Sunday, September 28, 2014

Which Medical Specialty Should Medical Students Choose?

A medical student recently asked my advice on her decision to pursue a career in dermatology.  It was about 25 years ago when my own parents encouraged me to pursue this specialty.   What was their deal?  Perhaps, they anticipated future developments in the field and were hoping for free Botox treatments?   As readers know, I rejected the rarefied world of pustules and itchy skin rashes for the glamor of hemorrhoids, diarrhea and vomit. 

My parents were making a lifestyle recommendation.     Dermatologists are doctors who sleep through the night.  Spying one in a hospital is a rarer sighting than spotting a liberal Democrat at a Michelle Bachmann rally (unless a planted heckler).  Nocturnal acne medical emergencies are uncommon.   And anyone who has had cosmetic work done understands painfully that this is a cash business.

Diagram of Skin
Luckily, the Whistleblower is thick-skinned

Here’s where some readers or Dermophiles will accuse me of skin envy.  Not true.  Some dermatologists may be a tad thin-skinned over this assertion, but facts are facts.  These docs have a soft lifestyle and earn much more money than most physicians do.   Sure, these guys and gals see some serious stuff, but the nature of their specialty is less intense and frenetic than that of other colleagues.  

Many professions push back when it is suggested that they are afforded unique and soft perks that most of us don’t have.  Teachers, for example, never state out loud that having every Federal holiday off, enjoying school vacations every few months and having 10 weeks off in the summer are unbelievable soft padding that no one else has.  We know you work hard under difficult circumstances and we respect you and your profession.  But just admit that you have some unbelievable professional cushions.  This won’t diminish your self-worth or contributions to society. 

Many medical interns and residents don’t consider lifestyle when they are making their career choice, and they should.  Obstetrics is thrilling when you are 30 years old.  Fifteen years later when you are overworked, tired and have your own kids, it may be slightly less thrilling to bring new life into this peaceful world in the middle of the night on a regular basis. 

For me, leaving my own bed at an ungodly hour to haul out to the hospital is an unwelcome activity.  I do not relish being awakened with phone calls or having to attend to an individual in the emergency room when the rest of Cleveland is soundly snoring.   While gastroenterology is a more taxing specialty than the skin gig, it is still uncommon for me to have leave for the hospital during the black of night.   Since we are in the era of medical hospitalists who are on staff around the clock, there is only a rare need for me to make a personal appearance.   On most nights, my scope rests securely in its holster. 

Do I think that medical students should consider lifestyle as they are contemplating their future?   Absolutely.   Indeed, the emerging culture of the medical profession has morphed from the prior culture when doctors worked 24/7 and interns were proudly on-call every other night.   Medical doctors today are increasingly employed by institutions, work shifts and delegate the hassles of hospital life to hospitalists. Doctors are self-prescribing R & R.  

Leisure, relaxation, avocations and personal time for reflection are not evil pursuits.  They are the fuel that cultivates and sustains our humanity.   Who wouldn’t welcome a little more humanity in the medical profession?



Sunday, September 21, 2014

Medical Complications Torture Doctors Too

If you are a physician like me who performs procedures, then rarely you will cause a medical complication.  This is a reality of medical life.  If perforation of the colon with colonoscopy occurs at a rate of 1 in 1500, and you do 3000 colonoscopies each year, then you can do the math.

Remember that a complication is a blameless event, in contrast to a negligent act when the physician is culpable.  These days, for many reasons, an actual complication is confused or misconstrued as an error.
Some complications are more difficult on physicians than others.  For example, if I prescribe a medication and the patient develops a severe rash, I do not feel personally responsible.  It’s the drug’s fault.  However, when I perforate someone’s colon as a medical complication, I feel responsible even if this act was a blameless event which will occur at a very low but finite rate.  (Of course, there are perforations of the colon which result from medical negligence, but I am leaving these aside to make my point here.)  

I Didn't Cause This Rash.  The Drug Did It!

I feel responsible because my hand was on the instrument that caused harm.   I can’t as easily blame the scope, as I blamed the rash-causing drug.   I’m sure that surgeons feel the same painful emotions when they perform a routine operation and serious bleeding results that requires additional surgery and complicates what should have been an uneventful recovery.

When your hand is on the colonoscope or the scalpel, and the unexpected happens, it’s an awful experience for the doctor even if we have performed according to proper medical standards.
Of course, serious medical complications are much more difficult for the patients and families involved than they are for us.  But, we physicians suffer greatly when a patient is harmed from a procedure that we recommend and perform.    You can imagine how we torture ourselves with second-guessing when these events occur.

Complications are inevitable.  The only gastroenterologist who hasn’t had a perforation of the colon is one who is brand new.   So, if you are drawn to a gastroenterologist because he has a 0% perforation rate, caveat emptor!   Paradoxically, the most experienced colonoscopists have accumulated many more complications over their career because of a much higher volume of cases or that they are referred very challenging cases by virtue of their skill and experience. 

A medical complication is an especially difficult event when it occurs in what was expected to be a routine outpatient examination.   Patients who come to our office for a screening colonoscopy understandably expect to be home 2 hours later.  So do we.  On those rare occasions, when this recovery path is altered, we must have a very serious, sober and unexpected conversation with the patient and the family.  Our plan is always to tell the truth and reassure all involved that we will do all that we can to make it right. 

Medicine is not a simple or predictable endeavor.  Sometimes, it can be rather complicated.

Sunday, September 14, 2014

Should You Trust Your Doctor's Advice?

Is your doctor a hammer and you're a nail?  Here's some insider's advice coaxing patients to be more wary and skeptical of medical advice.  Should you trust your doctor?  Absolutely.  But you need to serve as a spirited advocate for your own health or bring one with you.  Ask your physician for the evidence.  Sometimes, his medical advice may result more from judgement and experience as there may not be available medical evidence to guide him.  Make sure you have realistic expectations of the medical out me.  And most importantly, try as best you can to verify that the proposed solution is targeted to your problem.

Is Your Doctor a Hammer?

Consider a few hypothetical scenarios.

A 66-year-old patient has chronic right lower back pain.  Physical therapy has not been helpful.  Radiological studies show a moderate amount of hip arthritis.  A hip replacement is flawlessly performed.  The orthopedist discharges the patient from his practice.  The pain is unchanged.

A 60-year-old patient has chest pains that are not typical for angina.  Her internist arranges a stress test and the results are equivocal.  A cardiologist performs a cardiac catheterization and a moderate narrowing is found in an artery.  A stent is successfully placed in the proper location.  The patient is reassured that her cardiac pipes are all wide open.  She returns to see him a month later wondering why the pains have continued.

A 50-year-old patient sees his gastroenterologist for stomach pain.  An ultrasound confirms the presence of gallstones.  The patient accepts the specialists advice to have his gallbladder removed.  The operation proceeds smoothly.  You can guess the rest.

This is not meant to serve as an indictment of the medical profession.  The examples above have been highly simplified to make a point.  First, making accurate diagnoses are complex undertakings that can frustrate even seasoned diagnosticians.  Patients' medical histories are often vague and evolving.  Many diseases and conditions have clever mimics that can lead doctors astray.  Every doctor can regale you with anecdotes detailing episodes when they have been fooled.  There isn't a medical doctor alive who hasn't fumbled over a case of chest pain. 

Just because medical advice doesn't lead to the desired outcome, doesn't mean that the advice was wrong.   I concede, of course, that bad medical advice can cause adverse outcomes, a self-evident statement. 

Despite the vagaries and uncertainties in the medical arena, physicians try as best we can to propose a remedy that is directed to your symptom, rather than serve as a fix for something that is not ailing you.  My advice to patients is that when your doctor is raising the healing hammer, is to try not to get nailed. 

Make sure this inquiry is in your tool box.  "Doctor, can you please explain why the treatment will cure the symptom that brought me to you in the first place?

Maybe a hammer is the right tool for you.  Without doubt, the time to have this conversation is in advance of pulling the treatment trigger. Having realistic expectations can prevent future frustration when a treatment doesn't bring you to the end zone. 

So, next time your physician proposes a plan of action, hammer away.




  

Sunday, September 7, 2014

Bariatric Surgery: Pulling the Gastric Bypass Trigger Too Soon

If losing weight were easy, we'd all be skinny.  If exercise were fun, we'd all be doing it.  If quitting cigarettes were effortless...

What should our response be toward rising societal tonnage?

A Weighty Issue
  • Pass laws restricting access to the wrong type of food.  Former Mayor Bloomberg got stiff-armed on this approach by the courts.  It's also always fun to watch folks argue over the definition of a 'wrong food'.  The debate on which foods warrant prohibition at least brings some entertainment into the public square.  Imagine trying to achieve consensus over 20 or so food items that should be banned.  If this task were actually accomplished, cigarettes and alcohol would still be legal.  Make sense?
  • Initiate a massive public education campaign to scare us skinny. Show ads of scary pictures with scary music reminiscent of an iconic anti-drug ad (This is your brain on drugs...) from a few decades ago.
         "This is your heart."  Screen shows cartoon of a happy and vigorously beating heart.
         "This is heart on ice cream."  Screen shows depiction of gasping and quivering organ, coughing up fat              globules.
          How would we fund this effort? Simple.  Tax the manufacturers of 'wrong food''.
  • Allow individuals to choose their food and beverages freely and to accept any health consequences of their decisions.  (LOL on steroids here.)
  • Give tax breaks for every 5% loss of excess body weight.  Interesting concept.  Might thin folks file a discrimination lawsuit here?
Most folks who are overweight want to be thinner.  The reasons why folks carry extra weight are complex and are not simply because they eat too much.  There is a powerful mental component that for many people is part of the problem and must be part of the solution.   Sure, caloric control is fundamental, but many overweight people do not eat just to satisfy hunger.  They do so for other reasons which must be attacked directly if a successful outcome is to be achieved and sustained. 

The quick fix has been luring folks with false promises for generations.  Infomercials on the air every day hawk agents that will melt fat away, although there always appears a disclaimer in a font size too small for the human retina to discern that states that 'results not typical'.  The threshold for recommending bariatric surgery is getting progressively lower, and it has not hit bottom yet.  My sense is that this treatment is becoming regarded as a routine remedy, rather than a last resort measure after multiple other attempts have failed.  I suggest that many dieters may not be as disciplined and determined with conventional weight loss programs knowing that a bariatric rescue is available. 

Obesity is a serious health issue without an easy external cure.  Weight  loss medicines are either ineffective or dangerous.  Fad diets don't work.  Gastric bypass surgery is a serious operation that profoundly changes every day of your life by design when it is working properly. 

Weight loss can be viewed as two distinct tasks.  Losing weight and maintaining the loss.
Success, in my view, will come from within. 

Weight loss is not a sprint, but is a long distance run.  Consider this point.  Very modest lifestyle changes over time can deliver big results.  Lose a pound per month, for example.  Do the math and calculate your new weight 2 years later.  This cold math works the same way if we gain a pound each month.

Write down your reasons why you are overweight.  Are these reasons stronger than you're desire and commitment to change?  If not, then get yourself to the starting gate.  Your marathon run is about to commence.




Sunday, August 31, 2014

The Meaning of Labor Day

Labor Day is here.  Like many of our National Holidays, we have forgotten the meaning of the day.  Is Memorial Day a time to reflect upon those who sacrificed so we would be free, or a time to grill burgers on the barbecue?   Same with the Fourth of July.  Martin Luther King Day is just a day off for many of us.  If greater participation and reflection on MLK is the objective, then why would this day be on a Monday when most of the country is at work?  Even Christmas, a holiday season that I enjoy but do not celebrate, has shed its deep religious significance having become a commercial enterprise.  This reality, I suspect, must sadden and disturb many believing Christians.

Labor Day, when many of us will be laboring over charcoal-broiled ribs and chicken, was created to remember and honor this country’s labor unions. 

Triangle Shirtwaist Factory Fire 1911

While I am hostile the politics of unions today, I readily acknowledge that they were a necessary response to egregious abuse by management.   The percent of workers who are organized today, and their influence, has been steadily declining.  Right-to-work support has risen as workers and the rest of us resist practices such as non-union workers being compelled to pay fees to the union.  I do not believe that an individual should be forced to join a union or to pay them fees.  Such coercion violates the free choice that a worker is entitled to, in my view.  Yes, I know the argument that union protections extend to non-union workers who should not receive a free ride by enjoying benefits that they do not pay for.  I simply believe that the right-to-work argument is more persuasive.

I am not against unions, but I do not support forcing people to pay them who do not wish to join.  If participation in a union will deliver greater benefits to workers, then these workers will want to join on their own free will.  If you have to force someone to do something, then I wonder if the ‘benefit’ is real. 

Years ago, while attending the National Storytelling Festival in Jonesborough, Tennessee, I remember listening to professional storyteller Gay Ducey tell a few thousand of us her rendition of the Triangle Shirtwaist Factory fire in 1911, a disaster where nearly 150 workers perished, when they could not escape from a burning building as the doors and exits were locked by management.  I was spellbound during her hour long recitation, and I have never forgotten it. 

Let’s give a nod to all those who go to work every day, supporting their families, and bringing goods and services to all of us.

I support a Right-to-Read principle.   I can’t compel anyone to read and meditate on my weekly homilies.  You have to want to come here.  And, I hope that you will.   

Sunday, August 24, 2014

Good Riddance to Routine Pelvic Examinations

So much in medicine and in life is done out of habit.   We do stuff simply because that’s the way we always did it.  Repetition leads to the belief that we are doing the right thing.
In this country, we traditionally eat three meals each day.  Why not four or two? 

We prefer soft drinks to be served iced cold.  I’ve never tried a steaming hot Coke.  Maybe this would be a gamechanger in the food industry?

Life gets more interesting when folks question long standing beliefs and practices forcing us to ask ourselves if what we are doing makes any sense.
In the medical profession, a yearly physical examination was dogma.  Now, even traditionalists have backed away from this ritual that had no underlying scientific data to support it.  Yet, patients would present themselves to this annual event believing that this ‘check-up’ was an important health preserver. 
Here were some medical routines that were never questioned.
  • Yearly ear drum examinations with the otoscope.   Always exciting.
  • Palpation of the abdomen.
  • Listening to the lungs with a stethoscope.
  • Testing your reflexes (Sure, this was fun, but did it help anyone?)
Keep in mind that I am referring to components of the physical exam that are performed on asymptomatic individuals who feel well.  Obviously, listening to a patient’s lungs has more value if a patient has fever and a cough.

Yes, I recognize that there may be an intangible value in having a physician make physical contact with his patients, which some argue help to create a bond in the relationship.   This may be true in part as patients have been taught to expect this from their doctors.  Indeed, a ‘hands off’ physician may be construed by patients as being an inattentive or even an incompetent practitioner. 

Recently, the American College of Physicians issued a new guideline published in the Annals of Internal Medicine stating that routine pelvic examinations should not be performed.  Why?  Because there is no persuasive evidence that they do any good.

Hands Off Gynecologists!

Sure, there will be pushback.   In medicine and elsewhere, there is often resistance to change from those whose practices are being challenged.   Review the following complex table that I have prepared.

Procedure Under Review      Resistors
 PSA                                                       Urologists
Mammograms                                   Radiologists
Colonoscopies                                   Gastroenterologists
Term Limits                                        Politicians
Tort Reform                                        Take a guess

If all of the elements of a routine check-up were subjected to scientific scrutiny, we might be shocked at how little of the exam remained.   This might create an unintended benefit.  It would free up time that we physicians could use to talk more with our patients.  So far, no scientific study has deemed this to be a waste of time.   



Sunday, August 17, 2014

Physicians Lose Right of Free Speech

I’m all for free speech and I’m very hostile to censorship.  The response to ugly speech is not censorship, but is rebuttal speech.   Of course, there’s a lot of speech out there that should never be uttered.  Indecent and rude speech is constitutionally protected, but is usually a poor choice.    We have the right to make speech that is wrong.

Does First Amendment Apply to Physicians?

I relish my free speech in the office with patients.   I am interested in their interests and occupations and sometimes even find time to discuss their medical concerns.  I am cautious about having a political discussion with them, but patients often want my thoughts and advice on various aspects of medical politics, and I am willing to share my views with them.   I don’t think they fear that politics or any other issue under discussion will affect their care.  It won’t.

A Federal Appeal Court recently decided in a Florida case that physicians could be sanctioned if they asked patients if they owned firearms if it was not medically necessary to do so.  Entering this information into the medical record could also result professional discipline.  The court was considering such gun inquiries to be ‘treatment’ and not constitutionally protected speech.

I am on the record in this blog more than once that I do not think we should look to the courts to make policy.  Their task is simply to rule on the legality of a particularly claim.  In other words, we should not criticize a legal decision simply because we do not like the outcome.  Nevertheless, this decision is simply beyond wacky and could create a theater of the absurd in every physician’s office

Could the following examples of physician inquires be prohibited?

  • A psychiatrist cannot ask about cigarette smoking as this is not relevant to the patient’s depression.
  • An internist cannot ask what the patient’s hobbies are as this is not germane to the medical encounter.
  • A gastroenterologist asks his patient who is a chef for a recipe and risks professional sanction for crossing a red line.
  • A surgeon asks a patient’s opinion about the town’s new basketball coach and hopes that this patient is not a planted mole recording the conversation.
So for those physicians who practice in the 11th Circuit, no gun inquires unless you can demonstrate with clear evidence that it has direct medical relevance.  The court left open for now asking patients about sling shots, fly fishing and skeet shooting, but medical practitioners are advised to consult with their attorneys regularly.

Apparently, idiotic judicial decisions can still be the law of the land.



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