Sunday, July 24, 2016

Is Medical Marijuana Safe and Effective? Who Decides?

Medical marijuana is a smokin’ hot issue in Ohio.  Marijuana enthusiasts targeted our state constitution again this year with another amendment attempt, which failed.  Instead, our legislature passed House Bill 523, which will legalize medical marijuana use. 

As a physician, with some training and experience in prescribing medicines to patients, these marijuana machinations are medical madness.  Is this how we want to bring new medicines to market?

I think it is absurd that a specific medical treatment – or any medical treatment - should become a constitutional issue.  Do we want to establish a constitutional right to a specific medicine?
Why stop at marijuana?  Why not start circulating petitions for constitutional amendments for screening colonoscopies, mammographies and MRI’s for back pain?  Patients with chronic lumbar disk issues have rights too! 

The Ohio bill specifies an array of medical conditions that could be treated with marijuana, including AIDS, hepatitis C, inflammatory bowel disease, Parkinson’s disease, PTSD and many other illnesses. Is it the legislature’s responsibility to decide that a medicine should be approved for a medical illness?  Do legislators have medical expertise?  Do we want the Senate or House weighing in on approving a new chemotherapy agent or artificial hip?

Will Cure Whatever Ails You?

Might I suggest with just a tincture of cynicism that medical marijuana mania has become a mite politicized? Do we want folks who stand to make money or enhance their political power from a new medicine – who have no medical expertise - to be the ones with a major role in approving its use? Are cannabis con artists using a political pathway because they fear that the medical avenue will less hospitable to their objective?

Once marijuana becomes a legal product, an inevitable outcome, will enthusiasts for its medical use support vigorous testing of its therapeutic value? 

I am deeply skeptical that the medical claims of medical marijuana adherents are supported by persuasive medical evidence. I remain open, however, to submitting marijuana to the same Food and Drug Administration (FDA) testing that all new medicines are subjected to. Let the scientific method with appropriate clinical studies and peer review judge the product for safety and efficacy. If approved, then the public and the medical profession can be confident that the approval was on the basis of science and not smoke.  Shouldn’t those who champion medical marijuana use demand this level of independent scrutiny?  If not, then why not?

Yes, I have heard powerful individual vignettes describing great benefits of medical marijuana. Every physician has similar anecdotes of patients who have achieved significant benefits from unconventional and unapproved medical treatments. But, anecdotes are not science. If medical marijuana is the healing elixir its proponents promise, then prove it. 

Let our politicians do what they do well, whatever that is, and leave medicine to the professionals. 

Sunday, July 17, 2016

Do New Medical Interns in July Threaten Patients?

Would you have elective surgery in the nearby major teaching institution on July 4th?
Why not, you wonder?

Prowling around the hospital wards every July are the fresh faced interns wearing starched white coats, with stethoscopes draped across their shoulders, with pockets stuffed with reflex hammers, K-Y jelly, and various cheat sheets to rescue ailing patients.

These guys know nothing.  How do I know this?  I was one of them.  Luckily, I knew that I was clueless and never pretended that I could treat athlete’s foot or even a splinter.

Imagine you are in a hospital bed in early summer complaining of chest discomfort.  Your nurse summons the intern who speeds into your room peppering you with questions.  Before you finish your answer to a question, another question erupts.  This physician is barely out of his shrink wrap and is understandably anxious that he is witnessing an impending cardiac catastrophe.   With his spanking new stethoscope, he establishes that there is a beating heart nestled inside your chest.   Your heart rate is high, most likely as a result of anxiety from witnessing the intern’s state of near panic.  I’m sure you will calm down when he whips out his Tips for Chest Pain Cheat Sheet which he will use to treat you. 

If the intern tries to test your reflexes with this - run!

Teaching hospitals have an important teaching mission.  This is the venue where physicians learn their trade – on real patients.  New interns start in July and they know nothing.  Sure, there are multiple levels of supervision over them, but these many layers can cause gaps and vulnerabilities in patient care.  The supervising medical resident, himself with only a year or two of experience, has several interns he is responsible for.  He can’t be with every intern every minute.  Sure, the intern can always call for help, but what if he doesn’t know that he needs help?

Patients at teaching hospitals enjoy many advantages.  There is often state of the art equipment and a renowned faculty.  They claim that with so many physicians of different hierarchical levels seeing patients, that this built-in redundancy catches errors and oversights.  This may be true, but as I have expressed, it is also a cause for miscommunications, excessive medical diagnostic testing, errors, exploding costs and gaps and lapses in care.

Imagine you are admitted by your internist and a cardiologist and a gastroenterologist are both consulted, a very common scenario.  Each of these 3 physicians has his own team of fellows, residents and interns.   You could be seen by 10 physicians in a day.  Communication lapses are expected as it is not possible for all of these physicians to know what all colleagues on the case are thinking and planning.

Contrast this with the situation in a community hospital, such as the ones I practice in.  There are no interns, residents or fellows.  I perform my own history and physical examination and take ownership of the patient.  I communicate with the nurses and other physicians on the case personally.  While this system is not perfect, there is much greater accountability to the patient.  There is no one I delegate to.  There aren’t layers of doctors pushing their own agenda to the extent there is in a teaching hospital. 

Our mission in the community hospital setting is patient care, not physician training.  In my experience, having been in both types of institutions, I think community hospitals have an intrinsic quality advantage.  Teaching hospitals would argue this point.   I don’t think it can be argued, however, that there are conflicts of interest in teaching institutions as patients are exposed to excessive medical care in order to provide education and training to young physicians.  This is undeniable.

If a July 4th hospitalization is in your future, you can choose your local community hospital or the Medical Mecca downtown.  If you choose the latter, get ready for some fireworks.

Sunday, July 10, 2016

Supreme Court and the Texas Abortion Law - A Victory for Truth

Readers are not aware of my personal view on abortion, and they won’t be after this post.  While abortion seems on its face to be a complex biomedical issue, interestingly, those with firm views on either side do not describe it as a great moral quandary.  Those who ardently favor abortion rights, and those who oppose them in equal measure, often express that this is not a controversial issue.  For them, it is a clear issue of right and wrong, with each believing that the other side is entirely wrong and misguided.  This observation applies best to those who are toward the poles of the abortion question.  If you believe that an embryo and a fetus are human beings, than abortion is murder.  Not much room for debate here.  If you do not confer personhood on an embryo and a fetus, then a right to abortion is a woman’s right to freedom and autonomy.  Clear cut argument here also
Of course, many thoughtful individual wrestle with this issue and do not grasp it in the black and white terms described above.

I have given this issue much thought over my adult life.  I do not feel that I can contribute to this wrenching public debate.  I have no new point or angle that hasn’t been offered or would change any minds.

I was pleased with the recent Supreme Court decision that struck down Texas law which had resulted in the closing nearly half of the state’s abortion clinics.  My view here is not related to my personal view on the issue.  I applaud the decision because I feel it is a victory for truth.

Our Best Functioning Branch of Government

Texas had required that abortion clinics be certified as ambulatory surgical centers (ASCs) and that providers must have hospital admitting privileges at an area hospital.  If these two conditions were not met, then the center would have to close.  I completely reject the law’s supporters who have claimed that the 2013 state law was to preserve women’s health.  This was unadulterated mendacity.  The law was not to protect women, but to limit abortions in Texas.  We don't expect veracity from our elected officials.  Indeed, politicians and partisans develop wheezing and hives whenever they unexpectedly make contact with the truth.  They should have announced at the bill’s signing the law's true intent – to limit abortions.  If you believe that decreasing abortions is a noble and moral objective, then say so.  If you believe that the unborn child merits all protections that can be legally conferred, then argue your case and try to pass laws that would accomplish it.

From a medical point of view, requiring the abortion provider to have admitting privileges or having the center regulated as an ASC is ridiculous.  Many other medical procedures performed outside of hospitals in Texas were not subjected to these restrictions.  Why not?  Don’t these patients deserve protection also?  The fact that the law has not been shown to have protected a single woman is powerful evidence of its true motive.

Tell the truth.  If you are a teacher who is protesting for a higher salary, don’t tell us that you’re doing it for the kids.  If you’re an older cop who wants to retain the current system that rewards seniority, don’t tell us that this is an issue of public safety.  And, if you’re a gastroenterologist who does colonoscopy for a living, don’t rail against a superior replacement arguing that you’re only protecting your patients. 

Sunday, July 3, 2016

Happy Fourth!!!

”I am apt to believe that it will be celebrated, by succeeding Generations, as the great anniversary Festival. It ought to be commemorated, as the Day of Deliverance by solemn Acts of Devotion to God Almighty. It ought to be solemnized with Pomp and Parade, with Shews, Games, Sports, Guns, Bells, Bonfires and Illuminations from one End of this Continent to the other from this Time forward forever more.”

Who authored the above?

Hint: His signature demonstrates excellent penmanship!

Sunday, June 26, 2016

Lebron James and Medical Ethics - Let Me Explain.

Medical ethical issues confront physicians daily.  Most of us contemplate ponderous ethical dilemmas, such as end-of-life care care, allocation of the limited supply of organs for transplant or our unequal access to health care.  Many ethical decision points are rather quotidian, not situations that would serve as content for bioethical conferences.

Here are some examples of everyday ethical issues that physicians deal with.
  • A patient asks his doctor to support a claim for disability that is not warranted.
  • A patient asks his gastroenterologist to change his constipation diagnosis after the fact so that his colonoscopy is covered more fully by the insurance company. 
  • An employee in a doctor’s office, whose own doctor is booked solid, requests an antibiotic prescription for a urinary tract infection from her physician boss.
  • A physician falsely claims to an insurance company that he has tried certain medicines on a patient in order to gain approval of a desired medication.
  • A doctor tries to limit diagnostic testing of a patient with no insurance in order to save the patient money.
This past week, I had a request from a patient under very unique circumstances.  I performed a colonoscopy on a young man this past Tuesday.  Prior to the procedure he remarked “that he needs a really big favor from me.”  Such phrasing portends an improper request.   Would he be asking for pain medicines or to sign off that he needed light duty for the rest of the week?  He wanted me to give him a medical excuse for Wednesday, the day after his procedure. 

From time to time, we have requests from patients for work excuses on the day prior to or following their procedure.  Nearly all of these requests are politely, but summarily denied 

The Curse is Broken!

Wednesday, 6/23/16, was not an ordinary day in Cleveland.  There was going to be a once in a lifetime celebration downtown for the triumphant Cleveland Cavaliers, who bested the Golden State Warriors in an epochal championship series.   Contemplate the narrative.  A poor kid from Akron is raised by a single mom under very challenging circumstances.  His talent leads him to the Cleveland Cavaliers where he brings hope to a city that has been cursed with sports failures.   He leaves Cleveland in a clumsy, arrogant and ‘cavalier’ manner for the Miami Heat where he picked up some rings.  The poster boy became a Cleveland doormat.   He returns home to keep a promise.  We lose to the Warriors last year.  Now, we win against them by a whisker in game 7.   Cleveland hasn’t had sports championship team in over half a century.  We have suffered under a curse.

Even folks like me who are not sports fanatics have been swept up into this movement.  We are so proud of our amazing team and the fans who, like Moses, had been permitted to look upon the Promised Land, but not to enter it, until now.

How should I have responded to my patient’s request?

Sunday, June 19, 2016

Appreciating the Gifts of Life

The value of anything becomes apparent when it is taken away from you.  Nothing profound here about one of life’s central truths.  It is an ongoing challenge not to take life’s gifts for granted.  I have never known hunger or lived without shelter. I have never been unemployed or suffered a serious illness. I pay my bills.  I have 5 children who enjoy excellent health and are forging pathways toward their dreams.  I love the people I work with.  I have found new love in the 6th decade of life.  And, I have ice cream every day of my life.

It would be shameful to have been bestowed so much and then to complain about some of life’s trivialities.  But, I am human.

The Mother of All Gifts

Consider the following list of events.  Has any of them ever dampened your mood, made you angry or resulted in an outburst of coarse language? 
  • You find yourself in a traffic jam which delays your arrival to a meeting by 20 minutes.
  • Your lengthy and detailed e-mail to a client suddenly disappears.
  • The concert of your favorite performer is sold out.
  • You have gained 10 lbs.
  • The women ahead of you in the cashier’s line at the supermarket is digging around in her purse for coins.
  • Your cell phone reception disappears.
  • The airline informs that you may change your ticket reservation for $200.
  • You have a flat tire.
  • Your doctor is running an hour behind schedule, again.
  • A driver cuts in front of on the road.
  • A police officer issues you a ticket for speeding because you were speeding.
  • Your dog has made your new Persian rug her toilet.
  • Your check bounces higher than a kangaroo in heat.
A man came to my office, accompanied by his wife, for his colonoscopy.  He was younger than I.  I had never met him before.  He was alert and in good spirits.  I was pleased that I could inform them both after the procedure that his colon was in excellent health.  Sadly, the health of his colon was more robust than his mind was.  He had dementia and couldn’t recall that he was taking prescription medicines.  How sad and unfair that he and his family were losing a gift.  After my day was over and I was driving home, how important would a traffic jam really be?

When I am headed out to see a patient in the emergency room at an ungodly hour, I remind myself that the patient has it worse than I.  He’s the sick person and I will be returning home to sleep in my own bed.

I want to be more grateful and appreciate for all that I have, but I am flawed human specimen.  The struggle continues. 

Sunday, June 12, 2016

Medical Statistics - The Art of Deception

“There are three kinds of lies: lies, damned lies and statistics.”   There is much truth in this quotation of uncertain provenance.  We see this phenomenon regularly in the medical profession.  We see it in medical journals when statistics are presented in a manner that exaggerates the benefit of a treatment or a diagnostic test.  Massaging numbers is raised to an art form by the pharmaceutical companies who will engage in numerical gymnastics to shine a favorable light on their product.   It’s massaging, not outright mendacity.   The promotional material that pharmaceutical representatives present to doctors is riddled with soft deception.

A favorite from their bag of tricks is to rely upon relative value rather than absolute value.  Here’s how this works in this hypothetical example.

A drug named Profitsoar is tested to determine if it can reduce the risk of a heart attack.  Two thousand patients are participating in the study.  Each patients receives either Profitsoar or a placebo at  random.  Here are the results.

                                1000 Profitsoar Patients      1000 Placebo Patients

# Heart Attacks                                                               6

As is evident,  only 2 patients were spared a heart attack by the drug.   This is a trivial benefit as only 6 of 1000 patients in the placebo group suffered a heart attack.  This means that taking the drug provides no meaningful protection for an individual patient.  However, the drug companies will highlight the results in relative terms to package the results differently.   They will claim that Profitsoar reduced heart attack rates by 33%, which would lure many patients, and a few doctors to drink the Kool Aid. 

Check out this promotional piece below which was recently mailed to me about Uceris, a steroid that I use at times for colitis patients.

See how low the actual remission rates are for the drug.  Only 18% of patients responded to the drug, a small minority, and the placebo rate was 6%.  No worries.   Just brag that Uceris is 3 times more effective than placbo!

Is this a lie?  Not exactly.  Is it the truth?  Technically yes.  

Most physicians are tuned into this deception.  I know from my own patients that the public is easily seduced by this slick presentation of data.  The next time you see a TV ad for a medication, which will be about 5 minutes after you turn on the TV, see if you can spot the illusion.  You'll have to watch quickly and repeatedly.  Like all skilled magicians, these guys are expert at distraction and sleight of hand.  Hint: Whenever you hear the word 'percent', as in "35% of patients responded...", you should pay particular attention.  

When we used to see a woman sawed in half on stage, we knew it was a trick even if we couldn't explain how it was done.  I've taken you behind the curtain here.  Let's make it a fair fight between us and illusionists.

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