Sunday, June 28, 2015

Is Gastric Bypass the Right Choice?

Bariatric surgery, including gastric bypass surgery, has become a popular remedy for obesity in this country.  Hospitals have weighed in on this issue and are marketing this service directly to the public who are ever willing customers of this slenderizing surgery.  I have many patients who have undergone the procedure and the results have been variable.   It’s too dismissive for me to refer to gastrointestinal bypass (GIB) as a ‘procedure’ as it is major surgery with major potential complications.  There are several types of bariatric surgery available today, but GIB is the standard surgery performed.

It profoundly reroutes the guts and changes every day of your life.  This is not like undergoing a heart bypass surgery when after a period of recovery you resume your normal life.  After GIB, there is no normal life afterwards.  Your life is irrevocably altered.  Meals are such a significant and personal part of our lives.  Think of all of life’s celebrations and you will recognize that food is a part of them.

Scale from Ancient Egypt

I point out these strong caveats to remind folks that the decision to proceed with GIB is not a casual one.  It requires careful deliberation and an understanding of the lifelong changes that one is committing to.  In addition, this operation is no quick-fix cure.  A patient who is a food addict, for example, will regain the lost weight after surgery, a sad and predictable outcome.  This is why high quality bariatric programs screen patients very carefully psychologically.   If a program accepts nearly all applicants, then one must wonder about the quality of the institution.

Personally, I feel that bariatric programs pull the trigger too quickly and that the public is too willing to serve as targets.  These surgeries, which should be regarded as last resort rescues are increasingly offered as front line therapies.  Eligible patients are rightfully told that GIB weight loss can melt away diabetes, sleep apnea and hypertension.

Before consenting or seeking GIB, have all other methods of weight loss been exhausted?  Has the individual received intensive dietary and nutritional counseling from weight loss professionals?  Has there been an adequate system of coaching and accountability?   Quitting a diet or two after a few weeks does not constitute exhausting all efforts.  I think that the existence and marketing of bariatric programs has influenced patients to leapfrog over conventional weight loss programs directly to the operating table.

I absolutely believe there is an important role for bariatric surgeries.  I am less sure that we are performing these surgeries only when they are the most appropriate option.  It's weighty issue for sure.  Feel free to weigh in yourself.
 

Sunday, June 21, 2015

Deflategate – Tom Brady Makes the Wrong Call

The Deflategate investigation has concluded that it was more probable than not that Tom Brady had general awareness of the mysterious shrinking footballs.  Now the fun started.  Although the investigator, Ted Wells, is highly regarded for his probity and objectivity, he was attacked by Brady supporters for what they argue were his tendentious findings.  As is so true today in our political world, when allegations are true and damaging, attack the messenger. 

Physicists from prestigious universities brought us back to high school science class with theories suggesting how the squishy pigskins could have been the result of natural phenomena.  I think the science was a little squishy here.   It was, however, sentimental for me to relive the tender memories from high school physics about the exciting relationships between pressure and volume.  There’s nothing like a discussion of the ideal gas law to liven up a dull evening. 

Would Sir Isaac Newton have given Brady a pass?

Brady has now suffered a deflation in his income with a 4 game suspension and the Patriots will endure a deflation in the number of their permitted draft picks over the next 2 years.  
So, Brady and his minions pushed back hard.  The 'Pats' can teach us all about integrity and fair play, as they did in 2007 when they were caught videotaping an opposing coach’s signals.  I think that he was aware.  His statements both prior to and subsequent to Wells’ report were tentative and calculated, not consistent with what one would expect from a man who was wrongly charged.  Moreover, his refusal to turn over his text messages and emails are not the actions of an innocent man.  Of course, he has the right to refuse to share them, and we have the right to draw conclusions based on this decision.  This is not a trial where he is entitled to a presumption of innocence.

Here’s what I would have advised Tom Brady to say before the microphones.

I love the game of football.  I have fallen short and did not live up to my own standards.  While I never asked directly for anyone to manipulate the game balls, I can understand how the equipment staff thought they were serving me and the team.  I accept responsibility for this and I accept the judgement of the recent investigation.  I will devote the rest of my career and my life to earning the trust of my colleagues and the public.  Football and the fans deserve no less.

In my view, this contrition would have shown us his humanity.  Since every one of us is a flawed creature, we would be inclined to be forgiving of a fellow human being who has missed the mark.  This would have been such a refreshing event to witness since accepting personal responsibility is a rare event these days.  He could have inspired us and returned to the game a bigger man.  Instead, he has become yet another example of responsibility deflection.  He fumbled.

If Brady couldn’t bring himself to utter a mea culpa because it is the right thing to do, then he should at least have done so because it is a smart play.  No one doubts Brady’s ability to call the right play in the huddle.  He should have ditched his advisors and called an audible. 


The lesson here is universal.  When we err or truly transgress, what do we do?  Do we lateral the ball or do we take the hit we deserve?

Sunday, June 14, 2015

Does Nexium and other Heartburn Medicines Cause Osteoporosis?

Every week, I am asked by patients if their heartburn medicine causes osteoporosis.  The most effective heartburn medicines are called proton pump inhibitors, or PPIs.  If you watch more than an hour of TV per week, then you have seen ads for some of them.   Nexium, Prilosec and Protonix are 3 examples of these medicines.

Many of them are now available over-the-counter at reduced dosages. 

Patients today are incredibly informed, and sometimes misinformed, about their medical conditions and their treatments.  Most of their information is from the internet, and it’s easy for patients to become unwittingly trapped in the world wide web.

The information dangling in cyberspace is entirely unregulated.  Information can be made to appear authoritative and objective when it actually is a paid advertisement.  Many blogs may appear to function to inform the public, when their true purpose is to serve the corporation that sponsors it.  If you are learning about probiotics, for example, consider the credibility of the site if you are encouraged to purchase certain products.  Caveat emptor.

Nexium - Bad for Bones?

I personally do not believe that Nexium can break bones, although I have read the same articles in the lay press that arouse my patients’ concerns.  I understand that a headline such as, Nexium Linked to Hip Fractures, will make my Nexium users so nervous that they might get wobbly and slip and chip a hip.

However, there is no convincing medical evidence that an individual user of Nexium or similar medicines has any significant risk of sustaining a fracture.  The belief that they can cause or accelerate osteoporosis is derived from large, pooled medical studies that are not truly capable of concluding cause and effect, a critical point often omitted from your hometown gazettes.

However, no patient should be on Nexium, or any medication, unless certain requirements have been satisfied.  Here’s what runs through my mind when I am recommending a medication for a patient.
  • The drug is absolutely necessary.
  • I am prescribing the lowest dose of the drug necessary for the medical task.
  • There is no safer alternative medication or other treatment available.
Of course, cost may be an issue depending upon the patient’s insurance coverage.  However, the patient’s financial status should not taint the physician’s recommendations.   The patient, however, can indicate that the doctor’s first choice is not possible, and he may choose a more affordable, but less effective option. 

If you want a second opinion on any of this, try the internet.   That’s where I go when I need reliable medical information.

Sunday, June 7, 2015

Are Physicians Racist?

Racism and prejudice are endemic in America.  Many of us reflexively answer, No, if we are asked if we are prejudiced.  I don’t.  I say yes.

While I do my best to give everyone a fair shake, I grew up in a white suburban family in the latter decades of the last century.   My friends, my parent’s friends and all those we associated with were all the same color.  In elementary school, there was but a single black girl in our classroom.

Is it possible for a white kid to grow up surrounded by all of the overt and covert prejudicial and stereotypical influences and somehow emerge pure?   I don’t think so.   Prejudice today among those of us who consider ourselves to be enlightened is more subtle and often hard to recognize.

I don’t want to overplay this here.  I often feel that a charge of prejudice with regard to race, gender, age or religion is spurious and is launched to advance a personal or a political agenda.  We all know this to be true and these instances deserve condemnation.   Sometimes, an applicant doesn’t get the job simply because he or she doesn’t deserve it.

The medical profession, as an integral segment of our society, is not immune to this phenomenon.  I’ve been reading over several years that medical professionals provide different levels of service to different races.   The Institute of Medicine convulsed the profession with its 2002 report that reported that blacks and minorities received fewer heart bypass operations, kidney dialysis treatments, proper cardiac medications and cancer detection tests than did whites, even after controlling for insurance status and other variables. 
More recently, in 2012, a University of Illinois psychology professor wrote that physicians prescribed more pain medicine to whites than to minorities for the same broken leg.  Seems hard to believe.

You Shall Have Just Balances, Just Weights
Leviticus 19:36

As a physician, I find these reports to be preposterous, yet I cannot comfortably deny them either.  I can’t fathom, for example, that I would prescribe less morphine to a Hispanic man suffering a heart attack than I would to a white patient.  In fact, no doctor I know or work with would admit to this behavior.   Leaving overt racists aside, no physician believes that he provides unequal care to his patients.   In fact, most would zealously and sincerely refute such a charge.

The point by those who differ with defensive doctors like me is that the prejudicial treatment is unconscious and, therefore, cannot be detected by the physician perpetrators. 

I am not accepting all of this as irrefutable truth, but I believe that the disparate medical care provided to different segments of our population needs to be explained.  It’s a complex issue and there are many moving parts at play here.  It is certainly possible that physician bias is an explanatory factor.

I remind my physician colleagues that for years we vigorously denied that pharmaceutical salesmen who came to our offices with food and drink influenced our prescribing habits.  We now know the truth here and we should admit that we are susceptible to influences that we cannot easily detect.

I do my very best to treat every patient equally.  If I am not doing so, I am truly not aware of it.     Like many medical conditions, the challenge is in the treatment, not the diagnosis.    

Hidden biases are not restricted to healers.   Law enforcers, educators, juries, salesmen, hiring managers, journalists and the rest of us are not as pure as we think we are.  Contemplating our prejudices is sensitive, nuanced and personal - not a simple black or white issue.

As published in the Cleveland Plain Dealer.

Sunday, May 31, 2015

When Your Loved One is an Alcoholic

I was asked to consult on a 43-year old female with abnormal liver blood test results.  It took but a few minutes to determine that she was an alcoholic, which was the likely explanation for her abnormal blood results.  She drank several beers daily over several years.

My diagnosis was alcoholism, but did the patient concur?

“Do you feel that you are drinking excessively or do you have it under control,” I asked.

She replied, “I’ve got it under control.”

That sad reply indicated that the probability of helping her to help herself was zero.  Ultimately, the addict must forge a pathway to healing.  Sure, we can help, coach and support the effort, and we should.  But, no addict ever reached the Promised Land by force or persuasion.

Pouring One for the Road

Sure, we’ll got this patient out of the hospital, back into the cauldron of inexorable self-destruction.  Did we help her?  I don’t think so.  This is not like treating a urinary tract infection where healing requires no effort from the individual.  The addict, in contrast, can never be healed from without. 

I have witnessed family members of alcoholics agonize in their frustration and disappointment that they cannot coax their loved one onto a path leading toward sobriety.  If I were in their place, I might behave similarly. 

I have many patients who have conquered addictions.  I admire them for vanquishing demons that prey upon so many of us.  Some struggled ferociously and prevailed while others curiously threw off the yoke with seemingly little effort.  Life isn’t fair.  Without exception, these folks broke free because they decided to pursue a different direction.   No yelling, screaming, threatening, begging or bribing can bring an afflicted addict across the finish line.

When loved ones reach the point where they realize that they can’t be the solution, they experience a sense of resignation and peace, even though the pain remains. 

The serenity prayer offers wisdom to us all.


God, grant me the serenity to accept the things I cannot change.
The courage to change the things I can.
And the wisdom to know the difference.



Sunday, May 24, 2015

Memorial Day - A Time to Reflect

It’s Memorial Day tomorrow.  What is it exactly that we are charged to remember?

Cole Slaw?
Lighter Fluid?
BBQ Sauce?



My father was a member of the greatest generation, having served in the U.S. Navy for 39 months.  He was stationed in California and was never in combat, despite some apocryphal vignettes he regaled us with.  I’ve never served in the military and none of my friends have served.  If not for my job, I would have very scant exposure to military professionals.  I have numerous patients who have served in all branches of the military during the 1940's and 50's.  Many are true heroes who recall their service with understated modesty.  I have also cared for many Vietnam vets who still bear physical and psychological scars of a war we couldn’t win and should never have joined.

Freedom is not free, a quote that moved me deeply when I first saw it on the Korean War Veterans Memorial in Washington, D.C.  I know that Memorial Day has deep meaning for families who have sacrificed or have a loved one wearing the uniform.  Folks like me just can't have the same depth of appreciation of what Memorial Day means.  

I’ve never worn the uniform.  I’ve never marched in formation.  I’ve never endured boot camp.  

I wish I had learned to salute so I can salute you all.

Sunday, May 17, 2015

Is Office Colonoscopy Ethical?

While I consider myself to be an ethical practitioner, I am not perfect, and neither is the medical profession.
I will present a recurrent ethical dilemma to my fair and balanced readers and await their judgment.
Our gastroenterology practice, like all of our competitors, has an open access endoscopy option.  This permits a physician to refer a patient to us for a colonoscopy, without the need for an initial office visit.

Ready, Aim, Fire!

Patients can also schedule procedures themselves, such as a screening colonoscopy, without a physician referral, if allowed by their insurance carriers.  These patients enjoy the convenience of  bypassing an office visit.   We agree that an office consultation should not be required for routine screening procedures or to evaluate minor gastrointestinal symptoms.

Of course, if a patient wants to see us in the office in advance – and some do – we are happy to do so.  I enjoy these pre-op visits which allows me to develop some measure of rapport with the patient and to discuss the upcoming endoscopic adventure, before the patient is naked with an IV dripping into his arm.

When these open access procedures are scheduled, we carefully screen patients on the phone to verify that bypassing an office visit does not pose any safety risks for the patient.   We do not want to meet a patient for the first time for a screening colonoscopy, who is on kidney dialysis and uses an oxygen tank.

Here’s the rub.  There are times when I meet an open access patient who is prepped and primed for a colonoscopy that is not necessary.  In the most recent example, I greeted a patient who was poised to have a colonoscopy because there was a prior history of colon polyps.  However, according to current professional guidelines, the patient didn’t need the exam for a few more years.   I was meeting this patient for the first time.  She had taken a day off of work and had a driver with her.  She had enjoyed the delight of the gentle cathartic agent that colonoscopy patients imbibe with gustatory pleasure on the prior evening.  She believes, of course, that the procedure is necessary as her physician had recommended it.

What should my response, if any, to her be?

One of the pitfalls of open access is that we can never screen patients as carefully as we do during an advance office visit.  Should we halt a procedure that an internist has requested even if we may not believe the procedure is of medical necessity?   Should we be willing to serve as ‘technicians’ for referring doctors in the same manner that radiologists serve their colleagues?  When we order a  CAT scan, for example, the procedure is always done whether it’s needed or not.

I sit in judgment now awaiting your verdict.  May it be as probing and enlightening as a colonoscopy.  

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