Sunday, May 29, 2016

Memorial Day 2016 - We Remember

I am in coffee shops several times per week.  I prefer independent establishments with atmosphere and authenticity.  For that reason, it is rare to spot me in a retail coffee outlet whose HQ is in Seattle, Washington.  This past week, as I was carrying my cafĂ© mocha to my table, I spied some board games stacked up on a table.  On top was the game pictured below.

This brought back warm memories of playing this game as a young kid.  It recalled the wholesome and beautiful childhood that my parents gave me.  Millennials might not appreciate the raw and fierce competition of games such as Candyland, Chinese checkers or Trouble, which has caused a huge void in their lives. 

Looking back and remembering gives meaning to our lives.  We remember a song, a joke, a celebration, a concert, a speech and relationships.  Isn’t it amazing how hearing a song from years ago captures a mood?

This weekend, we remember and ponder something of infinite meaning and importance.  We remember what so many Americans have done and still do so that folks like me can blog without fear, read a newspaper that criticizes our government or protest lawfully in the public square.

I have never served so I cannot begin to grasp what you have done.  But, I have met many of you, and I am inspired by your heroism and your modesty.

Sunday, May 22, 2016

Measuring Physician Quality - Bully or Just Plain Bull

Patients are amazing creatures.   The current breed is hyperinformed on medical information and has an ever expanding reservoir of physician data to trove through.  I’m not just referring to physician reviews on Angie’s list.  Soon, the public will be encouraged to review our success and failure rates with respect to medical treatments, how much cash the drug companies grease us with, all disciplinary actions, comparison with peers, complication rates, medical malpractice entanglements and how much Medicare reimbursement we have received.

There will be published quality benchmarks on physicians so that the public can see how their physicians scored on these various quality measurements.  I have opined throughout this blog that I feel that these measurements are tantamount to taurine excrement.   Sadly, reimbursement will be tied to these results with physicians who don’t rate high enough having some of their income confiscated.  Physicians who don’t make the grade may game the system to achieve higher grades, which has nothing to do with true medical quality.  Is that what our patients want and deserve?

Source of Taurine Excrement

I was poised to begin a colonoscopy on an informed woman who asked me what my ADR was.  I will presume that readers are not aware of what this means.  Most physicians are likely also ignorant of what these letters stand for.  In fact, I’ll bet a decent percentage of gastroenterologists are clueless here as well.  The ADR refers to the Adenoma Detection Rate, which is one of the silly statistics that ‘experts’ feel separate skilled colonoscopists from pretenders.  Adenomas are polyps which are precursors to colon cancer and are the target lesion for screening colonoscopies.  When you consent to undergo a colonic delight at age 50, your gastroenterologist is seeking out adenomas, removing them before they can morph into a cancerous condition.

‘Experts’ advise that competent gastroenterologists should have an ADR of 25% in males and 15% in females who are undergoing screening colonoscopies.  Lower rates, they claim, suggest sloppy or rushed examinations.   Now, some colonoscopists are removing every pimple they find to make sure they will surpass these thresholds.  Does this sound like good medicine?

Remember, colon polyps are surrogate markers.   The true objective of colonoscopy is to prevent cancer, not finding small benign polyps.  A patient should be more interested to know if their gastroenterologist prevents colon cancer, which is not that easy to measure.   In contrast, measuring the ADR is simple, so it is used as a substitute for colon cancer prevention because it is so easy to do.   Similarly, the statin drug companies boast about their cholesterol lowering properties, which is easy to measure.  Cholesterol levels are also surrogate markers for what we should really care about – heart attacks and strokes – events that can’t be studied and measured as easily as simple blood test results.  A surrogate marker ‘benefit’ may not lead to the desired medical outcome, despite claims that it will.

My nurse assured the inquisitive woman on the gurney that my ADR was above threshold.   Am I a high quality gastroenterologist?   I must be.  I’ve got ADR mojo.    Let’s give a shout out to the government and the insurance companies for adopting the ADR standard.  Can we agree that it’s Another Dumb Regulation?

Sunday, May 15, 2016

Medical Insurance Companies: Heroes or Villains?

Physicians are expected to be hostile to insurance companies.  Indeed, a prior Whistleblower post directed arrows in their direction.  They are an easy target, often vilified for their greed and perceived indifference toward those they insure.  Ask most of us if we think insurance companies favor profits over patients, and most of us will respond that profits prevail.

Insurance companies are businesses, not charitable undertakings.  Sure, we all like free stuff.  Or, if it’s not free, we prefer that someone else pays for it.  We are outraged at the costs of chemotherapy, hepatitis C treatment and biologic treatments such as Humira and Remicade, leaving aside the zillions of dollars it takes to research, develop, manufacture, market and monitor innovative new drugs. 

We want to drive a Cadillac, but only pay for a Chevy.

We want to pay for this...

...and drive this.

No person, business or organization is wrong all of the time.  Consider the following practices.  Who’s side are you on here? 

A patient has chronic back pain and ran out of his pain medications on the weekend.  He calls the doctor and is connected to a weekend covering physician who declines to refill the medicine.  The patient then proceeds to an emergency room, where he is evaluated and given the desired prescription.  Who should pay for the ER care?

A patient is seen in the office and prescribed a 2 week course of antibiotics for diverticulitis.  The medicine nauseates him and he stops them in 3 days.  He does not contact his physician.  Ten days later, he develops severe abdominal pain and fever and needs to be hospitalized for severe diverticulitis.  He is in the hospital for 5 days and is seen by numerous medical specialists.  Who should pay the costs of this hospitalization?

A 55-year-old individual has never had a colonoscopy performed.  His primary care physician advises him to proceed, but the patient declines.  A decade later he is discovered to have colon cancer and needs to be hospitalized for surgery and evaluation by an oncologist.  Who should pay for the costs of his care?

If a patient with high blood pressure, skips appointments and his medications, and a complication develops…

I’m not carrying water for the insurance companies.  I am pointing out, however, that we often expect them to pay for medical care that is either inappropriate or should not have been necessary.  That’s not reasonable or fair.   Don’t we have a responsibility to be personally responsible?

Sunday, May 8, 2016

Should the FDA Approve Experimental Treatment for Severe Diseases?

I’ve never had the pain and agony of having a kid who is truly sick.  Broken bones and minor surgeries don’t count.  Even one of my kid’s bout with malaria doesn’t rate, as this illness was easily cured.

Parents of kids with chronic illnesses would sacrifice anything to help their kids get better or to suffer less.  In the news recently is a conflict between families of kids with Duchenne muscular dystrophy and the Food and Drug Administration (FDA).  A very small study of an experimental drug called eteplirsen suggested some benefit.   Understandably, the families want the FDA to grant approval so that their kids and others could have access to this drug that will fight a dreadful disease that is fatal.  Families argue that these kids have nothing to lose and can’t wait another 5 years waiting for more definite evidence of efficacy to emerge. 

The FDA is legally required to approve drugs that are safe and effective.  Obviously, the definitions of safe and effective are subjective, but the agency requires that a reasonable threshold be crossed for both of these parameters.  Gray areas create agonizing conundrums for agency officials and patient advocates. 

Should Unproven Treatements be Approved?

The FDA commissioned committee, which will advise the agency proper, did not advocate drug approval, which caused great consternation among family members and their supporters.  These wrenching decisions must be guided by science and medical evidence, not hope and emotion.  Here are some potential objections to approving the medicine.
  • The study was too small to have persuasive scientific validity.
  • The study did not have a proper control group, which further weakened the conclusions.
  • The drug may have unknown and serious side-effects.  Once the drug is approved, physicians can prescribe it lawfully for a variety of diseases and illnesses, some of which may not be life-threatening.
  • Acceding to understandable family demands for premature FDA drug approval will prevent patients from entering larger clinical trials, preferably in a randomized study with a placebo control, where safety and efficacy can be more accurately verified.
  • If the FDA weakens its standards for approval for a single drug to respond to a constituency, then be prepared for mission creep to erode standards across the board over time.  
It's the parents' job to everything they can do to protect their kid.  It's the FDA's job to protect all of us.  I wish we could protect and save everyone.

Sunday, May 1, 2016

Should Women Who Seek Illegal Abortions be Punished?

Every four years, abortion gets more press and attention as the candidates compete for electoral support.  My own position on this issue is not relevant for the points I offer here.  We all know that candidates massage their position on abortion and on other issues in an attempt to maximize their voter support.  It’s fun to watch them thread the needle as they dance and pirouette for us.  They are performers who can be as flexible as the amazing acrobats on Cirque du Soleil.  The emphasis, if not the content of their message, changes depending upon the audience.  Al Gore was ridiculed when he sported a more southern accent when he was campaigning below the Mason-Dixon line. 

Donald Trump was clearly unprepared for the abortion question when he rhetorically collapsed during a typically vigorous and frenetic interview with MSNBC’s Chris Matthews.  Of course, you don’t really have to prepare on an issue if you already have a principled position.  You can just tell the truth. 

Trump's Interview - Not Star Quality

Donald Trump initially responded that women who are seeking an illegal abortion should be legally accountable.  This was the bombshell.  While Trump walked this back in record time, I do not understand why his initial position was wrong.  And yet, even the most conservative politicians, such as Cruz and Huckabee, do not advocate targeting women in these cases.

Why not?

If abortion is against the law, then why isn’t a woman who seeks the procedure violating the law?  I suspect the reason that there is no support for this – and I’m not saying that I support it – is that such a view would be the equivalent of swallowing political cyanide.  I ask readers here to calmly explain from a legal perspective why the doctor and the abortion facility would be legally vulnerable, and not the woman.   Yes, I know the argument that woman is already a victim, etc., but this is not how we approach other legal violations.

If gambling is illegal, and the police raid an illegal casino, do we expect the gamblers would be set free?  If an illegal prostitution ring is discovered, are the clients not prosecuted?  Of course they are. 

To me this issue sounds like a duel between Principle and Pandering.  We know how these contests usually end.

Sunday, April 24, 2016

Risks of Probiotics - Who Cares?

Earlier this year I read about a medical study that concluded that a diet high in saturated fat won’t kill you after all.  Moreover, piling on polyunsaturated fat won’t save you.

Hee hee.  I love this stuff.  Established medical dogma back flips every 10 years.  Butter in, butter out.  Hormone replacement treatment for perimenopausal women is mandatory, until it isn’t.

Who knows what to believe when even doctors are confused or just don’t know.

We have a medical industrial complex that is a beast that needs to be fed.  It fuels itself on our fidelity to medical practices that are labeled as truths.  ‘Wellness’ rules.  How many decades did the public and the medical community preach that the P.S.A. blood test saved men’s lives?  While I believe that urologists were sincere in their mistaken beliefs and practices, there was a whole industry behind the scenes that was fueling the fire.  It was good business for hospital operating rooms, medical device companies and radiation therapy suites. 

Of course, you could make this same point with respect to my own specialty of gastroenterology, as I often do on this blog, as readers know.

Just because something sounds true, or we want it to be true, doesn’t make it true.

Is obesity really a killer on the loose?  When a reputable study is published that pulls back from this draconian conclusion, what happens?  The study is attacked by those who either truly believe that the study is flawed or by those who are threatened by it.  Mammography is a superb example of this phenomenon.  It is increasingly recognized that mammography is deeply flawed, problematic and harmful, but try discussing this with a mammography zealot.  If you dare to do so, don the Kevlar first.

Kevlar - Use for Zealot Protection

Probiotics are the rage for maladies spanning digestive disorders to depression to chronic fatigue.   Do they work?  Does it matter?   The science girding most of their claims is porous, deceptive or absent.  We should demand that their products be rigorously and independently tested, but this will not happen.  Why should these companies tamper with perfection?  We’re already buying their potions faster than you can say ‘gluten-free’.  Why risk the pesky scientific method that might cast a penumbra of doubt on their healing claims?

Think about the probiotic process.  Folks are swallowing billions (that’s billions with a ‘b’) of bacteria every day.   Of course, these are ‘good bacteria’, little microscopic elves that will gobble up diseases that are beyond the reach of conventional medicines.  First, let’s call them what they are – germs.   Is there any brave voice out there who is willing to vocalize concern about changing the human flora which took a gazillion years to develop through evolution?  Are bifidobacteria really smarter than millions of years of natural selection?

Years from now, when probiotics are off the shelves, folks will nod their heads wondering how millions of us swallowed billions of germs just because we wanted to believe. 

Skeptics of the world unite!

Sunday, April 17, 2016

Weight Loss Breakthrough Melts Pounds Off!

What’s all this chatter I hear about how hard it is to lose weight?  Relax.  Obesity has finally been conquered.  Those stubborn extra pounds that you’ve been stuck with will soon melt faster than a popsicle on a steamy summer day.  Although I am a practicing gastroenterologist who deals with nutritional issues routinely, I did not learn of this breakthrough in my medical journals or from experts in the field.  I learned it just by listening to the radio.

I’m in the car several times a day, so I get my share of radio time.  Not a day passes that I don’t hear an ad for some kind of fat-busting pill or potion.  The products are different but the pitch is always the same.

Obesity on the Run!
  • Rapid weight loss
  • No excercise
  • No work or effort.  Pound magically disappear

This seductive pitch is followed by testimonials from smiling ‘customers’ posing on the beach who corroborate the amazing result.  Their script usually includes:

'I've tried everything and nothing works.  When I heard about (insert product name), I was skeptical, but I've dropped twenty pounds and I'm eating more than ever!'

Then, viewers will see the before and after photos.  The 'before' shot is a grainy black and white photo with bad hair and a scowling expression.  You know what the 'after' shot looks like.

Then the announcer returns and cautions viewers that this product should only be taken for serious weight loss because it is 'extremely potent'.   Then, we will hear the incredibly clever tag line,' the only thing you have to lose is weight!'

As the ad concludes, a disclaimer is read at a speed faster than the human ear can process.  I can barely pick out the phrase, ‘results may vary’.  I think we all know what that means. 

Losing weight is tough work, as folks who have been battling against their bathroom scales can attest.  The weight loss journey should be regarded as a slow marathon jog, not a high speed sprint.  If losing weight were easy, then we’d all be thin.

But, it can be done.  We all know people who cracked the code against obesity and trimmed down.  How did they do it?  What are their secrets?

Here are some of the lessons I have learned from them after a quarter century of medical practice.
  • Losing weight is a mental and psychological process.  Don’t try to lose an ounce until you have made a strong mental commitment to the effort.
  • Understand why you eat excessively.  It’s usually not from hunger.  Understanding ‘why’ will help you plan an effective strategy.  For example, if you reach for food when you are stressed, then exploring stress reduction options will be a key component of your plan.
  • Avoid gimmicks.  They don’t work.  There’s no quick fix here.
  • Set modest weight loss goals and try to achieve them.  If you intend to lose 2 lbs per month, keep to this level.  Don’t overshoot – stay at a steady pace.
  • Make dietary changes that you can live with forever.  This is why gimmicks fail and nearly these folks regain the weight after experiencing initial rapid weight loss.
  • Have a friend or family member to serve as your coach and cheerleader.
  • You’re not perfect.  Don’t hold yourself up to an infallible standard.  Backsliding is not failure, it’s human.
P     Physicians can help here, but we can't do the work for you.  We can share with you the secrets of successful patients and we will do our best to make you one of them.  Talk to your doctor.  You have nothing to lose except....


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