Sunday, August 30, 2015

Patient Survives Death Sentence - Medical Negligence?

Doctors do not know everything.    We make mistakes and mistakes in judgment.  Sometimes we make the mistake of speaking when we should keep silent.  At times, patients ask us questions that we can’t or shouldn’t answer; and yet we do.  It shouldn’t be our objective to force certainty into an issue which is amorphous and murky. 

Here’s a response that I recommend in situations where certainty is elusive.

“I don’t know.”

I saw a patient for the first time when he was sent to me for a colonoscopy.  Prior to the procedure, we interviewed him to be acquainted with his medical history.  We are always particularly interested in the cardiac and pulmonary history, as these conditions impact on the risk of the procedures and the anesthesia.   This patient had a lung resection.   He related the details which left my staff and me aghast.

“The doctors told me that I had cancer and would be dead in 3 months.”

Of course, it is not possible for a spectator to imagine the horror of this pronouncement.  To know the date of your upcoming demise, a fate that is only known to those on death row, is cruel torture.   In this case, the doctors were wrong on two counts.  This man wasn’t going to die.  And, he didn’t have cancer.

What a horrible error that didn’t need to happen. While I didn’t have the medical details, here’s what I think happened.   He had a CAT scan of the chest because he was having respiratory symptoms.  A mass was found.  The physicians then followed up with a PET scan, which is a special radiographic test used to determine if a mass is cancerous.   While this result isn’t as definitive as a biopsy, a positive result usually portends unfavorable news.   Oncologists use PET scans routinely.  My guess is that this patient’s PET scan result was on fire and the patient was told that his days were numbered.   Surgery was scheduled.   When the final pathology of the resected lung specimen was issued, not a cancer cell was in site.  This patient had a fungal infection and completely recovered.

This was a colossal error, even though the outcome was a blessing.   If a patient is wrongly told that his condition is benign, and he has cancer, then the same error assumes a very tragic proportion.  My patient lived to relate his saga to the world.

An Error of Colossal Magnitude

Could he have successfully sued his treating physicians?  I think he had a reasonable case for pain and suffering damages, including perhaps, unnecessary surgery.   No case was ever filed.    I would hope that an unexpected gift of life would render a lawsuit to be a trivial pursuit, even if the case had legal merit.  He feels perfectly well now.  The damages diminished and faded while his life endured.  

I recognize that others may have a different view of what transpired here.  They may focus on what was taken from him and that he deserves to be made whole.  They may not feel that he has been given life, as his life was never truly in jeopardy. 

I’ve done about 25,000 colonoscopies and I’ve confronted scores of colon cancer.  I know it when I see it.   When I see a lesion that concerns me, I share this concern with the patient and his family after the procedure.   But, I still wait for my biopsy specimen results before issuing an authoritative declaration.  Shouldn’t I wait until I have 100% of the data before speaking with 100% certainty?

Sunday, August 23, 2015

Is Your Doctor a Spin Doctor?

We are in the Age of Spin as the presidential campaigns percolate along.  So much fun to watch!  It’s a performance in doublespeak, deflection and distraction that is so obvious, that even a person who knows no English can spot it.  I used to get exasperated when I would watch a politician dodge the question posed, but now I view it as pure entertainment.   I’m glad I made this transition, particularly since I live in Ohio where we will see more spinning than anywhere else.

Spinning is an old profession.

To those who are unschooled in spinning recognition, keep your ear out for these phrases which are classic spin initiators.

‘…what I will say…’

‘The question we should be asking…’

‘I have always said…’

Let me illustrate.

Reporter:  Do you support the president’s Iran deal?
Spinner:    The question we should be asking is why are we caving to the Ayatollahs?

Reporter:  Do you support a path to citizenship for the 12 million undocumented immigrants?
Spinner:   I have always said that this nation must have border security to protect our nation.

Reporter: Do you accept the Supreme Court’s decision legalizing gay marriage as settled law?
Spinner:   I am a champion for liberty and  I have always said that I believe that this issue should be addressed by the states.

Reporter: Will you say now on national television that you recommend American boots on the ground in Iraq?
Spinner: What I will say, is that if it weren’t for Obama’s leading from behind, we’d never be in this position.

The political spinmeisters are weaving a tapestry that is stretching across the country.

While the medical profession cannot rival the political class in spinning competence, we’ve been known to massage a phrase or two.  Have a look.

Medical Truth:  Regular exercise has a modest effect on weight loss.
Patient Spin:  Once I resume my exercise routine, the pounds will melt off.

Patient Truth:  Hey, where’s my doctor hiding?
Administration Spin:  If you like your doctor, you can keep your doctor.

Medical Truth: Proof of efficacy of probiotics for gastrointestinal diseases is lacking.
Health Food Store Spin:  After you swallow zillions of good and great bacteria, they become your personal warriors against digestive evil. 

PhysicianTruth:  The placebo effect is a real phenomenon.
Physician Spin: I think this pill has a good chance to deliver some relief to you.

What's your profession?  What yarns have you spun lately?

Sunday, August 16, 2015

Who Deserves Quality Medical Care?

We all should know the difference between a slogan and real substance.   One of these has size and shape while the other is just a shadow.   Why then, is the slogan so powerful?

A slogan is one of the weapons wielded by the Guardians of Political Correctness.  They will point toward the slogan du jour, and then, with cameras rolling, demand to know if you support it.  Even a moment’s hesitancy will be taken as weakness.   Expect to see your waffling go viral for all to see, edited down and sans context. 

Politicians Advised to Avoid Waffles.

During a presidential election, this practice is omnipresent. 

Mr. Bush, do you support fair trade?
Mrs. Clinton, is your immigration policy to give amnesty to all illegal aliens?
Mr. Cruz, do you believe in the rule of law?

These questions cannot be adequately answered with a reflexive yes or no.   The slogans contained within these 'gotcha' questions point to complex and nuanced issues that need layered responses.  Of course, if a politician were to begin his response with, ‘Yes, but…’, he will be tossed aside as a spineless waffler.  

I hear the slogan ‘equal pay for equal work’ bandied about.  If a reporter shoved a microphone in your face and demanded to know if you support this slogan, would you scream ‘Yes!’ while you pumped your fist in the air for emphasis?   After all, who could oppose equal pay for equal work?  Shouldn't a man or woman receive the same wages for the same job?

Try this example.  A new teacher who has just completed his training becomes a 3rd grade teacher.  He is qualified and brings youthful enthusiasm into the classroom.  His colleague across the hall, has been teaching 3rd grade for 15 years.  This teacher is a seasoned professional whose students benefit from a career of experience during which she has honed her craft to higher level of performance.  Both are 3rd grade teachers.  Should each be paid the same salary?   I don't think so.  Does this mean that I do not  support equal pay for equal work?

Slogans are rife in the medical world.  How often do we read or hear about ‘quality health care’?  Not a day passes that I don't confront this slogan.  It’s an empty phrase that masquerades as something real.  It’s a phantom, a cloud, a ghost.  It falls apart if you try to hold it.  

I think every American deserves quality health care from quality physicians who prescribe quality medications dispensed by quality pharmacists purchased by quality patients.

My point?  Try to define quality medicine.  It’s not as easy as it seems.  Could you do it as a quality reporter with a mic and a camera demands a quality definition in 5 seconds?

Context anyone?

Sunday, August 9, 2015

When Does Life End? Ask a Humble Doctor.

About a week before I write this, I met a man for the first time.  Though it is unlikely that I will see him again, it is unlikely that I will forget him.

This was a side trip for us, as we meandered for a weekend through the beauty and nostalgia of Ohio.  Once you find yourself about an hour south of Cleveland, you are in a Land of Barns, where cornfields and cattle punctuate the countryside.  There are miles and miles of open roads unblemished by Starbucks, CVS or Big Box Retail.  Is the air truly fresher or does it just seem that way?

On the Open Road in Ohio

We drove out to meet this man to examine his wares.  The GPS faithfully led us to the desired location, but we assumed that we were misled as there was no business sign to alert customers like us.  Not quite the marketing strategy we know from city life where advertisements will soon appear on toilet paper.   He has an unusual profession, which I will not identify, as this might be enough to identify him which would violate his privacy.

We looked over his shop and he then invited us into his home to show us how his stuff might look in an actual home.  When he learned what I did, he then told me that he had seen several gastroenterologists on a medical odyssey that started 3 years ago.

The man’s profession is not important.

The medical facts that resulted in a delay in his diagnosis of cancer are incidental.

His Christian faith, evidenced by numerous crucifixes adorning his property, would likely be deemed to be paramount by the man himself.

The doctors told this man that he had 3 months to live.  That was 3 years ago.  As a trained medical professional, it is my considered judgment after decades of medical training and experience, that he is quite alive.  Not just alive, but alive and well.  Not just well, but downright inspirational. 

When he was given this dire news, his response was that ‘it’ll have to kill me’, as he intended to fight back.  He did.  He has one final surgery remaining this fall.

The doctors were wrong, dreadfully wrong.  Perhaps, they were relying upon textbooks, which my new friend didn’t read.  He had his own playbook, which helped him to find a pathway back to life. 

Of course, doctors, as members of the human species, make mistakes.   We give wrong advice.  Sometimes, we give the correct advice, but something unexpected happens, as I suspect happened in this case.   Arrogance is the enemy of good medicine.

Sir William Osler, one of medicine’s preeminent physicians of all time, implored physicians to have ‘the grace of humility’’  No second opinion needed here.

Sunday, August 2, 2015

Planned Parenthood Videos Threaten Truth

While we have all heard the adage, any publicity is good publicity, I don’t agree.   See if you agree that the subjects of the following hypothetical headlines would have preferred anonymity.

Local Surgeon Loses Scalpel – in Patient’s Abdomen
Teacher Pursues New Career as Porn Star
Restaurant Owner Claims Rats are Really Pets

Planned Parenthood is in the news.  Several videos, surreptitiously taken, have been released showing discussions between Planned Parenthood personnel and folks who were pretending to be interested in procuring fetal parts.  It is illegal under federal law for Planned Parenthood to make a profit selling fetal parts.  More fact gathering will be necessary to determine if a legal line has been violated.  Legalities aside, the videos have generated revulsion across the ideological spectrum by how unseemly and casual the Planned Parenthood folks discussed a subject with huge ethical and legal ramifications.  The public heard how the abortion technique could be ‘adjusted’ so that fetal organs would not be damaged so they could be harvested.  The faux venders were told by Planned Parenthood that they prefer that the surrendered organs would be considered for ‘research purposes’, rather than as a typical business transaction as this would give the organization some ethical and legal insulation. 

One’s ultimate view on the legality and propriety of Planned Parenthood’s behavior should be independent of one’s view on the abortion question.  I am always agitated when an individual or organization’s views on an issue are tainted to conform to an ideology.  For example, if you are a Democrat who believes that Hillary Clinton’s email practices are entirely proper, then you should have the same view if Dick Cheney were substituted in her place.

If Dick Cheney says the earth is round, some folks will say he's wrong.

Regrettably, this is not the standard that operates in the public square.  Pro Life believers are clamoring to defund Planned Parenthood, an organization many of them loathe.  Pro Choice adherents, sidestep the videos’ content and focus instead on the deceptive techniques used to obtain them.  Both sides are missing the point on purpose.

If Planned Parenthood broke the law, then this fact should not be mitigated or expanded depending upon one’s abortion views.

This story has various medical ethical dimensions.
  • Must an abortion provider obtain consent from the patient for giving away fetal parts?
  • Is it ethical for an abortion provider to modify the procedure in order to preserve specific organs?
  • Is informed consent necessary for an abortion provider to use a different technique for a purpose unrelated to the medical task at hand?
  • Could the patient charge the vendor for fetal parts?

 I have not given my own view on the abortion question here.  It shouldn’t matter.  This issue should be judged separately from one’s view on the abortion question.   Call it straight. Support your adversaries and rebuke your own team when the facts demand this.  Telling the truth is good publicity.  

Sunday, July 26, 2015

Warning! Cell Phones Can Kill You!

In medicine and beyond, folks just want stuff to be true.  Sometimes, we believe stuff that is unproven, but might be true.  We doctors recommend such treatments to patients every day.  On other occasions, a benefit of a drug or food item is extrapolated way beyond the data.  For example, if Nexium is known to be effective against stomach ulcers, then why not use it for patients with stomach aches who are ulcer-free?  There’s not a gastroenterologist on the planet that hasn’t engaged in this therapeutic mission creep.  More interestingly, folks often persist in beliefs that have been disproven.  The notion, for example, that certain vaccinations can cause autism has been thoroughly debunked by rigorous scientific study, yet there remain diehards who defy the science. 

Curiously, many unproven or disproven practices have gained a fair measure of street cred in the Court of Political Correctness.  Keeping a gluten-free diet today is downright chic.  Colonic cleansing is the bomb.  Kale is king. 

If we want to generate some heat in the green crowd, just mention the word ‘radiation’.  Ingesting irradiated food, for example, is believed to be tantamount to swallowing strychnine.  No persuasive evidence necessary.  Faith will suffice.   Nuclear reactors are regarded as atomic bombs in waiting, as if burning coal or hydraulic fracturing (fracking) are as clean and pure as the first snowfall.  The sun’s radiation, which assaults us daily is somehow not demonized, nor are cosmic rays, high energy radiation which bombards our atmosphere and can reach down to earth itself.

Cell Phone-Free Zone!

The City of Berkeley, the epicenter of New Age Goofiness, has just passed an ordinance that requires retailers to warn customers about the medical risks of devices that emit radiation, such as cell phones.
Here’s an excerpt from the caveat.

If you carry or use your phone in a pants or shirt pocket or tucked into a bra when the phone is on and connected to a wireless network, you may exceed the federal guidelines for exposure to radio frequency radiation.  This potential risk is greater for children...

Luckily, I'm mostly in the clear.  I am not a child and do not don female underwear.  I secrete the phone into the left inside pocket of the sport jackets I wear each day to work.  The phone, therefore, rests above my heart.  Perhaps, the gentle radiation from my beloved iPhone is conferring a cardiac benefit on me?  While it's just conjecture, perhaps, if my heart gets tempted to beat out of step, that my iPhone's rays keep my rhythm sure and steady.  

If I were the cell phone companies, here's how I would fight back.  Forget about litigation or trashing the fiends who fear all radiation, foreign and domestic.  I would sell my theory of cardiac protection to the American Heart Association. For a proper donation, they might consider cell phones to be 'Heart Healthy'.  

If your adversary argues without facts, then shouldn't you?

Sunday, July 19, 2015

Should Physicians Profile Our Patients?

Profiling in this country is highly discouraged and is illegal in many circumstances.  Anti-profilers decry this technique which, they argue, unfairly targets innocent individuals violating their rights.  Our beloved Transportation Security Administration, or TSA, is charged not to use profiling as a screening tool.  Personally, I object to this prohibtion.  While an individual’s rights are important, it must be weighed against the rights of the community.  Our cherished rights to free speech and assembly are not absolute.

I have flown on El Al airlines, whose personnel actively profile in an effort to keep its passengers safe.  Anyone who has been a passenger on this airline will likely agree with me that he has never felt safer on an airplane.  I have a right not be blown up, and if profiling further minimizes this risk, then call me a fan.
Last year, my mother, who appears as threatening as a school librarian, was patted down twice when she traveled to visit me in Cleveland.  I’m sure that the patter-downers were following the rules and regs, but this doesn’t seem to be a well targeted effort. 

A Non-controversial Profile

I’m familiar with the argument against law enforcement using profiling to reduce crime and protect public safety.  I understand that this can lead to abusive practices by overzealous police officers.  But I wonder if, as El Al believes, this can be a legitimate tool in law enforcement’s armementarium.  I’m open to the debate here.

I’m a physician and I certainly profile my patients.  I don’t have a single template for treating abdominal pain in all  patients.   For example, if I see a recent immigrant from China with stomach issues, a part of the world where gastric cancer is relatively common, this may affect the speed and intensity of my evaluation.   If an American born patient comes to my office with the same complaint, my response might differ.   If breast cancer is more common in Ashkenazi Jewish women, shouldn’t we factor this in when we are advising them on risk reduction?  Certain populations have different health risks.  Physicians are always trying to separate out patients who might warrant special attention. 

If you are trying to reduce a certain disease that is largely restricted to one segment of the population, doesn’t it make sense to target this segment rather than everyone?

I realize that health and law enforcement may not be analogous.  I also realize that profiling in law enforcement is a very sensitive issues, particularly for minorities who have been victimized by this technique.   But, if we abandon the procedure entirely, are we forfeiting a tool that could keep us all safer? 

El Al has a different view.  Here, in America, TSA is trying to detect evil stuff. El Al is trying to detect evil people.  Which makes more sense?

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