Sunday, December 9, 2018

Chinese Researcher Defends Gene-Edited Twins -The World Must be Wrong

Physicians confront alcoholism regularly.   Indeed, nearly every day on my hospital rounds, I treat patients who are suffering the ravages of alcohol abuse.   While these patients may have a genetic predisposition toward alcohol abuse, or faced other personal pressures and demons, ultimately the disease is initiated by a person who made an unfortunate decision.  I do not judge these individuals as their doctor, any more than I do my hepatitis C patients who contracted the virus as a result of intravenous drug use.   But, when are examining the causes of these maladies, personal responsibility and accountability must be considered.  In fact, failure to do so will frustrate our efforts to prevent various injurious addictions. 

Physicians and others have heard the vignette when an alcoholic denies his addiction despite that every other person in his life feels otherwise.  “They are all wrong,” he states emphatically.

'I can quit anytime.'

There are many examples of individuals who stand their ground despite popular disapproval.  This might represent truly noble behavior and high principle when a person defies public opinion by doing the right thing.  This is called leadership.  More commonly, when a person lurches forward in defiance of the opinions and advice of experts and others, it is not leadership, but ignorance, hubris and arrogance. 

Recently, a Chinese researcher announced that a set of twins were born after altering their genes so that they would be protected against infection with the HIV virus.  The scientist announced that other births with gene alterations would be arriving soon.  I’ll not relate the scientific details, much of which is beyond my knowledge and understanding.  But, readers need to be aware that these genetic changes will not only affect the specific individuals but would be passed onto their offspring.  If true, it would constitute a permanent and heritable change in a person’s genetic code.  This is to be distinguished from utilizing genetic science to treat a single patient only, a more ethically palatable procedure.

I’ll leave aside the obvious fears that such a wanton ethical breach generates.  Even a lay person can appreciate the potential dangers at play here.  Scientists and ethicists could give us a fuller account of what is at risk.  And they themselves would admit: ‘Imagine what we don’t know’. 

The global ethical community, including in China, expressed opprobrium against this arrogant, dangerous and rogue action.   It is rare for any of us to witness an issue that unifies people, organizations and nations that are so often in conflict.  

The Chinese researcher in the face of worldwide outrage continues to defend his work.  In other words, the world is wrong. 

When there is responsible opposition to our own views and beliefs, shouldn’t we consider that we might be wrong?

Sunday, December 2, 2018

The Risks of Drug Side Effects - A Case for Caution and Humility

I prescribe heartburn medicines every day.   There’s a gaggle of them now – Prilosec, Nexium, Prevacid, Protonix – to name a few.  As far as experts know, their primary effect is to reduce the production of stomach acid.  This is why they are so effective at putting out your heartburn fire.  In simple terms: no acid, no heartburn.

I am quite sure that well-meaning physicians like myself do not understand or will ever know all of the unintended effects of tampering with a digestive process that took a few million years or so to evolve.  Are we so arrogant that we believe that these drugs only target gastric acid production? 

They are absorbed into the blood stream and course through every organ of the body.  Is it not conceivable that certain tissues might be sensitive to these foreign invaders?  Might there be unintended consequences that occur far downstream well beyond our horizon similar to a butterfly effect.    Do we really think that gastric acid is present just to bother us and it serves no useful function?

A minor change in a complex system can cause faraway effects. 

The human body is a supremely elegant, complex and integrated structure.  Tampering with one part of it may have wildly indirect consequences so far removed that we will not recognize the connection.  Consider these examples:
  • A certain class of antibiotics can cause rupture of the Achille’s tendon.
  • An anti-malarial medicine can cause nightmares.
  • Rotovirus vaccine can cause intestinal blockage.
There is science underlying the 3 examples above, but consider how implausible the causal connections between the drugs and the side-effects are?  Imagine what we don’t know.

This is why seasoned medical professionals prescribe new medicines sparingly.    A new vanguard of medicines has entered the arena.  Biologic medicines have stormed into the medical universe promising to stem the progression of many stubborn diseases such as Crohn’s disease, rheumatoid arthritis, psoriasis and ulcerative colitis.   We have all seen commercials for these agents on television, where the actors posing as patients are always fit and often engaged in some athletic activity.   These medicines, which tamper with the immune system by design, must be taken FOREVER.   The list of potential known side effects covers several pages in small print and range from life-threatening infections to cancer.  And, to repeat a line from this very post, imagine what we don’t know.  

The human body is a masterpiece of design and function.  When we pull on a thread, we may be distorting the far corners of the tapestry and never even realize that we were the culprit.

My advice to my colleagues and to my patients?  Be skeptical and humble always.

Sunday, November 25, 2018

Thanksgiving 2018 - Finding Joy in a Dark World

We are still recovering from the tragedies in Pittsburgh and Chicago.  Fires out west have roared over thousands of homes with more fatalities than have been yet accounted for.   Immigrants streaming toward our southern border in search of a better life are demonized and politicized.  Our nation's allies who have stood with us for a century are now reassessing their faith in our faithfulness.  Our free press, despite its lack of accountability and presence of bias, is under unfair attack.  Harvard's preferential admission policies have become exposed with other universities to follow.  Road rage had become the rage.  Facebook has exploited and deceived us. Truth has become an elastic concept.  Our political opponents are regarded as enemies.  I win if you fail.  The citizenry has deepened its disgust and cynicism.  An errant remark can lead to public vilification and loss of a job or reputation.  We have become an angry populace.

What did you discuss at your Thanksgiving tables?  Did you reach across the table in fellowship?  Was the table regarded as a politics-free zone?  Or, did you simply enjoy the experience as a needed oasis from the surrounding darkness and cacophony?

We have made the work of repairing the world harder than ever and harder than it has to be.  I truly believe it can commence 1 person at a time with the smallest of gestures.  Buy the person standing behind you in line at Dunkin' Donuts a cup of coffee.  You'll be rewarded by a sincere smile.  Smile back with a soft reply to 'pay it forward'.

Yes, I am very thankful for so many blessings and good fortune, much of it undeserved.  I truly hope that all of us found some joy that they could enjoy and share with others.

Sunday, November 18, 2018

Overdiagnosis Threatens Elderly Patient

Yesterday, a physician asked my opinion if a patient needed a colonoscopy.  My partner was already on the case and I was covering over the weekend.  The facts suggested that a colonoscopy was warranted.  The patient had a low blood count and had received blood transfusions.  Certainly, a bleeding site in the colon, such as a cancer, might be responsible.  We do colonoscopies to address similar circumstances on a regular basis. 

Why did my partner and I demur in this case?

We Placed this Sign on the Patient

Because to us, our medical judgment trumped the medical facts.  First, the patient was elderly and extremely debilitated.  The challenge of having an individual in her state ingest the necessary laxatives is likely insurmountable.  If any readers have enjoyed the delight of guzzling down a colonoscopy prep, contemplate doing so as an elderly, ailing and bedbound individual.

I asked the physician if the patient’s family would consent to surgery if a cancer was found. 

“Absolutely not”, she responded. 

Now there were two strikes against proceeding with a colonic invasion.  Beyond the near cruelty of the laxative prep, if a cancer were found, then it would be left in place.  So, why subject the patient to the risk and indignity of a diagnostic test that would not help her?

Readers here with medical knowledge can offer hypothetical diagnoses for this patient where a colonoscopy or scope exam of the esophagus and stomach could make a difference. I acknowledge this.  But, medicine is not a pure discipline like mathematics.  There are always exceptions and we are never 100% sure of anything.  Regardless, I believe that the evidence against subjecting this patient to scope examinations is beyond a reasonable doubt. 

When a diagnostic test is being proposed to you, make sure that it will make a meaningful difference in your care.  Will it yield information that you and your physician want to know or need to know?   

Sunday, November 11, 2018

The Agony of Insurance Company Denials

I just read of a a jury award in excess of $25 million against an insurance company who denied a recommended cancer treatment to a patient who ultimately died.  I do not wish to review here the particulars of this case, and admit that my knowledge is limited by one news report that I read earlier today.  While I will not invoke the ubiquitous phrase FAKE NEWS, I always bring some measure of skepticism to various news sources, even those who enjoy excellent reputations.  

The Olde Town Crier Always Told the Truth

But this jury case raises an issue that physicians and patients wrestle with regularly.

The physician prescribes a medication or recommends a treatment.

The insurance company denies coverage for the recommendation.

Sometimes, the reason for the denial is entirely reasonable.  For example, if an insurance policy restricts a patient to a network of physicians, the company will deny coverage if the patient wants to seek care out of the network.  It would not be reasonable for a patient who had access to network cardiologists to expect that a visit with an out-of-network cardiologist would be covered. 

Sometimes, the reason for a denial is absurd.  A physician prescribes a medication.  The insurance company denies coverage insisting that the medicine would be covered only if different medicines were tried first and were not effective.  The term for this is step therapy requirement and doctors despise it.  So, this is not a categorical denial, like with the cardiologist example above, but is a qualified denial.  The medicine is covered if the physician complies with insurance company edicts.  Here’s what the physician might tell his patient.

“I prescribed a medication to you that my training and experience informs me is the best choice for you.  Instead, let’s spend the next few months giving you some different medicines, just for fun.  I don’t think this medicine really makes sense in your case; that’s why I didn’t prescribe it.  Your insurance company, who always has your health and welfare as its highest priority, want us to wander off course for a while.  Who knows?  Miracles happen.  Maybe the stuff might work by accident.  No need to fret too much.   Eventually they will give in and you will ultimately get the right stuff covered.  And think of all the quality time the two of us will enjoy on our journey together!”

Here are some of the benefits of the qualified insurance company denial.
  • It wastes money.
  • It exposes patients to risks of side-effects from unnecessary medications.
  • Physicians and their staffs get to fill out lots of fun forms filled with ridiculous documentation requirements.  This is a welcome distraction for our staffs from the stress of their typical office responsibilities.
  • Some patients and physicians simply give up.  Do you think this might be one of the unstated goals of Big Insurance?
  • It delays the right medical treatment.
  • It pisses off patients.
  • It pisses off doctors.
  • It reinforces the narrative that insurance companies are self-serving corporate entities whose overriding mi$$ion is profit.
There are also many occasions when a denial is neither clearly reasonable nor unreasonable.  It can be difficult to determine if a recommended treatment is standard or experimental, especially if experts disagree on this point.  This is not a major issue if one is considering a treatment for acne.  But, what if an oncologist recommends a bone marrow transplant (BMT) for a desperately ill person, which some experts and institutions regard as experimental?   Does it matter if the F.D.A. has not approved the treatment?  What if other countries have decided that a BMT in the same circumstance is standard treatment?

These scenarios can be agonizing and vexing for patients, family members, physicians, insurance company personnel, the public and juries to sort out.   I have no easy formula to offer readers.

Just because a doctor recommends a treatment, doesn’t mean it is established care.  And, just because an insurance company denies a treatment, doesn’t mean the company is evil.  

If one of my loved ones was desperate for a medical treatment, and many doctors felt it was the right and reasonable choice, I know how I would feel.

Sunday, November 4, 2018

Light and Darkness in Pittsburgh

The lights went out in Pittsburgh 8 days ago.   The shade from this moral eclipse reached far beyond the Pennsylvania border and, indeed, extended throughout the nation and onto foreign lands.  I know Squirrel Hill well, having performed medical training in Pittsburgh a few decades ago.  I’ve been to the Tree of Life synagogue in the prior era when none of us were afraid to engage in the routine activities of life. 

I am saddened and horrified to witness yet another momentary triumph of evil.  I wondered how it is possible that a person who was born pure could over time morph into a seething cauldron of hate, completely unmoored from the moral guideposts that keep us civilized.  

The man who stormed the innocents, wounded by selfless law enforcement professionals, was taken to the hospital to receive medical care.  Yes, we cared for his health and his life, despite that he massacred others who were in synagogue to pray and to celebrate a new life that had recently come into this world.  His nurse, a Jew, attended to him.   A society and individuals are defined by their ability to show compassion – not when it is easy to do so – but when it is hard. 

Example of an Eternal Light in a Synagogue Hovering over the Holy Ark

There has been much chatter if other people and influences might bear some indirect responsibility in this tragedy.  In my view, this is not the time to introduce other agendas that distract us from what should be commanding all of our attention.   

I remarked above my amazement that the hate of a thousand men could be contained in one man.  At times, we see the opposite phenomenon.  From time to time, we encounter a person who exudes more love, faith, tolerance and compassion than we think one man can possess.  Mr. Rogers lived near the Tree of Life synagogue.   

“Mr. Rogers, you left us too soon.  We need you so desperately.  Can you find your way back here even for a day?” 

The wound is grievous and raw.  I cry inside for the families and the Squirrel Hill community.  Within the Tree of Life synagogue, as in all Jewish places of worship, is an eternal light, which is situated in the front of the sanctuary.   With this light which still burns today, and all of our own lights, we must strive to wash away the darkness.  The work will never be done. 

Sunday, October 28, 2018

Behind the Scenes in a Medical Office

Here is a potpourri of medical vignettes.   All are real life scenarios that I have experienced in my practice.  The absurdities of life also permeate the medical profession.  An insider’s view of medicine, as in any profession or industry, may be less sanitized than its public face.  Here are some Scenes from Scopesville, Ohio.

Act I, Scene I
  • Patients are routinely told that they should not eat or drink on the day of their colonoscopy.   Recently, a patient decided that these instructions did not prevent him from eating a full breakfast.  This is where the phrase, ‘you prepped for nothing’, applies.
  • A patient comes to see me on the advice of his primary care physician.  He has no idea why he has been sent.  Let the sleuthing begin!
  • A patient asks for a work excuse for the entire week following his colonoscopy.
  • I am asked to fill out disability papers for a patient I saw once a year ago.
  • A patient complains to me and my staff about a $20 copay.  We have nothing to do with this fee, which is established by the insurance company.  He who collects the money must be at fault.
  • A patient arrives 45 minutes late and still expects to be seen.
  • A doctor arrives 45 minutes late and acts as if he is on time.
  • The insurance company denies a patient’s prescription.   Of course, these corporate folks deny that they deny anything.  They use phrases such as, ‘…the medicine your doctor prescribed is not a covered benefit.’  In other words, they are not technically forbidding the physician from prescribing anything.  If it’s the physician’s best medical judgment that his patient needs a $4,000 a month drug, then the insurance company would never block this.  They just won’t pay for it.
  • A patient is sent to see me who barely speaks English without a translator.   This is always fun for me and the staff. 
  • A patient is transferred to my office from a local nursing home.  The documentation explaining the reason for the visit is poor or absent and the patient may be demented or ill to provide meaningful details. This has happened repeatedly.  Each time it does, I make a phone call to the nursing home staff and offer a candid and pointed assessment of my view of this inexcusable conduct.  
  • A patient does not bring in a list of her 11 medications, as every patient is instructed to do.   
  • A patient asks me, the gastroenterologist, to refill the cardiac medicines.
  •  A patient wants a referral to a primary care physician.  She prefers a female physician.  I point out that I am a male.
  • A patient asks me how much a colonoscopy costs and is perplexed that I do not know the answer. 
I hope that you enjoyed Act I of this literary work in progress.  Interested to see Act II?

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