Sunday, July 20, 2014

When Should Doctors Turn Patients Away?

A few days before this writing, a 32-year-old woman came to see me for an opinion on stomach pain.  Why would I refuse to see her again?  Abdominal pain is an everyday occurrence for a gastroenterologist.  She was accompanied by her mother.  I had never met this woman previously. 

She had suffered abdominal pains for as long as she could remember.   She recalled frequent visits with the school nurse when she was a young girl.

Illu stomach.jpg

The Stomach - Usually Not the Source of 'Stomach Pain'

She has abdominal distress of varying severity every single day. Despite this medical history, she was not ill and appeared well. Why did I refuse to take on her case?   She seemed like a very appropriate patient for my practice.  I have expertise in evaluating and treating abdominal pain.  The patient was pleasant and cooperative.   I believe she would have been comfortable with me as her gastroenterologist.

I learned that the patient lived in another state and was only in Cleveland to spend the holidays with her family.  In fact, she was leaving Ohio the day after my visit with her.   I advised her that it was not in her medical interest to have a chronic condition managed by a physician hundreds of miles away. 

Sure, I have some folks in the practice who live in other parts of the country, but I don’t manage their chronic conditions.   These people return to Cleveland with some regularity, and I will do their periodic routine colonoscopies.    Conversely, if one of my patients with active Crohn’s disease is off to Arizona to escape the oppressive Cleveland winter, I insist that he consult with a gastroenterologist there.

I know we are entering the era of telemedicine.   I certainly do a lot of medicine on the phone every day, and many evenings.  But, for many medical issues, there is no substitute – nor should there be – for a face to face visit with a doctor.   Chronic abdominal pain, particularly in a new patient, can’t be solved in a visit or two.   It takes serial office visits over time to deeply grasp the patient’s symptoms and understand the patient as a person.    It needs regular physical examinations, which is a crucial piece of data for the doctor that can’t yet be acquired through cyberspace.

Managing chronic disease is a wandering journey for the patient and physician with unforeseen pitfalls and challenges.  Such a patient may awaken one morning with new symptoms or a flare in his condition and may need to see a doctor on that very day.   Even when the patient’s condition is relatively stable, there may be phone calls in between visits, or phone calls to determine the necessity of an office appointment.

So, I didn’t cure her in a half hour, but I did offer her advice.  I recommended that she select a gastroenterologist where she lived.   I forecasted the conversations  that I anticipated she and the new doctor might have over the ensuing months.   She and her mom understood why local medical care was the proper option for her. 

Maybe eventually, my iPhone will have an app that can palpate an abdomen, discern body language and gauge if a patient ‘looks sick’.   Until then, for most patients I will rely upon my eyes, my hands and my gut. 



Sunday, July 13, 2014

Hobby Lobby vs Obamacare: 1-0

Hobby Lobby, unfairly demonized in various corners of the public square, had their religious beliefs upheld in the highest court of the land in a 5-4 decision this week.   The company’s leaders are deeply believing Christians, which I believe is still a lawful practice in this country.  The company tithes to charity and pays its full time employees at least $14.00 hourly, both evidence of a culture of compassion and fair play.

No, not these Supremes, the other ones.

There is a din of shrill protestations that the company is against contraception and women, which is a complete falsehood.   Hobby Lobby is not the Catholic Church who objects to all forms of artificial birth control as fundamental religious dogma.  The company always intended to cover 16 different forms of contraception, including oral contraceptives, condoms and tubal ligation.  It objects to birth control methods that take action after an embryo has been created.

I don’t grasp the notion that an institution that approves 16 different methods of contraception is against contraception or is posing an undue burden on women, although I admit that I view this issue through the lens of an XY chromosomal organism.   Might the arguments against Hobby Lobby’s beliefs have a political basis that is beyond the substance of the issue?

Although I recognize that the Affordable Care Act mandates coverage of all 20 birth control methods, in the medical universe that I inhabit, insurance companies do not cover every available treatment for every malady.  For example, a particular insurance plan may cover heartburn prescriptions, but not every one of them.

Keep in mind that the Supreme Court decision affects only closely held, for-profit companies, which affects only a small fraction of American working women. 

I personally believe that women who work at Hobby Lobby have a right to the 4 methods of birth control that the company objects to, including intrauterine devices and ‘morning after’ pills.  However, when I weigh the rights of the owners, who have a lifelong and deep Christian belief that forbids these practices, I am persuaded that their religious freedom argument is stronger.   If they had lost the case, they would be complicit in a practice that they find to be sinful and abhorrent.  If they prevailed, as was the case, Hobby Lobby female employees would still have access to numerous forms of birth control.

The Obama administration in its zeal to impose health mandates, has underestimated the resistance from groups and individuals who guard their personal freedoms and liberties with equal zeal.  This governmental myopia has led them to some uncomfortable crossroads, such as their pending litigation against the Little Sisters of the Poor, who will not accept the government’s accommodation to their objection to contraceptive coverage.   I would be reluctant to sue a group of nuns who are respected all over the world for their selfless, charitable endeavors.

I’m not sure I’m right on the Hobby Lobby issue.  Four Supreme Court Justices, all great legal scholars, think I am wrong.   The 5-4 decision is proof that this was no legal slam dunk.   Additionally, a different set of justices may very well have decided the case differently.  Yet, I feel that Hobby Lobby and Conestoga Wood Specialties who joined with them in this case, had more to lose than women had to gain. 

I am neither pro-life nor Christian.  I’m a political moderate who has voted for candidates from both major political parties.   I’ve never even seen a Hobby Lobby store, but I’d like to meet the owners.  Are they warriors in the war against woman or freedom fighters for individual liberty?  I think the Court got it right. 


Sunday, July 6, 2014

The Fourth of July - Musings on the Declaration.

The meaning of many holidays can be elusive.  On Memorial Day, are we contemplating our fallen heroes, or grilling burgers?  How many shopping days ‘til Christmas?  Labor Day?  Isn’t that the last weekend at the beach?

The Fourth of July has just passed.   Hopefully, we paused at least for a few moments to meditate on what happened in Philadelphia in 1776. 

I’ve seen the actual Declaration twice in my life.  The first time was when my mom took me to D.C. as a young child.  Later, I took the kids to the National Archives, where we waited in a long line to be rewarded with a few second gaze at the very faded ink that was sequestered behind thick glass.



History is such a thrill.  It’s a dynamic discipline that breathes.  This past week, a scholar from Princeton, New Jersey claims that a punctuation mark – a period – does not appear on the original parchment, but was included in the official transcript of the Declaration authorized by the National Archives.  The omission of the period casts a different slant on the sentence that begins with the iconic phrase, We hold these truths to be self-evident.

Fifty-six men signed the document.  Here are their concluding words to King George III.


And for the support of this Declaration, with a firm reliance on the protection of divine Providence, we mutually pledge to each other our Lives, Our Fortunes and our sacred Honor.  

We owe a debt that can never be repaid.  

Sunday, June 29, 2014

Are Your Medical Priorities Straight?

The world is asunder.  As I write this, Iraq is sinking into a sectarian abyss.  ISIS, a terrorist group, now controls a larger territory than many actual countries.  Russia has swallowed Crimea and has her paw prints all over eastern Ukraine.  China is claiming airspace and territories in Southeast Asia increasing tensions with Japan, Vietnam and the Philippines.  The Israeli-Palestinian peace process is in another deep freeze.  Terrorists in Sudan and Nigeria are kidnapping and murdering innocents with impunity.  The Syrian regime has resulted in 160,000 deaths and has displaced over 6 million people.   The Taliban continue to destabilize and terrorize in Afghanistan and Pakistan.  Disease and hunger claim millions of lives in the developing world while other world regions have a surplus of food and medicine.  We have an immigration crisis in this country that gets worse by the day.  Several million Americans are still out of work.

Let’s not be distracted by these trifles.  A looming apocalypse exists that dwarfs the above issues and demands our overriding attention.

Should the Washington Redskins change their name?

Sometimes, folks have difficulty deciding what’s important.   

Weigh the priorities

Assigning rational priorities is an important professional and life skill.  Collectively, we all waste an incalculable amount of time, energy and resources pursuing ventures that should be left for another day.  All of us do this.   Sometimes, we do so deliberately when a lower priority activity will deliver some pleasure or entertainment.   In these instances, at least we are aware that we are dipping down on our priority list.
An important physician skill is to judge which medical issues and tests should have a priority status.  Hmmm, a patient suffering a heart attack also has athlete's foot.  Which issue do I address first? We would recognize that a patient recovering from a severe pneumonia in an intensive care unit should not undergo a mammogram or a screening colonoscopy.  Often, it is not so easy to determine the medical priorities and different physician specialists on the case may disagree on what should be the next step.

Here are a few hypothetical scenarios.

A surgeon insists that an operation is urgently required, but the cardiologist counters that stabilizing the patient’s congestive heart failure must be done first. 

A gastroenterologist advises stopping a blood thinner as the patient has a bleeding ulcer, while the pulmonologist disagrees as the patient has a new pulmonary embolus and argues that the blood thinner cannot be interrupted.

A patient comes to his internist very anxious over 3 days of rectal bleeding.  He wants a colonoscopy as soon as possible as his father had colon cancer.   The physician advises instead evaluating the patient’s recent episodes of chest tightness, which the patient dismisses as anxiety.

Knowing how to do something well is not nearly as important as knowing if and when it should be done at all.  Who wants to have his gallbladder flawlessly removed if it didn't need to come out?  You can substitute any surgery, medical procedure, diagnostic test or treatment in this example.  

Medical knowledge is important.  Technical procedural proficiency is necessary.  Communication skills are a distinguishing asset.  But, medical judgment is paramount.

Sunday, June 22, 2014

Standards of Decency in the Blogosphere

A few weeks back, I posted a piece entitled, Are Emergency Rooms Admitting Too Many Patients?   The essay was cross posted on KevinMD’s site a week or so after it appeared on my blog.  I received buckshot style criticism from various corners of cyberspace on my post.  What provoked particular ire, was my implication that Emergency Department physicians faced financial conflicts of interest with regard to admitting patients into the hospital.  

I’m open to criticism and debate in the blogosphere and in my own life.  My father was an attorney and my brother is a sitting judge.  I’ve raised my kids to question, argue and to seek out the other sides of issues despite that they may already feel that they grasp them sufficiently.  Now, that they are adults, I am often the target of these skills that I worked so hard to cultivate in them. 

Numerous physicians were offended by my reimbursement implication.  In reading their responses, it was clear to me that I was not sufficiently informed on how ED physicians are reimbursed.  In my comment on Kevin’s blog, I indicated that I was prepared to stand down from these particular statements that had caused a cyberconflagration.   I didn’t double down; I stood down.

My blog has been alive for 5 years and has over 300 posts.  With one exception, I have authored every essay and they all appear under my own name.   The blog is commentary, not immutable truth.  I expect and welcome vigorous debate, either because a reader has a different point of view or simply believes that I am wrong on the facts.  As a member of the human species, I commit error with some regularity.  Presumably, readers face this same reality.

I was disappointed that some who opposed me spewed forth venomous personal attacks against me both as a physician and as a person.  Demeaning comments and character attacks, in my view, only demean the source of the vitriol, not the target.  Many comments were ad hominem thrusts that contributed little to the civil dialogue that should have ensued from my post.  Indeed, one commenter complained that Kevin deleted his comment, and I have every reason to suspect that this decision was warranted.   I let all comments on my own site stand without revision.

As readers of my blog and others in my life know, I will not engage in this coarse caliber of discourse. 

It's easier to make noise than...

...music

The notion, as was suggested in a vituperative riposte, that I am focusing attention on the incivility of some dissenters because I am bereft of a substantive response is false.  In contrast, I suspect that the converse is true.  Shrill and strident views are often hurled when the case is weak.   Let the argument rise or fall on its own merit.  Turning up the volume only turns off the debate.  

If you disagree with me, bring it on.  If my facts are wrong, point it out and I will readily admit it. If you charge me with having human imperfections and frailty, then no trial will be needed as I will confess to this outright.    If I have miscalculated or misfired in an essay or elsewhere, I would hope that a reader would consider the totality of my work before disparaging me in an unseemly manner.  

If I err, as I did in my post, then I will say so.  If I disagree with you, then I will explain why.  If you have the better argument, then I will change my mind.

I believe that conversations, discussions and debates in the blogosphere and beyond should occur with respect, tolerance and fair-mindedness.    If you have a different view on this style of expression, then make your case.

Words matter.   They are the tools we use to present our ideas to others.   Shouldn’t we choose them with care?  

Sunday, June 15, 2014

Is My Medicine on the Prescription Drug Formulary?

One of the frustrating aspects of medical practice is trying to divine if the medication I am prescribing is covered by the patient’s insurance company.  Even with the advent of electronic medical records, which should be able to determine this, we are often left to hope and pray.

Here’s how it works.  Individual insurance companies have formularies – lists of approved drugs – that they encourage patients and their physicians to use.  Of course, this is all about the money.  There’s nothing evil about an insurance company making a deal with a particular drug company that gives them a price break.  The drug company will be delighted to offer the insurance company a discount in return for an anticipated high volume of prescriptions.   You can easily picture an insurance company negotiating with several different GERD medication representatives watching them each lowering their bid trying to get the contract.  

Nexium Guy:   We’ll only charge you $.67 a pill
Prevacid Gal:  We’ll only charge you $.84 a pill and will throw in the Japanese steak knives
Protonix Guy:  We’ll lower our already rock bottom price down to $.65 a pill for an exclusive contract
Prilosec Gal:  We’ll only charge $.57 a pill for a brief term of 10 years with an option to renew

When a patient sees me for heartburn, and I recommend a medication to ease their pain, often neither the patient nor I know which of the 6 proton pump inhibitor medicines (e.g. Nexium, Prilosec, etc.) or the generics will be covered.   That’s when the guessing starts.  My objective, of course, is that the patient pays the least amount of money without sacrificing medical benefit.   When I guess wrong, I am then welcomed by phone calls, faxes and other forms of denial that we then devote time to sort out.  Recently, I called a pharmacist with the patient seated before me to try to be a hero and figure out which medicine was the right stuff.  Even the pharmacist couldn’t figure it out.  She explained to me that she couldn’t price the medicine for this specific patient unless I prescribed it officially and she then processed it through.   I thanked her, hung up and resorted to my default strategy.  I guessed.

Which Medicine?  Roll the Dice!

Keep in mind that these formularies change yearly.  In other words, a medicine that’s preferred  in December may be tossed aside in January when a new drug underbids them.  This adds to the adventure.  We have an office pool every December when we offer prizes for guessing the new medication changes.  We use this changeover as an opportunity to increase staff morale.  

Next time you're in your doctor's office, ask what a 'prior auth' is.   

In my practice, I might see 15 or 20 folks each week who want me to put their GERD fires out.  They have different insurance plans with different formularies and different restrictions.  The chance that I prescribe the preferred medicine to each of them on the first try is much lower than winning the lottery.  If fact, if I were to achieve this pharmaceutical tour de force, I think I am entitled to instant wealth.  Perhaps, the pharmaceutical companies would pool their resources an sponsor a contest for gastroenterologists.  What a slick marketing campaign!

Prescribe Heartburn Medicines Correctly for a Week and Win a Million Dollars!


They have nothing to fear.    While physicians may accept the challenge with enthusiasm, they will never succeed.  They would do better buying a lottery ticket. 

Sunday, June 8, 2014

Leave No Patient on the Battlefield.

Despite our professed values, everything has a price.

We value life, but our society is unwilling to lower the highway speed limit to 40 mph, which would surely save lives.  The price of our collective inconvenience and economic impact is too high.

Lower Speed Limit and Save Lives?

We leave no soldier on the battlefield, but this military value cannot be viewed in isolation.  We are told this week by our commander-in-chief and his acolytes that rescuing a captured soldier is worthy regardless of the price.  We are told that negotiating with terrorists, breaking the law by not notifying congress and the release of 5 hardened Taliban detainees is a reasonable price for the return of a captured sergeant.    I feel that the price exacted was too high, although admittedly my view would be different if the sergeant were in my family.  For those who argue that no price is too high to rescue one of our own, should we have surrendered to the Nazis in World War II in return for some captured U.S. soldiers?   So, the noble principle of leaving no soldier on the battlefield is not absolute and needs context.

We want a secure nation, but at what price?  There’s a tension in America between security and civil liberties that is ongoing.  North Korea is a very secure state, but we wouldn’t be willing to pay the price that Korean citizens are forced to pay.  We willingly tolerate some level of insecurity here in order to preserve our personal freedoms and rights. 

We strive for quality medical care for all, but at what price?  We expect timely access to medical specialists, diagnostic testing on demand, the newest medications, affordable prescriptions and second opinions on request.  We don’t object to the price as someone else is picking up the bill.   If we were paying the tab ourselves, would we do so willingly and enthusiastically?  And the aggregate cost of rampant over-diagnosis and over-treatment affects every one of us.  Decades of draining the system and providing medical care without limit and spending more money per capita than other nations that have healthier citizenry have exacted a heavy price called Obamacare. 

Like the military, we aim to rescue every patient.  But, can we?  What are we willing to give up to accomplish this mission?

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