This brought back warm memories of playing this game as a young kid.  It recalled the wholesome and beautiful childhood that my parents gave me.  Millennials might not appreciate the raw and fierce competition of games such as Candyland, Chinese checkers or Trouble, which has caused a huge void in their lives. 

Looking back and remembering gives meaning to our lives.  We remember a song, a joke, a celebration, a concert, a speech and relationships.  Isn’t it amazing how hearing a song from years ago captures a mood?

This weekend, we remember and ponder something of infinite meaning and importance.  We remember what so many Americans have done and still do so that folks like me can blog without fear, read a newspaper that criticizes our government or protest lawfully in the public square.

I have never served so I cannot begin to grasp what you have done.  But, I have met many of you, and I am inspired by your heroism and your modesty.

Sunday, May 22, 2016

Measuring Physician Quality - Bully or Just Plain Bull

Patients are amazing creatures.   The current breed is hyperinformed on medical information and has an ever expanding reservoir of physician data to trove through.  I’m not just referring to physician reviews on Angie’s list.  Soon, the public will be encouraged to review our success and failure rates with respect to medical treatments, how much cash the drug companies grease us with, all disciplinary actions, comparison with peers, complication rates, medical malpractice entanglements and how much Medicare reimbursement we have received.

There will be published quality benchmarks on physicians so that the public can see how their physicians scored on these various quality measurements.  I have opined throughout this blog that I feel that these measurements are tantamount to taurine excrement.   Sadly, reimbursement will be tied to these results with physicians who don’t rate high enough having some of their income confiscated.  Physicians who don’t make the grade may game the system to achieve higher grades, which has nothing to do with true medical quality.  Is that what our patients want and deserve?

Source of Taurine Excrement

I was poised to begin a colonoscopy on an informed woman who asked me what my ADR was.  I will presume that readers are not aware of what this means.  Most physicians are likely also ignorant of what these letters stand for.  In fact, I’ll bet a decent percentage of gastroenterologists are clueless here as well.  The ADR refers to the Adenoma Detection Rate, which is one of the silly statistics that ‘experts’ feel separate skilled colonoscopists from pretenders.  Adenomas are polyps which are precursors to colon cancer and are the target lesion for screening colonoscopies.  When you consent to undergo a colonic delight at age 50, your gastroenterologist is seeking out adenomas, removing them before they can morph into a cancerous condition.

‘Experts’ advise that competent gastroenterologists should have an ADR of 25% in males and 15% in females who are undergoing screening colonoscopies.  Lower rates, they claim, suggest sloppy or rushed examinations.   Now, some colonoscopists are removing every pimple they find to make sure they will surpass these thresholds.  Does this sound like good medicine?

Remember, colon polyps are surrogate markers.   The true objective of colonoscopy is to prevent cancer, not finding small benign polyps.  A patient should be more interested to know if their gastroenterologist prevents colon cancer, which is not that easy to measure.   In contrast, measuring the ADR is simple, so it is used as a substitute for colon cancer prevention because it is so easy to do.   Similarly, the statin drug companies boast about their cholesterol lowering properties, which is easy to measure.  Cholesterol levels are also surrogate markers for what we should really care about – heart attacks and strokes – events that can’t be studied and measured as easily as simple blood test results.  A surrogate marker ‘benefit’ may not lead to the desired medical outcome, despite claims that it will.

My nurse assured the inquisitive woman on the gurney that my ADR was above threshold.   Am I a high quality gastroenterologist?   I must be.  I’ve got ADR mojo.    Let’s give a shout out to the government and the insurance companies for adopting the ADR standard.  Can we agree that it’s Another Dumb Regulation?

Sunday, May 15, 2016

Medical Insurance Companies: Heroes or Villains?

Physicians are expected to be hostile to insurance companies.  Indeed, a prior Whistleblower post directed arrows in their direction.  They are an easy target, often vilified for their greed and perceived indifference toward those they insure.  Ask most of us if we think insurance companies favor profits over patients, and most of us will respond that profits prevail.

Insurance companies are businesses, not charitable undertakings.  Sure, we all like free stuff.  Or, if it’s not free, we prefer that someone else pays for it.  We are outraged at the costs of chemotherapy, hepatitis C treatment and biologic treatments such as Humira and Remicade, leaving aside the zillions of dollars it takes to research, develop, manufacture, market and monitor innovative new drugs. 

We want to drive a Cadillac, but only pay for a Chevy.

We want to pay for this...

...and drive this.

No person, business or organization is wrong all of the time.  Consider the following practices.  Who’s side are you on here? 

A patient has chronic back pain and ran out of his pain medications on the weekend.  He calls the doctor and is connected to a weekend covering physician who declines to refill the medicine.  The patient then proceeds to an emergency room, where he is evaluated and given the desired prescription.  Who should pay for the ER care?

A patient is seen in the office and prescribed a 2 week course of antibiotics for diverticulitis.  The medicine nauseates him and he stops them in 3 days.  He does not contact his physician.  Ten days later, he develops severe abdominal pain and fever and needs to be hospitalized for severe diverticulitis.  He is in the hospital for 5 days and is seen by numerous medical specialists.  Who should pay the costs of this hospitalization?

A 55-year-old individual has never had a colonoscopy performed.  His primary care physician advises him to proceed, but the patient declines.  A decade later he is discovered to have colon cancer and needs to be hospitalized for surgery and evaluation by an oncologist.  Who should pay for the costs of his care?

If a patient with high blood pressure, skips appointments and his medications, and a complication develops…

I’m not carrying water for the insurance companies.  I am pointing out, however, that we often expect them to pay for medical care that is either inappropriate or should not have been necessary.  That’s not reasonable or fair.   Don’t we have a responsibility to be personally responsible?

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