Sunday, May 28, 2017

Memorial Day 2017



Freedom is not Free.


Expressing profound gratitude to all those who served our nation and serve today, and to their families who share their sacrifice.

Sunday, May 21, 2017

Why My Patient Will Quit the Military

I had an interesting conversation with a patient in the office some time ago.  He was sent to me to evaluate abnormal liver blood tests, a common issue for gastroenterologists to unravel.  I did not think that these laboratory abnormalities portended an unfavorable medical outcome.  Beyond the medical issue he confided to me a harrowing personal tribulation.  Often, I find that a person’s personal story is more interesting and significant than the medical issue that led him to see me.

I am taking care to de-identify him here, and I did secure his permission to chronicle this vignette.  He is active duty military and is suffering from attention deficit disorder (ADD).  He likes his job.  He was treated with several medications, which were either not effective or well tolerated.  Finally, he was prescribed Vyvanse, which was a wonder drug for him.  The ADD symptoms melted away.  This is when military madness kicked in.  He met with military medical officials who concurred that this medicine was appropriate for him.  This decision, however, was overruled by a superior, since Vyvanse, is a controlled drug, which was prohibited.  My patient was told that he could choose between taking this drug or keeping his job.  In other words, if he opted for the one drug that worked for him, that he would have to quit. Who wins here?

Scales Tipped Against Him

While I do not know all of the relevant facts , this seemed absurd to me.  My guess is that the decision came right out of a Policy & Procedure Manual, which so often contains one-size-fits-all directives that override any measure of common sense.  It is this mentality that expels a first grader who kisses a classmate because the school has a rigid zero-tolerance policy against sexual harassment. 

When the patient was in my office, he had been off Vyvanse as required by his military superiors.  He was not feeling mentally well.  Not only was he off of his medication, but he was facing a profound professional decision that would change his life. 

And here’s the most ludicrous aspect of the situation.  The patient told me that other branches of the military had no issue with their servicemen taking VyVanse.  These branches apparently use  different Policy & Procedure Manuals. 

If this vignette is representative of the how decisions are made in his military branch, then they have a deeper issue to address.  Is there a medication that can combat rigid and robotic thinking?  If so, let’s hope it’s not a controlled substance.  

Sunday, May 14, 2017

Patients Who Drink Too Much

When I am facing an alcoholic in the office, I do not advise him to stop drinking.  Other physicians may advocate a different approach.  We live in a free society and individuals are free to make their own choices.  I have decided, for example, not to own a firearm, ride a motorcycle or bungee jump as these activities are not only beyond my risk tolerance threshold, but are also activities that I have decided would not enrich my life.  Many smokers, though addicted, enjoy the experience and are aware of the risks of this activity. 

Preparing One for the Road

My responsibility as a physician is to inform and counsel, not to lecture or preach.  I tell alcoholics with clear candor the medical risks they face if they decide to maintain this lifestyle.  I advise them that if they wish to aspire to sobriety, that I will refer them to appropriate professionals for treatment.  I further inform them that in my decades of experience, very few alcohol addicts can quit on their own, despite their vigorous declarations that they can do so.  Finally, I tell them that if they decide to venture on the difficult journey away from wine and spirits, that I will be there at every step to assist and encourage them.  However, there is no hectoring or finger-wagging from me.  No threats or intimidation – which never work anyway - just cold facts and honest predictions.  The patient is then free to make his decision, as he is with any medical proposal.

Patients aren't obligated to accept my advice.  Indeed, the bedrock concept of informed consent places the authority of the decision where it properly resides, with the patient.  

Alcoholsim is an insidious disease whose tentacles slowly suffocate the addict and causes many friendly fire casualties.  Yes, I am aware that there may be a genetic predisposition to the illness, but at some point the decision to drink was still a choice.  Ultimately, only the afflicted one can cast off the chains. 

What do you think?  Am I derelict by not delivering an energetic exhortation, “You’ve got to stop your drinking!”  Is it my job to tell patients what to do, or to give them a fair presentation of their options so that they can choose for themselves?  

Sunday, May 7, 2017

Should Physicians Provide Futile Care?

I was covering for my partner over the weekend and saw his patient with end stage liver disease, a consequence of decades of alcohol abuse.  He was one of the most deeply jaundiced individuals I have ever seen.  His mental status was still preserved.  He could converse and responded appropriately to my routine inquiries, although he was somewhat sluggish in his thinking.  It’s amazing that even after the majority of a liver is dead, that a person can still live.

The Liver - Alcohol's Enemy

When I do my hospital rounds, it is rare that one of my patients is not suffering some complication of chronic alcoholism.  In the hospital, the disease is rampant.  In my office, this addiction is much more easily disguised.  I know that many of the high functioning alcoholics whom I see there have kept their addiction a secret.  Some lie and others deny. 

There was a dispute with regard to the jaundiced patient referenced above.  There was no disagreement among the medical professionals on treatment options.  At this point, there was no medical treatment to offer beyond his current medications.  A palliative care specialist advised that hospice care was the most appropriate option.  The physicians and nurses concurred.  Why didn’t it happen?

The patient’s wife, who lived out of town, insisted that all medical measures be pursued.  Hospice care was a non-starter. While the patient and his wife were separated, she was still the legal spouse and next of kin.  The patient had not prepared a living will.  It was not felt that the patient possessed sufficient mental capacity to make this profound medical decision.  So, the wife's view prevailed.

My task was easy as I was only responsible for his gastro care over the weekend.  But, there was a huge ethical task that demanded to be confronted.  Physicians were continuing to provide futile care because a wife demanded it.  Such care, in my view, is unethical and need not be provided, despite the insistence of a family member.

Physicians are under no professional obligation to provide care that is futile, oris  extremely unlikely to offer benefit, even if patients and families demand it.  The fact that a third party is usually paying for this treatment only deepens the ethical infraction.  Physicians should not feel obligated to accede to futile care requests, or feel that they need a court order to protect them against such requests.  In my experience, surgeons are more comfortable than are medical specialists and internists in declining to provide care that won’t help.  I have often heard surgeons tell patients and their families that an operation simply won’t help and shouldn’t be done.  For some reason, this issue seems to be murkier for non-surgeons. 

Of course, physicians must be sensitive when discussing these issues with patients and families who understandably want anything and everything done to save their loved one.  But, giving care that won’t work is wrong. 

Over the weekend that I saw this patient, I was not in a position to set the patient free.  It seemed surreal that everyone on the case knew the right thing to do, but none of us were doing it.


Sunday, April 30, 2017

Does the Patient Need a Feeding Tube?

What should a medical consultant do when the referring physician wants a procedure that the consultant does not favor?

Of course, this sounds like a lay up.  The consultant, readers would surmise, should have a conversation with the referring colleague to explain why the procedure is not in the patient’s interest.  The colleague then thanks the consultant for his thoughtful input, and for sparing the patient from the risks and expense of an unneeded medical procedure.  Then, a rainbow appears, songbirds tweet in harmony and the lion lies down with the lamb.

When Physicians Dialogue, the Heavens Open and Music Plays!

This is not how it works in real world of medical practice.  I wish it did.  Indeed, this issue has tormented me more than, perhaps, any other in my decades of work as a gastroenterologist.  Many referring physicians request procedures from us – not our opinions – and expect that their requests will be complied with.  This is the same mentality that all physicians, including me, have when we order a CAT scan.  We generally do not consult with the radiologist in advance soliciting their opinion.  We simply click ‘CAT Scan’ on the computer and then the magic happens. 

On the morning that I write this, a physician has consulted a gastroenterologist to place a feeding tube in a patient hospitalized for this purpose.  The patient is not only demented, but speaks no English.  I called the son to acquire more understanding of his dad’s condition.  The patient has lived with the son for 7 years and knows his feeding habits intimately,   From time to time, he will have some coughing spells during meals, but this pattern has not accelerated.  This is his normal pattern.  The son related that his dad ate sufficiently and has not lost weight.

While I am able to connect the dots here that would lead to a feeding tube, for me this would require a lengthy caravan of dots to reach the referring physician’s request.  While I acknowledge that the patient likely has an impaired swallowing mechanism, it does not seem to pose a medical threat.  Today is Sunday and the physician expects that the tube will be placed tomorrow.

I am covering over the weekend for the gastroenterologist who will assume the patient’s care tomorrow.  I did not schedule placement of a feeding tube.  I requested instead that a speech pathologist, who is an expert in swallowing, offer an opinion.  I think that was the right answer here.

Consultants know that all referring physicians are not created equal.  Some welcome our opinions and others don’t.  Still others will punish us by cutting us out of their referral stream if we push back against their requests.  This is a sad reality that I wish I could remedy.

I’ve certainly complied with procedure requests for tests that I might not have personally favored.  This is not unethical, as long as there is a rational basis for the test, and the referring physician will use the information gained to adjust a treatment plan.  Additionally, we consultants may be wrong.  Perhaps, the referring physician’s request for a colonoscopy is the proper test, even if we may not think so.  No one knows it all.

Oftentimes, when folks are offered a ‘peek behind the curtain’, they are surprised to see what is happening behind the scenes.  Anyone shocked here?


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. 


Add this