Sunday, April 23, 2017

Is My On-call Doctor Any Good?

Physicians spend a lot of time counseling patients on the phone.  Often, these conversations occur at night with patients we have never met before. When I am on-call in the evenings or on the weekends, these are some typical phone calls I receive from patients I have never met.
  • I have a very bad stomach ache for the last hour.
  • I started having rectal bleeding an hour ago.
  • My wife tells me that my eyes are yellow.
  • My chest is hurting.  It feels different from my usual heartburn.
How do we manage patients with issues like those above?  We get hundreds of calls like this every year.  Do we send every patient to the emergency room just to play it safe?  Do we tell them to hang in there and to call their regular doctor when office hours open?   How can we be sure that a simple stomach ache isn’t the first warning of appendicitis or some other severe abdominal condition?

My After Hours Medical Equipment

Phone medicine relies on an entirely different skill set than physicians use in the office or in the hospital.  Consider these obstacles:
  • We often don’t know the patient.  The doctor who does know him may readily recognize that the complaint is benign.
  • On a phone call, we cannot read body language to gauge a patient’s level of distress.  Seasoned physicians get a gestalt feeling about a patient’s intensity of illness from simple observation.
  • There is no opportunity to perform a physical examination.
  • Prior medical records may not be available, although many electronic medical record systems to do permit remote access.
During my 3 years of internal medicine training and my 2 years of gastroenterology fellowship, I received not a whit of training in phone medicine.  This was a gaping oversight in medical education considering how important these skills are to practicing physicians.  I use them every day.   I confess that during my first several months on the job, there were many anxious moments for me as I fielded phone calls from anxious and sick patients.   It would have been easier had my educators given me a few pointers.

Understandably, patients who are calling physicians off hours are not aware of the handicaps that these doctors face.  Patients often seem to feel that even on a phone call, we somehow have our full toolboxes available and can make diagnoses or prescribe treatments.  Consider the following scenarios.

  • Driving at night wearing sunglasses.
  • Playing guitar with a broken string.
  • Enjoying a movie without sound.
  • Preparing a dinner party with only a saucepan available.
  • Providing medical care to a stranger on the phone.
Want to discuss this further?  Give me a call after hours.

Sunday, April 16, 2017

Overcoming Drug Addiction Solo - A Mother FInds Strength

Recently, I saw a young woman referred to me for an opinion on her hepatitis C infection.

In the latter part of 2013 she made an unwise decision and started using intravenous drugs.  She also made a more unwise decision and shared needles.  She is fortunate that the only virus she contracted was hepatitis C, now curable.  I do not know the details of her life then which led her to lean over the edge of a cliff. It would seem to most spectators that her new lifestyle would portend an inexorable slide into an abyss.  Young addicts, for example, often cannot fund their addictions, and resort to criminal activities to generate necessary revenue.  Employment status and personal relationships become jeopardized.  The tapestry of a person’s life can rapidly unravel. 

But, none of this happened.  About two years after the first shared needle pierced her vein, she quit and she’s been clean since. It was nearly a year later that she first saw me in the office accompanied by her young, spirited son.  I asked her how she molted and emerged from a grim and dangerous world of self-destruction.  “Who helped her?” I inquired.   “No one,” she said.   She had thrown the devil off her back herself, and had dispatched him to a place so distant that he would never find her again.

Devil, Be Gone!

Consider how extraordinary this life-preserving act was.  Only someone who has overcome a true addiction can understand the magnitude of this act.  That she succeeded alone only magnifies the accomplishment.  I admired her grit and devotion, but I couldn’t feel it on a visceral level since I have never suffered from an addiction.

She told me that she her two young kids gave her the motivation she needed to put her needles aside.  She owes them a great debt.  They gave her a gift that she can never repay.  But, I have a sense that she will spend the rest of her life giving back to them. 


Sunday, April 9, 2017

Health Care Reform 2017 Solved!

Have you noticed over the past several weeks that reforming the health care system must be slightly more complicated that we were told?  The promise that Obamacare would be repealed and replaced on Day 1 seems to have been met with a few minor obstacles.  In other words, it’s dead in the water.

Whose fault is it?  It’s like Agathe Christie’s Murder on the Orient Express [Spoiler alert!] – everyone is guilty!

The Freedom Caucus stiff-armed the Speaker of the House.  The GOP House moderates dissed the Freedom Caucus.  President Trump learned that being the leader of the free world is not quite the same as being a CEO of a private company.  If the repeal plan was adjusted to capture a few more hard line GOP members, then moderate GOPers jumped ship.  The Democrats gloated at the GOP’s failure, although their smiles became slightly more taut once Judge Neil Gosruch was confirmed to occupy the GOP’s 'stolen' Supreme Court seat. 

Remember John Boehner?   He’s the happiest man on the planet!

Now, I don’t pretend that the Whistleblower can reform the health care system in a blog post, although I don’t think my results could be worse than the GOP controlled House of Representatives.


Health Care Reform - Searching for Low Hanging Fruit

As a medical insider, consider a few issues listed below that would save zillions and improve our health.  They are not controversial.  Why then, aren’t we pursuing ideas that every medical professional supports?  Perhaps, one of my erudite readers can enlighten us, as I am stumped.   
  • Tens of millions of dollars are wasted on unnecessary antibiotics, which result in serious side effects and are creating superbugs. 
  • We are spending too much money on end-of-life and futile medical care.
  • Every physician who is breathing orders CAT scans, stress tests and colonoscopies that are not truly necessary.
  • Patients are punctured much too often for blood tests, particularly in the hospital when multiple specialists (like me) are on the prowl.  Most patients need only occasional blood tests.
  • Patients, particularly our elderly, are overmedicated.  The length of some of their medication lists are staggering.  Any wonder they are routinely sent to gastroenterologist to explain their nausea and other side-effects?
  • Whatever happened to watchful waiting?  Does every complaint that a patient brings to the office have to result in test or a prescription?   How often does a patient’s medical issue simply resolve on its own?
  • The PSA, prostate specific antigen has single handedly harmed more men and wasted more money than perhaps any other screening test.  Despite mountains of evidence supporting my contention, the diehards are still hanging on.
That was a quick list of some very low hanging fruit.  I’ll wager that if all of them were implemented, that we could reform the entire system and have enough money left over to subsidize obscenely high drug prices.   The absurdity is that the above bullet items would be supported, if not championed, by every reasonable physician, informed patient and health care policy pro.  Here’s the riddle.  Why do we persist in behaviors that we all agree are destructive?   Why do we keep furiously digging in the same hole that leads nowhere?






Sunday, April 2, 2017

Is My Doctor Up to Date?

Professional training and development are critical.  Police officers, educators, orthodontists, painters, chief executives, musicians and chefs all need ongoing training to remain current.  Job requirements evolve, and we must adapt.  An accountant who hasn’t kept up with new or anticipated tax law changes might not account for much when computing your tax obligation or refund.

Physicians need to be dedicated to ongoing professional development as much as any other occupation.  Patients often wonder if their doctor is up to date.  Does your primary care physician know about new medications for your condition?  Does your orthopedist use the latest medical hardware when replacing your hip joint?  Is your anesthesiologist using the same old laughing gas to put you asleep?  Is your dermatologist’s knowledge of his field only skin deep?

In the medical profession, there has been a paradoxical emphasis on reducing professional training.  Here’s what I mean.  In hospitals, it is no longer true that every patient relies upon a registered nurse, or R.N., for nursing care.  Now, lower level personnel such as nurses aides and other care assistants are frequently utilized.  I’ll let the reader surmise what motivated this hospital ‘reform’.  Nurse practitioners now roam the hospital wards, technically under the authority of a physician who is seeing his own patients in an office miles away.  Why see your own primary care physician, when the ‘minute clinic’ on the street corner is open for business.  These clinics are conveniently housed in pharmacies so that any antibiotics prescribed, which we hope and pray are truly necessary, can be purchased on site. 

Who should be doing your colonoscopy?  Do you prefer a trained gastroenterologist, or would you be satisfied with a nurse who has been trained in how to technically use the instrument, as some cost cutters have advocated?    Even a casual reader might appreciate that competency in a colonoscopy, heart catheterization or knee arthroscopy extends far beyond the technical requirements of the procedures. 

Gastroenterologists are similar to Navy SEALS.  We both train to a knife’s edge and do all that we can to stay razor sharp.  To my patients, I want to reassure you that staying current in colonoscopy is my life’s mission.  The training manual pictured below is never out of reach.  Feel better?


Sunday, March 26, 2017

Beware of Joining a Clinical Trial - Medical Research Must Come Clean

From time to time, friends, patients and relatives ask my advice on participating in a medical experiment.  My response has been no.  More accurately, once I explain to them the realities of research, they don’t need to be persuaded.  They back away.

Here’s the key point.   When an individual volunteers to join a research project, the medical study is not designed to benefit the individual patient.  This point is sorely misunderstood by patients and their families who understandably will pursue any opportunity to achieve some measure of healing for an ailing individual.  I get this.  In addition, I believe that these research proposals are often slanted in a way to suggest that there may direct benefit that the patient will receive.  I am not accusing the medical establishment of uttering outright falsehoods to prospective study patients, but there are two powerful forces that may incentivize investigators to recruit patients with undue influence.
  • The Medical Research Industrial Complex is a voracious beast that needs a steady diet of new recruits.  In other words, the beast must be fed.
  • Investigators have bias favoring their research and truly believe that the new drug has a real chance of helping study patients.
The truth is this.  In general, research projects are designed to generate new knowledge that will be used to help patients down the road, not those in the study.  Of course, I cannot state with absolute certainty that a study patient won’t realize a favorable result, but this serendipitous outcome is not the study’s planned yield. It should be viewed as a happy accident.  This is why the study is properly called a research experiement.

Napoleon Has Stomach Pain.
Should He Join a Study?

Beware of the packaging.  If your mom or dad has Alzheimer’s disease, of course, you would be susceptible to the following hypothetical pitch.

Is someone you love struggling against Alzheimer’s disease?  Our Neurological Institute is fighting hard against this disease and is now testing a new drug to help conserve memory.  Call for confidential information. 

Recently, in France, 90 volunteers took a study medicine testing the safety of a psychiatric medication.  One volunteer is now dead and others have suffered irreversible brain damage.  We don’t know the underlying facts yet.  While a horrible outcome is not tantamount to guilt, this is a terribly troubling event that must be sorted out. We will find out soon enough if the French study subjects were given all the information they were entitled to, and if the investigators and others behaved properly.  The investigation that must be full and fair.  A conclusion of c’est la vie won’t be enough.

If you want to join a medical study to serve humanity – and not yourself – then you are free to make an informed choice.  Be mindful of the risks including those that are not known. 

Helping others is a praiseworthy act.  So is telling the truth.


Sunday, March 19, 2017

Medical Marijuana Use - Ready, Fire, Aim!

Promoting medical marijuana use is hot – smokin’ hot.  States are racing to legalize this product, both for recreational and medical use.  In my view, there’s a stronger case to be made for the former than the latter. 

Presently, marijuana is a Schedule I drug, along with heroin, LSD and Ecstasy.  The Food and Drug Administration (FDA) defines this category as drugs with no acceptable medical use and a high potential risk of addiction.  Schedule I contains drugs that the FDA deems to be the least useful and most dangerous.  Schedule V includes cough medicine containing codeine.

On its face, it is absurd that marijuana and heroin are Schedule I soulmates.  I expect that the FDA will demote marijuana to a more benign category where it belongs.  It will certainly have to if marijuana is going to be approved as a medicine. 

There is no question that some advocates favoring medicalization of marijuana were using this as a more palatable route to legitimize recreational use.  The strategy was to move incrementally with the hope that over time the ball would cross the goal line.  We have seen this same approach with so many other reforms, legal decisions and societal acceptances, many of which we take for granted.  Consider gay marriage and women’s role in the military as two examples of goals that required a long journey to reach.

Marijuana has had no personal or professional role in my life.  I do not object to responsible recreational use and would support such a measure.  To criminalize marijuana use while cigarettes, chewing tobacco and alcohol are entirely legal seems inconsistent and hypocritical.  Is smoking marijuana more dangerous than riding a motorcycle?

Paradoxically, I have hesitancy at this point to endorse medical marijuana use based on the fragmentary data that supports its efficacy.  If you ‘Google’ this subject, and you believe what you read, you will conclude that marijuana is the panacea we’ve been waiting for.   It helps nausea, neuropathic (nerve) pain, glaucoma, muscle spasms, Crohn’s disease, multiple sclerosis, epilepsy, Hepatitis C, migraines, arthritis, Alzheimer’s disease, cancer and numerous other ailments.  Do we accept so readily that one agent can effectively attack such a broad range of unrelated illnesses?  It sounds more like snake oil than science. 

Cure is Just a Puff Away!

Shouldn’t high quality medical studies demonstrate benefit before we sanction medical marijuana use?

The medical profession and our patients should demand that all our medicines be rigorously tested for safety and efficacy.   I realize that there is huge public acceptance that marijuana is real medicine.  Not so fast.  Let the FDA evaluate marijuana as it does for all medications and treatments.  I do not think we should relax our professional standards just because the public is willing to inhale without evidence and entrepreneurs want to cash in.

If you had a chronic disease, would you expect your doctor to offer you a medicine with definite risks but no proven benefit?  Why would you accept it and why would he prescribe it?  

Sunday, March 12, 2017

Why Are Drug Prices So High?

Why are the costs of prescription drugs so high?  While I have prescribed thousands of them, I can’t offer an intelligent answer to this inquiry.  Of course, all the players in this game – the pharmaceutical companies, Pharmacy Benefit Managers, insurance companies, consumer activists and the government- offer their respective bromides, where does the truth lie? 

While I don’t fully understand it, and I don’t know how to fix it, we all know that the system is broken.  More than ever before in my career, I am seeing patients who cannot afford the medicines I prescribe for them.  In the last few weeks of this writing, 3 patients with colitis, a condition where the large bowel is inflamed, called me to complain about the cost of their new medicine.  The annual cost was in the $2,500 - $3,000 range, which is way out of range for normal folks.  While I was only focused on the colitis drug, many of these patients face prohibitive costs over multiple medicines.  All of these patients had medical insurance, thought it didn’t feel like it to them. 

Medicine or Retirement?

Should sick patients be given the added burden of price gouging?

I'm not an attack dog against PhRMA.  I've expressed sympathy on this blog and elsewhere that it costs pharmaceutical companies a fortune to design, test and market new medicine.  R & D is not cheap.  If we want this industry to take risks developing tomorrow's drugs, then they deserve a profit high enough to justify the investment.  Nevertheless, from the prescribers and the consumers points of view, the system is out of balance and needs to be recalibrated.  

I reviewed my colitis patients' formularies, which is the list of medicines that patients' insurance companies cover.  If a drug is labeled as a ‘Tier 1’ drug, then the cost to the patient is the lowest.  The higher the Tier #, the more the patient will pay.  This is how the insurance company ‘guides’ physicians to prescribe cheap drugs.  Of course, the insurance company will never say that the patient can’t receive an expensive drug.  That’s a decision, they claim with a straight face, that’s between a patient and the doctor.  Give me a break.  Ordinary folks, especially retired people on fixed incomes, are confined to lower Tier medicines.

I have no issue with the Tier system as long as there is at least one Tier 1 drug that can do the job.  If there are half a dozen heartburn medicines that are equally effective, I understand if an insurance company makes one of them Tier 1, their preferred choice.  This happens when the insurance company gets a special discount on this particular medicine.  

With regard to my 3 colitis patients, the only Tier 1 drug was one that came on the scene decades before I was born.  The standard colitis medicines that every gastroenterologist would have prescribed were all upper Tier. My patients had no choice but to accept an inferior drug. 

If any reader can explain why our drug prices are the highest in the world, can you also explain why insurance companies are not practicing medicine?



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