Sunday, December 14, 2014

Does Quality of Colonoscopy Depend on Time of Day?

Over the past decade, there has been renewed effort to increase the quality of colonoscopy. New data has demonstrated that colonoscopy quality is less than gastroenterologists had previously thought. Interestingly, colonoscopy is less effective in preventing colon cancers in the right side of the colon compared to the left side. Explanations include that some pre-cancerous polyps in the right side of the colon are more subtle to recognize and that the right side of the colon has many hidden areas that are difficult to visualize. New examination techniques and equipment are addressing these issues.

The goal of colonoscopy is not to detect cancer; it is to remove benign polyps before they have an opportunity to become malignant. A new measure of medical ‘quality’ is to record how often gastroenterologists (GIs) remove polyps from their patients. For example, if a GI only detects polyps in 5% of patients, which is under the quality threshold, then someone will conclude that this physician is not diligent. So, now GIs may be scouring the colons to remove every pimple in order to reach threshold. While this may result in higher ‘quality’ colonoscopies, will patients actually benefit? We don’t know. Pay-for-performance and other quality initiative create opportunities and incentives to game the systems. Is our mission to help patients or to play the game?



An interesting issue regarding colonoscopy quality has been published in medical journals. GIs who are doing colonoscopies all day long lose their edge as the day progresses. It may be that that physician fatigue is a factor, or that afternoon patients are not as thoroughly cleaned out as morning patients are. This issue has been covered in the press and patients have asked me about it. I am not aware that my procedural quality is time dependent, but I haven’t looked at my own data. I wonder what my optimal colonoscopy time slot is. Perhaps, I should run my data and then charge fees in accordance with my polyp detection rate. In other words, if a patient is seeking a bargain colonoscopy, then he gets the last slot of the day. However, if a patient wants concierge medical quality, and is willing to put some cash on the line, then he’ll get scheduled accordingly.

I wonder if other medical specialties, including primary care, experience quality decay over the course of the day. I am interested if any physician readers are aware of published data on this issue or can share relevant personal experiences.

The lessons gleaned from the lower portion of the alimentary canal may apply beyond the medical arena. Do other professions perform better in the morning than they do in the afternoon?

Here are some studies I propose, which can be funded in our government’s usual manner – borrow.

Profession                    Quality Measurement per Shift Hour

Policeman                           Arrest Record

Thief                                      Successful Robberies

Financial Advisor             Profitable Advice

Politician                             Promises Kept

Stage Actor                         Lines forgotten

Judge                                    Decisions Reversed

Since pay-for-performance is the panacea that will cure the medical profession, why shouldn’t we share it with the rest of you?

Sunday, December 7, 2014

Should Your Doctor Consider Medical Costs?

This blog is devoted to an examination of medical quality.  Cost-effectiveness is woven into many of the posts as this is integral to quality.  Most of us reject the rational argument that better medical quality costs more money.   Conversely, I have argued that spending less money could improve medical outcomes.  Developing incentives to reduce unnecessary medical tests and treatments should be our fundamental strategy.  Not a day passes that I don’t confront excessive and unnecessary medical care – some of it mine - being foisted on patients. 

At one point in my career, I would have argued that physicians and hospitals were motivated only to protect and preserve the health of their patients, but I now know differently.  Payment reform changes behavior.
As an example, it is impossible for a patient with a stomach ache who is seen in an emergency room to escape a CAT scan, even if one was done for the same reason months ago.  I saw a patient this past week with chronic and unexplained abdominal pain.  She has had 5 CAT scans for the same pain in recent years.  This is a common scenario.  Once reimbursement policy changes to punish physicians and hospitals for overtesting, we will witness the Mother of All Medical Retreats!

Are 5 scans enough?

Physicians and the public have an interest in preserving medical resources to serve society.   There is an emerging debate if physicians who are counseling patients should be mindful of society’s needs while in the exam room.  In other words, if I am prescribing a medicine for a patient with Crohn’s disease that costs $25.000 annually, should I also be considering if this is a wise use of society’s resources?   Would this money be better spent giving influenza vaccines (‘flu shots’) to uninsured or medically underserved individuals?  If you were my patient, do you expect that I am focused exclusively on your medical interests regardless of the cost?  Do I have a responsibility to consider how my advice to you impacts on others’ health since health care dollars are finite?  Should patients be willing to sacrifice their own medical care in order to serve the greater good?

Cost-effectiveness is presumed if someone else is paying the bill.  If patients had some skin in the game, then they would exert some restraint on the current frenzy of diagnostic testing and treatment.  If my patient cited above had to pay a portion of the 5 CAT scans that she had undergone, there may have been only one scan.  And, if the hospital and the radiologists were paid only for necessary testing, there would have been a similar outcome.

More medical care often means lower medical quality.  How much longer do we want to pay more to receive less?


Sunday, November 30, 2014

Thanksgiving - A Chance to Spread Sunlight

This is the only Thanksgiving holiday in my memory that I was not on call for hospital work.   Physicians, like many other folks, are not automatically off on holidays and weekends.  I’m not complaining here, but there are times that I am envious of individuals who are home on every weekend and holiday.  Americans need health care, law enforcement, and various emergency services even on days of national leisure.  When I am driving to the hospital on one of those days, I remind myself that the sick person I am headed to see has a much worse deal than I have.

I have been bestowed with many blessings, and I am grateful for all of them.  Some of them, I may have earned, while others just fell my way.   Similarly, life’s travails can result from a bad decision or just bad luck.  Life isn’t fair.

Spread Sunlight

I admire folks who always spy a rainbow through a storm, and I want to be like them. Appreciating one’s lot in life, especially a midst dark days, brings much light into the world.  It becomes a contagion for good.  The opposite approach becomes a powerful force spreading discontent and unhappiness and has a wide ripple effect. We've all seen this.  There’s a reason that most of us enjoying spending time with folks who exude sunlight. We don’t all have to be supernovas that can enlighten the universe, but we can try to spew off enough photons to bring some light into the world.

Last week, my family converged in New York City to surprise my mother for a milestone birthday.  She was in the presence of the most important people in the world to her.  A week later, I am still in the rarefied aura of this unforgettable event.   I am so thankful for this incredible blessing.

Let's seek out light and spread some of our own.  

President Lincoln's 1863 Thanksgiving Day Proclamation opens with the following sentence. 
 
The year that is drawing towards its close, has been filled with the blessing of fruitful fields and healthful skies. 

Remembering what his world was like in 1863, we can agree that this man could see light during the darkest days we ever had.  Our gratitude endures.



Sunday, November 23, 2014

Are Doctors Good Businessmen? Get a Second Opinion!

We’ve all heard or used the phrase, ‘leave it to the professionals’.   It certainly applies to me as the only tools that I can use with competence are the scopes that I pass through either end of the digestive tunnel.  Yeah, I have a ‘toolbox’ at home, but it is stocked similarly to the first aid kit that your new car is equipped with.   It contains a few BandAids, adhesive tape and, hopefully, the phone number of a local doctor.  My home tool box has an item that can practically fix anything – the phone number of a handyman.

Nothing for Hemorrhoids Here.   

It is essential to know one’s limitations, regardless of one’s profession. 
  • Politicians shouldn’t speak authoritatively as if they are climatologists.
  • Gastroenterologists should not prescribe chemotherapy, even though we are permitted to do so.
  • Bloviating blowhards on cable news shows are likely not military experts.
  • The guy who fixed your toilet might not be a top flight kitchen remodeler even though his business card includes home remodeler, along with railroad engineer, IT professional, seamstress and stand up comic.
Some of us are good at a lot of stuff.  Some of us have a narrower, but deeper range of competence.  Yes, we’re all good at something, as our moms and teachers taught us during our early years.   Without doubt, most of us are not good at lots of stuff, and it’s important to know where our comfort zone approaches the chaos zone.   In my own profession, it is absolutely critical that physicians readily solicit assistance from a colleague when additional knowledge, experience or judgment is needed.   Asking for help to help a patient is evidence that the physician is focused on his patient’s welfare.  Every doctor has witnessed circumstances when a physician is reaching too far beyond his tool box, and it’s not pretty. 
  • Should a surgeon perform a complex operation that he only seldom performs?
  • Should a local oncologist treat a patient’s rare cancer or refer the patient to the expert downtown?
  • How long should an internist struggle with a patient’s hypertension before recruiting an expert?
  • If an allergist’s patient keeps losing weight, is it time to consider a cause beyond the scourge of gluten?
Last year, our practice needed some restructuring.  We met with our accountants for advice on streamlining and managing our practice.  I was impressed how quickly these pros looked over our financial statements and readily understood the state of our practice.  Of course, these guys see the world through Excel spread sheets, just like we GI physicians do through our colonoscopes.  To us physician clods, these reams of number filled pages containing every permutation of various financial reports were encrypted codes that would require NSA cryptographers to decipher.  Most physicians are not good businessmen, although many feel otherwise.  Luckily, my partner and I know the truth about ourselves.   We didn’t ask the accountants for a ‘second opinion’.   We came to them first, and we’re glad we did.   I presume that when they need a colonoscopy, they won’t try it themselves.


Sunday, November 16, 2014

High Drama in an Ambulatory Surgery Center

A few days before I wrote this, a patient had a complication in my office.  I have discussed on this blog the distinction between a complication, which is a blameless event, and a negligent act.  In my experience, most lawsuits are initiated against complications or adverse medical outcomes, neither of which are the result of medical negligence.   This is the basis for my strong belief that the current medical malpractice system is unfair.  It ensnares the innocent much more often that it targets the negligent.

I performed a scope examination through one of the two orifices that gastroenterologists routinely probe.  In this instance, the scope was destined to travel inside a patient’s esophagus on route to her stomach and into the first portion of the small intestine.  Sedation was expertly administered by our nurse anesthetist (CRNA).   The procedure was quickly and successfully performed.  The patient’s breathing became very impaired and her oxygen level decreased markedly, a known and uncommon complication of sedation medications.   We took the appropriate measures, but her low oxygen level did not respond.

At that point, our experienced and calm CRNA decided to intubate the patient by passing a breathing tube into her lungs, in the same manner as is routinely performed prior to surgery.   The RN on the case, an ICU veteran, showed how quickly and superbly her medical skills and judgment could be recalled.  In decades of medical practice, I had never had a patient whose scoping test and sedation led to a breathing tube insertion.   Moreover, this procedure was performed in our outpatient ambulatory surgery center, not in the hospital, so drama like this is exceedingly rare.

Physicians prefer to see drama in the theater.

The patient’s oxygen level immediately returned to normal and she was transferred to the hospital in stable condition.  She was appropriately treated and discharged after a few days. 

I was so grateful to have a team in place that had the skills to rescue a patient who was in a dire situation.   I told this to them directly and they seemed to regard the matter in a more routine manner than I did.  They saved her life.   Nothing routine about this, as I see it. 

For nearly all of the patients we see in the office, our staff is overqualified.  But, once or twice a year, we need these folks on site, locked and loaded.

Physicians and the rest of us need back up.  Do you have a contingency plan in your job if a crisis befalls you?  Will you wait for a catastrophe before implementing one?  We’ve all heard vignettes about cities who were warned about a dangerous intersection, but failed to ask until a tragedy occurred.

Finally, if someone helps you out of the abyss, give the credit to whom it is deserved.   Conversely, if something goes wrong and it’s your fault, do the right thing.  

Sunday, November 2, 2014

Ebola Hysteria in Ohio

The Ebola hysteria continues.  True, we might have a greater chance of being struck twice by lightning, but the press would have us think we need to purchase Hazmat suits for our families just to be prepared.  I’m surprised that an entrepreneur hasn’t at least constructed prototypes for Hazmat suies for newborns, popular dog breeds, pet rodents and heirloom tomatoes.

Tomatoes?

Yes, tomatoes.   I have not heard any authoritative official from either the NIH, the CDC the WHO or Medicins Sans Frontieres (Doctors Without Borders) who have stated unequivocally that you cannot contract Ebola from an heirloom tomato.  To me, the hypothesis is entirely plausible as the sneaky virus  can hide in the heirloom’s surface crevices just waiting and hoping to gain access into an unsuspecting mucous membrane. 

Smooth Skin Tomatoes Probably Safe

As of this writing, there are 159 contacts in Ohio who have had contact with an Ebola infected nurse who for reasons known but to God was cleared by the CDC to board a commercial airplane with a fever after she had treated an Ebola patient in Texas.   Each day, the number of Ohio contacts grows, so by the time these words are posted on Sunday, I expect that there will be more contacts.

Gerbils Need Ebola Protection

The definition of what constitutes contact with an Ebola patient is evolving.  As of today, the new and improved definition of contact is being an enclosed space with the patient for any length of time.  Hmm, if I am watching the Cleveland Cavaliers in our downtown stadium from the last row, and an Ebola patient is in the first row on the opposite side, am I now considered a contact?  Would all 10,000 fans be forced to enter into a 21 day period of quarantine? 

Does it matter that medical experts have consistently explained that you cannot catch this virus unless the infected individual is symptomatic and you are within reach of that individual’s bodily secretions?
An Ohio school was closed as a staff member was on the Frontier airplane that the nurse had traveled on although on a different flight.  Two hospitals in Cleveland sent nurses home with pay and admitted publicly that this was for PR protection, not for patient protection.   What hope is there when our medical institutions are lubricating our hysteria instead of battling it?

This past Monday, I noticed a new procedure had been implemented in our office.  On the advice of local and state medical authorities, we were asking every patient who enters our office, if they have in to West Africa or had contact with an individual who has been there.   This nonsensical policy would protect no one.  There are zero known Ebola patients in Ohio at present.   This is a difficult disease to contract as contracting this virus requires that one is in direct contact with bodily fluids of an infected person.  Querying every patient about recent travels from West Africa only feeds the hysteria, while it burns up our staff’s time.   Asking Granny who comes to see us from her assisted living facility if she’s been to Sierra Leone recently, doesn’t seem to be sound preventive medical policy.

I think that our moratorium on heirloom tomato ingestion makes more sense than the Ebolaphobia policy. Can this post go viral?

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.  

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