Voting for Gridlock in Washington: First, Do No Harm

Inauguration Day

Presidential election seasons are always exciting times for Americans. Read the newspaper any day for a reminder of how much we take for granted here. Every four years we have the opportunity to hire, rehire and fire a commander-in-chief. Of course, our system is not perfect, and is often downright maddening. But, most of us would not trade our system for another.

The presidential election year is especially exciting when you can share it with your kids. I cannot calculate or even recall how many dinnertime discussions we had where all of us would debate the issues and evaluate the candidates. It was great fun to watch the kids engage in the electoral process. While I lean toward the political right, I tried to be a fair (and balanced) moderator during these dinnertime debates. My prediction is that 3 of the 5 will be Democrats, 1 will be a Republican (but doesn’t know it yet) and the 5th kid could go either way.

As we know, one’s political affiliations tend to change as one’s life and circumstances change. Folks tend to protect their own interests, and these interests change as they enter different phases of life. College kids, taxpaying parents raising children and senior citizens likely have different political and economic interests and may vote differently. While some folks, such as presidential candidate Ron Paul, have maintained their political views throughout their lives, most of us modify our views over time.

Remember the joke that a conservative is a liberal who’s been mugged?

The 4 remaining GOP presidential candidates all profess to be true conservatives. One is mocked as being a moderate, as if this is a scarlet letter shaming the former Massachusetts governor. Wouldn’t most of us want a president to be moderate? One is accused of espousing a dangerous nihilistic foreign policy. One is referred to as an erratic time bomb. And one is labeled as not ready for prime time.

All four compete as to who would repeal Obamacare the fastest.

“When I take the solemn oath at the Capitol, I will place my left hand on the bible and raise my right hand. And, in that right hand I will be clutching a pen so that the moment after my swearing-in, I can sign the repeal as the Chief Justice who upheld Obamacare looks on.”

Which candidate made this pronouncement?  Don’t bother Googling. I made it up.

The Supreme Court will hear arguments challenging the constitutionality of Obamacare next month. Most of us expect that the core of the plan – the individual mandate – to slip through. However, just because something is legal, doesn’t mean it’s a good idea.

While Romney wants us to accept the inevitability of his nomination, he hasn’t closed the deal. Anything can happen. Who would have predicted that a one term senator from Illinois would prevail over the Hillary Clinton machine to become the Democratic nominee for president?

If President Obama is reelected, which I expect, then brace yourself for Obamacare on steroids. The hope of those like me who think that Obamacare is bad medicine is that the GOP maintains control of Congress. Why would I actively support gridlock? Because as a physician, I subscribe to the principle, Primum non nocere, First, do no harm.

Obama And Health Care Reform: Leading or Misleading?

Leadership is convincing folks to follow a new and uncomfortable path. Folks have to believe that the new direction will ultimately serve their interests, even if it feels awkward and unsettling at first. This works when there exists a foundation of trust between leader and followers. Otherwise, there will be doubt as to the motives of the leader who will be suspected of serving his own parochial interests, and not the greater good.  Consider some examples.

• If your boss has always been stingy, it may be difficult for him to convince workers that the 'new and improved' health care plan is better for their families.
• If a presidential candidate receives $400 haircuts, can he convince the hoi polloi that he understands the common man and his travails?
• If a religious leader is discovered siphoning donations into his private accounts, will folks still call the ‘prayer line’ to offer a tithe?

When trust in the leader is squandered, distrust lingers and will frustrate and impede future leaders. Decades of dashed promises have created deep cynicism in our society. Want proof? Take a look at the public’s approval ratings of Congress – either party – any day of the year. With those numbers, it’s amazing that any of them get reelected, but they do, and repeatedly.

How well has Obama led on health care reform? Not as well as he could have and should have, in this blogger’s view. He deserves great credit for campaigning on the issue of health care reform and for taking it on as president. Passing Obamacare was a singular presidential achievement.

Although the Patient Protection and Affordable Care Act passed, this wasn’t a result of presidential leadership. It was the result of Democrats voting in lockstep, with the administration cheering from behind. While I’m not suggesting that the GOP would have behaved like Eagle Scouts had they been in the majority, Dems dissed the Republicans and shut them out. Real leadership, especially on an issue of paramount importance to the country, should have forged a different path forward including minority participation and respect.

I still believe that the president believes that government controlled universal care is ideal, but he still can't state this outright, at least not yet. He hopes to achieve this, perhaps in his 2nd term. Elections matter.

Did the medical interest groups, who were feted at the White House really believe that their interests would be protected as they were promised? The strategy of pitting one medical player against another is good politics, but is it good policy? Does the country win when hospitals compete against physicians who compete against insurance companies? Why is the pharmaceutical industry, affectionately known as Big Pharma, demonized regularly by the government and the press? Sure, this throws red meat to the crowd, but don’t we need these guys to deliver the next generation of cures and treatments?

The public wasn’t led, it was misled. This is why they delivered the U.S. House of Representatives back to the GOP in 2010. Polling consistently shows that about half the country wants Obamacare repealed, although interpreting and crafting polls is tricky business. By any poll, it is clear that the country has not drank Obama’s Kool Aid.

Many years ago, a man was born on this very day. He was a leader who led the nation to where it needed to go. While he was a very ambitious man, he was always guided by the nation’s interest. His goal, as he wrote in his 2nd inaugural address, was to achieve a just and lasting peace among ourselves and with all nations.  He is an inspirational model of leadership everlasting.  Can the other president from Illinois make this claim?

When Should a Doctor Fire a Patient?

His signature is, 'Your're Fired!'.
Photo by Gage Skidmore

Rarely, I have fired patients from my practice. Why do I do this? You might think that we send out termination letters to patients who haven’t paid their medical bills. We don’t. We try to work with these folks and will keep seeing them as long as they are making the barest effort to address their financial responsibilities. If they refuse to make any payment, or won’t return our billing office’s phone calls, or are hostile to our staff. then we may withdraw as their physician, provided there is no medical urgency present. Our office will see patients who have no medical insurance so that these folks have access to medical care.
The process of terminating a professional relationship between physicians and patients is well presented in EverythingHealth, one of my ‘must read’ medical blogs.

The more typical reason why we fire patients from the practice is because of continued behaviors and actions which place them and me at risk. For example, if a patient with cirrhosis, a severe liver condition, will not keep scheduled medical appointments, we may have to cut him loose. I can’t accept the responsibility for his health or a medical catastrophe if the patient is conspiring against himself. If a patient won’t take his medicine for Crohn’s disease, and it’s not a matter of affordability, then I need to reassess whether I want continue serving as his gastroenterologist. If he ends up in an operating room to face emergency surgery that could have been avoided had he followed medical advice, could he convince an attorney with some tortured logic that my care was inadequate? I can imagine the deposition with an attorney asking me pointedly:

“Doctor, did you know that your patient wasn’t taking the medicine because he was worried it might cause side-effects? Why doesn’t your office note mention this?”

“Doctor, why didn’t you write the patient a letter after his office visit encouraging him to take his medicine? Don’t you think this might have helped? Was a 44 cent stamp to much to invest in your patient’s health?”

“Doctor, if it was so important that your patient take his medicine as prescribed, why didn’t you take 2 minutes to call him to reinforce the advice? Were you simply too busy?”

“Doctor, the patient never knew that failure to take the medication could result in a colostomy. Why doesn’t your office note specifically document this risk? Of course, had my client known this, he would have swallowed the medicine with zeal and enthusiasm.”

Of course, we care for patients who reject our medical advice. Medical care is a collaborative process and patients are ultimately charged with making the decisions, although many are happy simply to accept our guidance. This acceptable practice is distinct from, “I’m not taking any high blood pressure pills and you can't make me!”

So, there are times that we fire patients from our practices. Perhaps, some readers can offer comments explaining why patients decide to fire us.  

Drug Marketing and Data Mining: Free Speech or Free Ride?

Pharm Tractor Mining Physician Data

Drug reps come to our office fairly regularly, but not as often as they used to. Some of them look like regular folks, but many still look a lot like Barbie and Ken. These guys have a tough job. It’s hard to cultivate relationships when you can’t pay off physicians with free trips or offers of remuneration for serving as a ‘consultant’. Remember ‘dine and dash’?

Despite these prior excesses, I do not disparage pharm reps, many of whom are ethical professionals who have developed vertical knowledge on a narrow niche of medicine. I have learned from them, but I remember that they are salesmen. Caveat emptor.

Drug reps face other challenges beyond the ban on ballgame and theater tickets. We physicians are often constrained by insurance company formularies that dictate what we can prescribe. The insurance companies would balk at that statement and would offer a lawyerly response that, of course, we physicians can prescribe any drug that we believe best serves the patient’s medical interest, but that this selection may not be a covered benefit. Get the idea?

One tool that pharmaceutical companies have relied on for years is to purchase individual physician’s prescription data from pharmacies. This data mining gives pharmaceutical companies lists of physicians by name and the drugs prescribed by each doctor. In other words, the Nexium rep can learn how much or how little of the drug I prescribe compared to its competitors. (No patient identifying data is included.) Drug reps can be given sales goals based on this data.

Memo to Barbie and Ken

Kirsch is prescribing too much Prevacid, which is giving the corporate folks heartburn. More aggressive sales techniques required. Launch OperationBURYPREV ASAP.

Physicians have always hated this open secret in the pharmaceutical industry. It’s open because we all know it is practiced and it’s secret because drug folks won’t talk about it. Doctors, test this the next time a drug rep wanders into your office. Use the following ice breaker as a guide.

“Yo Rep, can I see my individual prescribing data that your company has mined on me?”

At that moment, you will be amazed at the stillness of the lips and larynx that are facing you. An orifice that is usually a portal for endless chatter becomes a hollow cavern. It’s almost a miracle.



The Supreme Court ruled in a 6-3 vote at the end of their term last year that data mining by pharmaceutical companies is constitutional. Vermont had previously passed a law restricting this practice, which the Court has struck down.

I respect the decision because the Supreme Court’s responsibility is to determine if an action is legal, not to make policy. The court did so to protect free speech. Drug reps, however, won’t be speaking freely on this to physicians. Wonder how they and their bosses would feel if we mined their data. Would they agree that free speech goes both ways?



Concierge Medicine and Boutique Medical Practices: Cure or Disease?

Some time ago, I rented a car during a visit to another city. I chose among the various categories of vehicles which are listed from the last expensive to the most costly. Here were my choices.


• Economy

• Compact

• Intermediate

• Standard

• Full Size

• Premium

• Luxury

As I have pointed out on this blog with regard to medical care, people spend other people’s money much more easily than they spend their own. This is why I have argued that patients need to have some ‘skin in the game’ to serve as a brake on profligate medical spending. There may be other effective brakes to consider, but diagnostic and therapeutic restraint demanded by patients is a potent and reasonable option.

In the rental car case, I was not on someone else’s expense account, but was handing over Kirsch cash. I chose a standard sized vehicle. Of course, I could have saved $$$ by driving off in an economy vehicle, but rental cars are priced like movie popcorn. For a few dollars more per day, you can drive a bigger car. It is a brilliant pricing strategy that encourages the consumer to upgrade.

Here’s the point. I ordered and paid for a standard sized car. I cannot expect that I will be presented with a luxury automobile when I arrive at the rental car lot. Of course, I can upgrade to a higher category, but I will have to pay more. Isn’t this fair? If you are paying for a Chevy, don’t expect to drive away in a Cadillac.



This concept relates to the practice of concierge medicine, also known by the even more derogatory description of boutique medicine. In these practices, patients pay a premium to the physician in return for higher level medical services. These physicians can earn the same income, or more, while caring for much fewer patients.

Why Do Insured Patients Pay More For Concierge Care?

• Same day appointments

• On time office visits that last as long as needed

• Direct access to the physician’s cell phone

• Physicians accompanying patients to specialists’ offices

• Comprehensive annual physical examinations and health review

• Emphasis on preventive medicine, nutrition and wellness

• Posh waiting rooms with New Age soothing music

Concierge Medicine Criticisms

• It’s not fair

• Insured patients should be getting these services anyway

• It’s elitist

• It siphons primary care physicians away from those who can’t afford concierge care

Concierge medicine didn’t emerge in a vacuum. It was not concocted by greedy physicians who were seeking to provide Cadillac care so they could continue to drive Cadillacs.

1903 Cadillac



Boutique medical practices have become popular because private practice primary care physicians faced three mounting challenges.

• Financial pressure with declining reimbursements and rising overhead

• Declining quality of care from seeing higher volume of patients

• Burnout

Concierge medicine is a response to this reality. Concierge practices are financially solvent and provide premier quality medical care to a smaller group of patients. This is not exclusively a benefit for the wealthy. Many average income folks have decided that spending $100 each month for superior medical services is worth it for them and their families. How much do you spend each month on your cell phone? Is concierge medical care more important to you than an iPad, a smart phone or joining a pricey gym? We all make choices in how we spend our money.

For those who want this higher level service for their families, they may need to cut back on other expenses. What kind of car are your driving now? Full size? Luxury? Sports Car? Hybrid? Perhaps, it is worth downsizing your wheels and upgrading your medical care.

I realize that many folks don’t have this option right now, particularly under current economic conditions. We all wish that they, and everyone, could receive concierge level medical care, but this is not how our society works.

Concierge medicine isn’t the avaricious aggressor here. It’s self-defense.

Does Revised American College of Physicians Ethics Manual Need Revision?

I regard myself as a spirited patient advocate. (What doctor doesn’t?) When facing a patient, I try to focus entirely on the patient’s interest. My advice is hopefully not tainted by the patient’s insurance status or external influences. A patient without medical insurance should receive the same medical advice as a corporate CEO, although the former may reject the medical advice for financial reasons.

As Whistleblower readers know, I am a conservative practitioner of the art and science of gastroenterology. I first developed this medical world view as an intern and resident, and remained a parsimonious practitioner even after completing a gastroenterology fellowship at an institution where patients were routinely subjected to a tsunami of testing.

I don’t pull the colonoscopy trigger easily or order many imaging studies. I prefer to prescribe a tincture of time instead of a test. Most patients appreciate this measured approach, although some prefer the tsunami.

I don’t practice conservatively because it is cost-effective. I do so because I think it’s best for patients. I think it is inarguable that our patients are over imaged, over treated and over tested. I am convinced that there is more than enough wasted money in the health care system to rescue it. Reminiscent of Eisenhower’s warning of a military industrial complex, we are now trying to chip away at a medical industrial complex that is an expanding hydra that takes no prisoners. This is not to suggest that I support Obamacare as a remedy,.  I don't. For a fuller airing of my Obamacare opposition, I invite you to wander through the Health Care Reform Quality category on this blog. But, our health care system surely needs better health. It has inadequate access for millions of patients, conflicts of interests, misaligned incentives and quality lapses that must be addressed. I think that Obamacare aims to restrain excesses and remedy deficiencies by settling for mediocrity. I’d rather strive for excellence.

Physicians are strongly advised to practice cost-effective medicine, a practice that is often resisted by patients who interpret this as an effort to save money at their expense. Of course, the term cost-effective communicates that the mission is to save dollars and not save lives. Perhaps, the medical linguists who have concocted phrases including pay-for-performance and medical provider and pharmacy benefit manager can create a more appealing label. Here are some suggestions.

• No Frills Medicine
• Cheapo Medicine
• Medicine on Five Dollars a Day

Seriously, even the hackneyed evidenced base medicine (EBM) phrase would be a step forward. However, EBM is limited since so many clinical issues that doctors face must be addressed without any available medical evidence to guide us. Perhaps, readers have a suggestion of a better phrase than cost-effective. 

Recently, the American College of Physicians issued revised guidelines in its newly published ethics manual that instructs physicians that our responsibility extends beyond the patient before us. Here’s an excerpt.

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.

This is an ethical game changer. According to the updated ethics manual, physicians should consider preserving health care resources for the population at large, which may conflict with our patient’s interest. Now, we are told that we are ethically obligated not only to advocate for our own patient, but also for hundreds of millions of other patients. If this becomes standard operating procedure, how will it impact the doctor-patient relationship? Will patients, who are increasingly skeptical of the medical profession, trust us? Will they suspect that we are restraining their care to serve the greater good?

I think that the merits of cost-effective medicine can be persuasively made to individual patients without having to consider society’s needs. Of course, preserving medical resources and health care reform are legitimate issues. But, do they belong in the exam room?

How would patients respond to the following question?

When seeing your doctor in the office, do you expect that he is focused on

(a) your medical interests exclusively?


(b) your medical interests exclusively on Mondays and Wednesdays?


(c) your medical interests exclusively if you are a concierge medical patient?


(d) your medical interests and society’s need to save money?

Physicians are trained advocates. Remind me, who are we advocating for?

As always, your comments are most welcome.

Cigarette Warning Labels May Go Up in Smoke

We live in a free society. One of our most treasured freedoms is our right to free speech. This means that we are free to advertise goods and services to potential customers, although commercial speech does not enjoy the same constitutional protection as does noncommercial speech. Some advertised products are good for us and others aren’t. In many cases, the worth and value of the product are in dispute. Nevertheless, if a product is legal, the manufacturer is entitled to advertise and to lure customers.

While an advertisement may not be false, it may not be the complete truth either. We expect that these pitches will be buffed and sanitized to present the product in a favorable light. That’s why they’re called advertisements, and not testimony.

It would be absurd for a company to include negative material about its products in its promotional materials, barring a legal requirement to do so. While issuing product warnings and legal disclaimers may be a laudable public interest maneuver, it’s not a way to run a company.

Imagine the following scenarios.

Join Our Tanning Salon. Get skin cancer!

Join Our Gym. Have a stroke on our treadmills!

Dine at our Family Restaurant. We don't wash hands!

Computer Protective Services Our PCs have viruses!

Expert Car Repair. We're Crooks!

The tobacco companies, the mother of all villains, had been required by the Food and Drug Administration (FDA) to include graphic and dire death and illness warnings prominently on their packages. One of the warnings depicts a corpse with the traditional autopsy incision visible. I don’t dispute the accuracy of the health claims. Indeed, I’ve often issued them personally as a doctor in my office. But is it fair, reasonable and necessary to compel cigarette companies to scare folks from purchasing their legal products? It would be more rational and intellectually honest for the FDA and the federal government to declare tobacco to be illegal. How can they permit a product so dangerous to be freely sold to the public? The reasons that restrain them from doing so are self-evident. Readers are free to offer their own views on the government’s paradoxical (in)action.

A federal judge recently issued a preliminary injunction against the FDA’s edict arguing that the cigarette companies were likely to prevail in a First Amendment challenge. The judge recognized that graphic and macabre material likely exceeded a reasonable government requirement to inform smokers of health risks on cigarette packaging. Their purpose was quite transparently to shock, not inform. Not surprising, my beloved liberal New York Times has editorialized that the judge’s injunction was wrong. This judge, in my view, was spot on. I predict that his ruling will be upheld on appeal.

As an aside, are there folks out there who are not aware that smoking cigarettes is not a salubrious activity?

Our medical office needs new promotional material. Since I’m a taxpayer, perhaps the FDA can assist me. Here's my draft.

Michael Kirsch, MD

Specialist in Screening Colonoscopy

WARNING!

 He Has Perforated Many Colons.

You Might End Up Here!