Sunday, August 21, 2016

Who is Responsible for Prescription Drug Abuse?

I have written about pain medicine previously on this blog, and it generated some spirited responses.  Let me be clear that I am completely against all forms of pain, whether foreign or domestic, physical, spiritual, psychic or even phantom.  The medical profession has superb tools to combat and relieve pain, and physicians should utilize them, within the boundaries of appropriate use.  We now have an actual specialty – pain management – who are physicians with special training on the science and treatment of all varieties of pain.  I utilize these specialists when necessary and I am grateful for the help they provide to my patients. 

There are two forms of drug abuse in our society – legal and illegal.  The latter has become a health scourge that is shattering families across the country.  A few days before I wrote this, I read the stats of overdose deaths in my state of Ohio.  I was shocked to learn that in our state alone, we lose thousands of individuals every year to drug overdoses, most of which are not intentional.  The street drugs are often impure, or laced with potent additives or substitutes that become a fatal concoction.   Extrapolating Ohio’s stats across the country would create a stunning number of drug deaths.  The causes and the potential solutions to this plague are vexing, but must be pursued.

An Opium Poppy - Cure or Disease?

There is also a legal avenue for drug abuse, medicines prescribed by doctors.  This sphere of abuse will be easier to control than the illegal counterpart, as the process is initiated by a doctor’s prescription and subsequently involves a pharmacist.  No doctor or pharmacist wants to be a pawn in this game.  I believe that these professionals have adapted to a looser culture of prescribing pain medicines and changing expectations on pain relief of the public.

Consider this staggering statistic:  According to the National Institute on Drug Abuse, Americans consume more than 80% of the planet’s opioid medicines, yet are less than 5% of the world’s population.  Does this make any sense?   Would advocates of the status quo argue that America has nearly 20 times more pain than other nations have?

I can state plainly that I have never seen so many patients in the hospital who are on intravenous and powerful narcotics for stomach pain.  These same patients a few decades ago were treated differently, and I recall that we kept most of them reasonably comfortable.  The risks of narcoticomania are self-evident.   Many patients and their families are suffering heartache and misery whose origin can be traced back to a narcotic prescription.  This is a great tragedy.

Narcotics have an important role in our patients’ care, and I support their appropriate use.  There are patients who need opiod use to manage chronic conditions.  But, opiods and narcotics are overused and we need to admit this so we can begin to remedy this reality.  Physicians and the public need to reach an understanding on what each expects from the other.  Both doctors and our patients need more training on this issue.  Doctors should do all we can to make our patients comfortable.  Indeed, relieving pain and suffering is fundamental to the healing mission.  Patients should recognize that physicians may not be able to guarantee 100% pain relief for every situation that you may face.   We have an obligation to minimize your pain and discomfort, but also a responsibility to protect you from wandering down a dark and destructive path that may lead you ensnared in a den of demons.

Sunday, August 14, 2016

Are Doctors Paid Too Much?

Years ago on Cape Cod, my kids and I stumbled across a man who had spent the day creating a sand sculpture of a mermaid.  It was an impressive piece of art.  “How long did it take you to make it? ” we asked.   While I can’t recall his precise words, the response was something like “25 years and 7 hours”.  I’m sure my astute readers will get his point.

We are transfixed now watching Olympic athletes performing in Rio.  So much depends upon their brief routines which can last seconds to a few minutes.  While a diver’s acrobatic plunge may take 2 seconds, it would not be fair to leave aside the years of work and training that prepared the athlete for this moment.

The same point can be made for anyone who has worked and trained hard to reach a point where the action performed seems easy to a spectator or a customer.   If an attorney prepares estate documents, we can assume that the fee for this reflects the prior training and research that the lawyer has done on this issue, as it should.  If an appliance repairman, by virtue of his expertise, fixed our ailing washing machine in 5 minutes and charged us $100, should we balk at this price gouging?  If a less skilled competitor spent 2 hours before finding and correcting the glitch, would we feel better about handing over $100?  Is this fair?  A musician doesn’t just wake up one morning and hop onto a stage to give a concert.  When we pay to listen to an artist perform for 2 hours, we are likely listening to the product of years of grinding work, disappointment, innovation and discovery.

What's a fair price for an hour of Aretha?

I believe that this same principle applies to my own profession.  Over the years I have heard patients complain about various medical charges and fees. While we all know that there have been excesses, many of their gripes are misplaced, in my view.   It’s not fair to equate the medical fee with the time that the physician expended on providing your care.  A cardiac bypass operation takes just a few hours.  A colonoscopy takes 10 minutes.   Treating a patient in an emergency room with a drug overdose may take just a few hours.  A psychiatrist might guide a suicidal patient to choose another path in half an hour.  A spine injection to relieve chronic pain takes only a few minutes.  A dermatologist recognizes a suspicious lesion in a few seconds.  A seasoned surgeon tells an anxious patient after a 20 minute consultation that surgery is not necessary.

Often, folks who make is all look easy are fooling us.  If we think it’s as easy as it looks, then we’re the fools. 


Sunday, August 7, 2016

Overtreatment and Unnecessary Medical Testing? You Make the Call!


Ok, readers.  I know how many of you fantasize about being part of the high drama and glamor of the medical profession.  Believe me, it’s even more exciting than the medical TV shows that have been part of pop culture for generations.  Remember Ben Casey?  Marcus Welby?  Dr. Kildare?  Dr. Seuss?   Rescuing folks hovering over the Grim Reaper was just another day at work for these guys.


The Grim Reaper

Here’s your chance to play doctor for the duration of this post.

A patient wants a colonoscopy, but it is not medically necessary.  Assuming he cannot be convinced to withdraw the request, should you perform it?

A physician wants you to perform colonoscopy on his patient, but it is not medically necessary.  Assuming the physician cannot be convinced to withdraw the request, should you perform it?

An elderly patient’s son wants a colonoscopy performed on his father, but it is not medically necessary.  The patient is ambivalent and delegates the decision to his son. Assuming the son cannot be convinced to withdraw the request, should you perform it?

A nursing home requests that a feeding tube be placed on an elderly resident.  While the tube would be much more convenient for the staff with regard to administering food and medication, the tube could be avoided if a staff member had sufficient time to assist the patient with meals and medicines.   Should you place the feeding tube? 

An anxious mom (please forgive the sexism here) demands an antibiotic for her child’s sore throat, which is not medically necessary.  Assuming she cannot be dissuaded from her request, reinforced by prior physicians who prescribed antibiotics under similar circumstances, should you acquiesce?

A man is critically ill in the intensive care unit and is nearing the afterlife.  The consensus among the treating physicians is that additional care would be medically futile.  There is no advanced directive or medical power of attorney.  The next of kin insists that the patient be placed on life support.  He is not persuaded to withdraw his demand and suggests that there would be consequences if his relative is simply allowed to die.   What would you do here?

So, ‘doctors’, any thoughts?


Sunday, July 31, 2016

Should Doctors Lie for Patients

Even the most honest among us do not tell the truth all of the time.  We are flawed human beings.  We covet, we gossip, we steal, we lie and we stand idly by. You don’t think you steal?   Have you ever ‘borrowed’ someone else’s idea and represented it as your own?

A few weeks before I penned this, I was presented with 2 opportunities to lie in order to save a patients a few bucks. The first patient wanted a refill for her heartburn medicine, which she takes once daily.  She asked if I would refill the medicine to take twice daily, so she could get double the supply for the same price.  The second patient asked me to write a note that he was at risk for Hepatitis B so that he could get the vaccine for free.   Writing the note would be easy, but claiming that he faced risk of Hepatitis B infection would require some prevarication. 

I’ll assume that Whistleblower readers know how I responded to the above two issues.   However, many patients, and perhaps some physicians, who are so harassed by insurance companies and an uncaring medical bureaucracy are looking for any measure of relief when they can grab it.  Many of them have risked rising blood pressures and panic attacks trying to talk common sense with insurance company ‘customer service’ representative,s who have less medical training than hospital housekeepers, about getting their medications approved.   I’ve been down that tortured road more times than I can count, and I feel their pain. 

I routinely receive disability forms for patients who are seeking this benefit.  I advocate zealously for every patient who has a legitimate claim for any benefit they are entitled to, often making the phone calls with the patient seated beside me.   There are occasions; however, where no matter how hard I squint at the patient’s chart, I just can’t discern any medical evidence of a disability.  Sometimes, I haven’t seen the patient for years.  (Often, disability forms are sent to every physician the patient has seen, so some of these physicians are not appropriate targets.)  

  
George Washington, not a doctor, didn't lie.

Ethical quandaries can be tormenting.   Let’s say a patient is sent to me to evaluate constipation.   A colonoscopy is scheduled.  Since the procedure is diagnostic to evaluate his symptom, he will have to pay much more out of pocket than if the procedure is coded as a routine screening colonoscopy.    Should I slightly adjust my coding to help the guy out?  

It doesn’t take much effort to rationalize siphoning a few bucks from insurance companies that many of us think deserve it.  Somehow, we don't regard this theft as we would shoplifting or stealing a neighbor's TV.

I could state here that I respect medical insurance companies because of their unwavering devotion to protecting our health and serving the greater good.  But, I’d be lying.  

Sunday, July 24, 2016

Is Medical Marijuana Safe and Effective? Who Decides?

Medical marijuana is a smokin’ hot issue in Ohio.  Marijuana enthusiasts targeted our state constitution again this year with another amendment attempt, which failed.  Instead, our legislature passed House Bill 523, which will legalize medical marijuana use. 

As a physician, with some training and experience in prescribing medicines to patients, these marijuana machinations are medical madness.  Is this how we want to bring new medicines to market?

I think it is absurd that a specific medical treatment – or any medical treatment - should become a constitutional issue.  Do we want to establish a constitutional right to a specific medicine?
Why stop at marijuana?  Why not start circulating petitions for constitutional amendments for screening colonoscopies, mammographies and MRI’s for back pain?  Patients with chronic lumbar disk issues have rights too! 

The Ohio bill specifies an array of medical conditions that could be treated with marijuana, including AIDS, hepatitis C, inflammatory bowel disease, Parkinson’s disease, PTSD and many other illnesses. Is it the legislature’s responsibility to decide that a medicine should be approved for a medical illness?  Do legislators have medical expertise?  Do we want the Senate or House weighing in on approving a new chemotherapy agent or artificial hip?

Will Cure Whatever Ails You?

Might I suggest with just a tincture of cynicism that medical marijuana mania has become a mite politicized? Do we want folks who stand to make money or enhance their political power from a new medicine – who have no medical expertise - to be the ones with a major role in approving its use? Are cannabis con artists using a political pathway because they fear that the medical avenue will less hospitable to their objective?

Once marijuana becomes a legal product, an inevitable outcome, will enthusiasts for its medical use support vigorous testing of its therapeutic value? 

I am deeply skeptical that the medical claims of medical marijuana adherents are supported by persuasive medical evidence. I remain open, however, to submitting marijuana to the same Food and Drug Administration (FDA) testing that all new medicines are subjected to. Let the scientific method with appropriate clinical studies and peer review judge the product for safety and efficacy. If approved, then the public and the medical profession can be confident that the approval was on the basis of science and not smoke.  Shouldn’t those who champion medical marijuana use demand this level of independent scrutiny?  If not, then why not?

Yes, I have heard powerful individual vignettes describing great benefits of medical marijuana. Every physician has similar anecdotes of patients who have achieved significant benefits from unconventional and unapproved medical treatments. But, anecdotes are not science. If medical marijuana is the healing elixir its proponents promise, then prove it. 

Let our politicians do what they do well, whatever that is, and leave medicine to the professionals. 


Sunday, July 17, 2016

Do New Medical Interns in July Threaten Patients?

Would you have elective surgery in the nearby major teaching institution on July 4th?
Why not, you wonder?

Prowling around the hospital wards every July are the fresh faced interns wearing starched white coats, with stethoscopes draped across their shoulders, with pockets stuffed with reflex hammers, K-Y jelly, and various cheat sheets to rescue ailing patients.

These guys know nothing.  How do I know this?  I was one of them.  Luckily, I knew that I was clueless and never pretended that I could treat athlete’s foot or even a splinter.

Imagine you are in a hospital bed in early summer complaining of chest discomfort.  Your nurse summons the intern who speeds into your room peppering you with questions.  Before you finish your answer to a question, another question erupts.  This physician is barely out of his shrink wrap and is understandably anxious that he is witnessing an impending cardiac catastrophe.   With his spanking new stethoscope, he establishes that there is a beating heart nestled inside your chest.   Your heart rate is high, most likely as a result of anxiety from witnessing the intern’s state of near panic.  I’m sure you will calm down when he whips out his Tips for Chest Pain Cheat Sheet which he will use to treat you. 

If the intern tries to test your reflexes with this - run!

Teaching hospitals have an important teaching mission.  This is the venue where physicians learn their trade – on real patients.  New interns start in July and they know nothing.  Sure, there are multiple levels of supervision over them, but these many layers can cause gaps and vulnerabilities in patient care.  The supervising medical resident, himself with only a year or two of experience, has several interns he is responsible for.  He can’t be with every intern every minute.  Sure, the intern can always call for help, but what if he doesn’t know that he needs help?

Patients at teaching hospitals enjoy many advantages.  There is often state of the art equipment and a renowned faculty.  They claim that with so many physicians of different hierarchical levels seeing patients, that this built-in redundancy catches errors and oversights.  This may be true, but as I have expressed, it is also a cause for miscommunications, excessive medical diagnostic testing, errors, exploding costs and gaps and lapses in care.

Imagine you are admitted by your internist and a cardiologist and a gastroenterologist are both consulted, a very common scenario.  Each of these 3 physicians has his own team of fellows, residents and interns.   You could be seen by 10 physicians in a day.  Communication lapses are expected as it is not possible for all of these physicians to know what all colleagues on the case are thinking and planning.

Contrast this with the situation in a community hospital, such as the ones I practice in.  There are no interns, residents or fellows.  I perform my own history and physical examination and take ownership of the patient.  I communicate with the nurses and other physicians on the case personally.  While this system is not perfect, there is much greater accountability to the patient.  There is no one I delegate to.  There aren’t layers of doctors pushing their own agenda to the extent there is in a teaching hospital. 

Our mission in the community hospital setting is patient care, not physician training.  In my experience, having been in both types of institutions, I think community hospitals have an intrinsic quality advantage.  Teaching hospitals would argue this point.   I don’t think it can be argued, however, that there are conflicts of interest in teaching institutions as patients are exposed to excessive medical care in order to provide education and training to young physicians.  This is undeniable.

If a July 4th hospitalization is in your future, you can choose your local community hospital or the Medical Mecca downtown.  If you choose the latter, get ready for some fireworks.

Sunday, July 10, 2016

Supreme Court and the Texas Abortion Law - A Victory for Truth

Readers are not aware of my personal view on abortion, and they won’t be after this post.  While abortion seems on its face to be a complex biomedical issue, interestingly, those with firm views on either side do not describe it as a great moral quandary.  Those who ardently favor abortion rights, and those who oppose them in equal measure, often express that this is not a controversial issue.  For them, it is a clear issue of right and wrong, with each believing that the other side is entirely wrong and misguided.  This observation applies best to those who are toward the poles of the abortion question.  If you believe that an embryo and a fetus are human beings, than abortion is murder.  Not much room for debate here.  If you do not confer personhood on an embryo and a fetus, then a right to abortion is a woman’s right to freedom and autonomy.  Clear cut argument here also
Of course, many thoughtful individual wrestle with this issue and do not grasp it in the black and white terms described above.

I have given this issue much thought over my adult life.  I do not feel that I can contribute to this wrenching public debate.  I have no new point or angle that hasn’t been offered or would change any minds.

I was pleased with the recent Supreme Court decision that struck down Texas law which had resulted in the closing nearly half of the state’s abortion clinics.  My view here is not related to my personal view on the issue.  I applaud the decision because I feel it is a victory for truth.

Our Best Functioning Branch of Government

Texas had required that abortion clinics be certified as ambulatory surgical centers (ASCs) and that providers must have hospital admitting privileges at an area hospital.  If these two conditions were not met, then the center would have to close.  I completely reject the law’s supporters who have claimed that the 2013 state law was to preserve women’s health.  This was unadulterated mendacity.  The law was not to protect women, but to limit abortions in Texas.  We don't expect veracity from our elected officials.  Indeed, politicians and partisans develop wheezing and hives whenever they unexpectedly make contact with the truth.  They should have announced at the bill’s signing the law's true intent – to limit abortions.  If you believe that decreasing abortions is a noble and moral objective, then say so.  If you believe that the unborn child merits all protections that can be legally conferred, then argue your case and try to pass laws that would accomplish it.

From a medical point of view, requiring the abortion provider to have admitting privileges or having the center regulated as an ASC is ridiculous.  Many other medical procedures performed outside of hospitals in Texas were not subjected to these restrictions.  Why not?  Don’t these patients deserve protection also?  The fact that the law has not been shown to have protected a single woman is powerful evidence of its true motive.

Tell the truth.  If you are a teacher who is protesting for a higher salary, don’t tell us that you’re doing it for the kids.  If you’re an older cop who wants to retain the current system that rewards seniority, don’t tell us that this is an issue of public safety.  And, if you’re a gastroenterologist who does colonoscopy for a living, don’t rail against a superior replacement arguing that you’re only protecting your patients. 


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