The Antidote to Big Box Medicine - Private Practice

I prefer to do business with small, privately owned establishments rather than patronize the big box centers that have pushed smaller stores to the margins or off the grid.  Of course, I do spend money at the large centers for the same reasons that all of us do.  But, I miss the personal attention and interest that a single proprietor and the staff can provide.  South Orange, the small town, or actually village, where I was raised was full of these stores where we bought hardware items, sandwiches, clothing, medicine, shoes and ice cream cones.  I would periodically stop into the bank, with my passbook, to deposit my accumulated cash from my paltry weekly allowance. (As a third grader, I received 10 cents per week.)  When I would pop into to one of these places, the owners knew me and my family, not quite the COSTCO experience, where one guard has to admit me into the store and another must scan my receipt before I can exit. 

Village Hall in South Orange, NJ

I had an out-of-body, or an out-of-wallet, experience a few weeks before writing this in a frame shop in downtown Willoughby, Ohio, not far from my office.  I brought in two large newspaper photographs that captured two amazing scenes after the Cleveland Cavaliers captured the NBA championships.  These were to be gifts for two of my kids who have been devoted fans of our basketball team.  I handed over the items to the owner who gave my project close and careful scrutiny.  He conferred with his wife to verify that his framing plan of action was the best option.  I asked how much of a deposit he would need, and he declined my offer.  I told him I had never in my life left an item for framing elsewhere without being asked for a deposit.  What if his frame shop did the work and the customer never returned or might balk against the agreed upon price?   Apparently, this couple trusted me or simply trusts all of their customers.  When I came to pick up the items, the credit card gizmo wasn’t working.  No worries, I was told. Just take the items and give a call in a week or so with my credit care information.

Who does business like this?  While I acknowledge that these folks are deviating from sound business practices, there was a warmth and humanity from this transaction that affected me.  I will surely return there.  

As readers know, I am part of a small private practice where we do our best to provide consistent and close personal attention to our patients, who are our customers.  As solicitous as we try to be, we are not able to be quite as relaxed and casual as the frame shop proprietors were with me.  I wish we could be.  We do collect copays, for example, prior to the visit, fees that are established by the patients' insurance companies, not by us.  

Just like this mom and pop frame store, our practice is surrounded by ‘big box’ medicine.  Fortunately, we still have a loyal patient base that values what we provide.  We think that our environment is warm, welcoming and friendly. We certainly try.  No guard stands at the door checking patients as they enter or leave.  I remember how I felt when I used to walk into Beck's Hardware or Jerry's Boys Town as a teenager in South Orange village.  I can only hope that when our patients come to see us today that we make them and their families feel like the living, breathing human beings that they are. 

When Diagnosing Colon Cancer Might be a Mistake

So much of life depends upon timing.   Sure, we plan, but we know how much of our life’s events are unplanned and unexpected.  So often, our jobs and our mates – two of our most defining accomplishments – are the result of a chance encounter or a random act.  Life does not reliably proceed in an orderly manner.

This is often true in the medical profession.   Here, physicians in our quest to seek out and squelch disease, often discover what would should have been left alone.  For example, is discovering prostate cancer in an older man a true benefit if the tumor would have remained silent throughout the man’s life?  Whenever possible, it is best to ask the question, ‘what will I do with the information?’, before recommending a diagnostic test to a patient.  There is a risk to disturbing the natural order of things.

Are we really just shooting dice?

Sometimes, medical events occur on their own without any prompting from a physician.  I was contacted by a physician regarding an 87-year-old man with rectal bleeding.   He had never had a colonoscopy in his life and had only minimal contact with the medical profession.  (Maybe this is how he reached the age of 87!)   His bleeding developed a few months after he was started on a blood thinner prescribed because of an abnormal heart rhythm, in an effort to reduce his risk of a stroke.  A CAT scan was performed which strongly suggested that the bleeding was coming from a cancer in his colon.

If the patient had not developed a cardiac rhythm disturbance, then he would not have been prescribed a blood thinner.  And, without the blood thinner, he would not not have developed bleeding.   And, his colon cancer would have remained a stealth stowaway in his large intestine, unknown to the patient and the medical profession.  Perhaps, the cancer would have remained quiet and never posed a threat to him.  Now, however, he will undergo a colonoscopy which may be followed by major surgery to remove the invader.   One need not be a trained physician to appreciate that major surgery in a near nonagenarian with heart disease has risks.

I cannot tell readers the denouement as the case is in progress.  But, it reinforces how much in our lives is far beyond our control and comprehension.   An innocent experience can create an opening that leads to a path that reaches a tunnel that connects to a labyrinth that ends by a bridge that crosses a river…

We all think we are such assiduous planners.   We might be, but to me it seems that we are often just shooting dice.  

Kavanaugh versus Ford: Who Really Lost?

The nation was transfixed this past Thursday with the sequential testimonies of Christine Blasey Ford and Brett Kavanaugh.  It is rare that a judicial or quasi-judicial proceeding generates this stratospheric level of intensity and interest.  In my recollection, the O.J. Simpson murder trial and the Anita Hill hearing before the Senate Judiciary Committee both reached this level.

I watched a good deal of the hearings and read about what I was unable to watch.

Personally, I don’t think that minds were changed.   Nearly every U.S. senator’s mind was firmly decided at the moment that the judge was nominated months ago.  Many offered up their strident support or opposition within 24 hours of the announcement of the nomination, if not sooner.   I will let readers decide if such a response is the diligent and fair reaction that a nominee and the country deserve.  To me, it seems that this massive pre-judgement was offered up without necessary fact finding or standard due diligence.  While there may be no presumed innocent standard in a judicial confirmation process, as this is not a trial, I would think that fairness and decency would instruct us to maintain some modicum of open mindedness.

Importantly, there remains a handful of senators from both parties that are still in play.  And with the GOP majority so shallow, one or two votes could be decisive.  

Sadly, this process has only served to reinforce the existing and widening fissure, or canyon, that is dividing this nation.  This has diminished the confirmation process, our legislators, the Supreme Court and the nation.   This is the overriding stark truth.   Do not let distractions about the loss of the filibuster, the shameless treatment of Merrick Garland, the relevance of a Supreme Court nominee’s high school and college drinking habits, the need for a formal FBI investigation, Diane Feinstein’s concealing Ford’s private letter from the Judiciary Committee, your residual anger over the Anita Hill hearing, your view on Roe vs Wade or the justifiable rise of the #MeToo movement, blind you to the horrible spectacle that is still ongoing.

I think that this has been a national embarrassment.   Who’s at fault?  It reminds me of Agatha Christie’s Murder on the Orient Express where everyone was guilty.

I am offering no opinion if Judge Kavanaugh should be confirmed or charged with a sexual crime.  I do not know what happened and neither do you.  The outcome of this debacle will make half the nation feel triumphant while the other half will seethe.  Does that sound unifying and healing?

Confirmation of Supreme Court nominees used to be an august demonstration of the majesty of our democracy.  Nominees were treated with respect by the senate and by the nation.  By and large, the process transcended politics.  No more.  Now, the partisan poison that has infected the executive and legislative branches has spread to the remaining branch.  

Whoever wins next in next week's vote, one thing is for certain.  We all have lost.  

When Should Your Doctor Say 'I'm Sorry'?

For many people throughout the world, this past week provided an opportunity to reflect on one’s life and to invest in one’s soul.   While self-examination should be an ongoing task,  the Day of Atonement is a singular opportunity to meditate deeply on this process.  While this day culminates a 10 day period of intense reflection – or so it should – once again, this does not relieve us of our obligation to pursue this task on all other days.

Atonement is a tough business and I admit that I am no expert.  Consider how challenging this process is.

• Personal reflection.
• Acknowledging personal flaws and transgressions.
• Approaching those whom we have wronged to make it right.
• Forgiving those who seek our pardon with grace.
• Committing not to repeat our offenses if placed in the same circumstance again.

Sounds easy?   Hardly.  Changing our traits and actions are very difficult.  Why do you think so many of us have the same list of New Year’s resolutions every year? 

But, change is possible.

Here are some actions that many in the medical profession might seek atonement for.  I am judging no one here, and I admit that as I construct this list that I am not without sin.

• A diagnosis is missed because a physician was not sufficiently diligent.
• Privileged health information was inadvertently disclosed.
• A physician is habitually late and is indifferent to his patients’ time.
• A doctor disparages a colleague.
• A physician fails to return phone calls from concerned patients.
• A doctor berates one of his staff who made an error.
• A doctor berates one of his staff who did not make an error.
• A doctor modifies a medical record for the wrong reasons.
• An impaired physician does not seek professional assistance.
• A physician has a lapse in his bedside manner and doesn’t demonstrate the empathy the patient deserves.
• A physician thinks of his own interest over the patient’s interest.

I don’t ask any reader to pay any heed to this post penned by a confessed imperfect and flawed man.

Artificial Intelligence and Medicine - Is Your Doctor Obsolete?

I read about artificial intelligence software that can rival high school juniors armed with #2 pencils.  The program attacked SAT math questions and performed at the level of a typical 11^th grader.  The study was too complex for me to grasp. I guess I should ask an 11th grader for assistance.  Artificial intelligence is well beyond conventional computational exercises. It can ‘think’.

Man vs Machine

Increasingly, we see functions executed by machines that were formerly performed by living breathing human beings.  Examples range from the mundane to the preternatural. 

• Order food and drink from an iPad.  No server needed.
• Driverless auto travel.   This may lead to a resurgence in prayer.
• Pilotless air travel.  Hard times ahead for the Airline Pilots Association. 
• Making precision tools – from 3D printers.
• Gourmet meals created with a voice activated command.
• Theater and film productions starring faux actors created on keyboards.

Will artificial intelligence invade the medical arena?  The question is only how deeply it will invade.  The role of the traditional physician is at risk of being marginalized as computer software hits the profession hard.  Sure, computers cannot palpate an abdomen or perform a rectal exam – yet, but they can listen to heart sounds with much greater accuracy than a physician with a stethoscope can.  Additionally, as most practicing physicians know, the physical examination is much less useful than the patient’s medical history, although our medical school teachers and mentors always preached how critical the physicians’ eyes, ears and hands were.  Most doctors know what’s going on most of the time after carefully listening to the patient’s story, the medical history.

I know that sophisticated computer algorithms can synthesize an individual’s personal medical data and generate specific diagnoses, many of which might not have been considered by a human physician.  Of course, there’s a lot more to being a decent physician than spitting out a list of diagnoses, as we doctors know despite when empowered patients bring us lists of diseases they think they have after spending some time in the Google School of Medicine.

Although artificial intelligence is not a real doctor, it offers an incredible tool for the medical profession to serve the public.  For example, if a 50-year-old man who has just returned from rural Kenya comes to see me with diarrhea, a 7 pound weight loss, vision change, fever and a rash, I may not be able to provide an instantaneous diagnosis.  If I could plug the patient’s profile with his symptoms into a computer program, along with various laboratory features and photograph of the rash and the retina, it might alert me to diagnostic possibilities that are beyond my reach. 

Let’s say that a machine outperforms me on my medical board certification exam.  If you could only see one of us, which of us would you choose?

Breaking News! A Cure for Baldness!

I have satellite radio in my car.  I listen to 2 or 3 stations.  I have a deluxe version of cable TV, giving me access to hundreds of channels.  I watch a handful of them.   There is no way, of course, that I could simply pay for the 7 stations I watch.   For example, if I want HBO so I can watch John Oliver’s uproarious Last Week Tonight on Sunday, I have to purchase some package of useless channels to secure my HBO spot.

I listen to CNN often in the car.  This network blares out ‘Breaking News’ every 5 minutes or so.  I wrote to them demanding an explanation for these idiotic announcements, but they couldn’t break away from the avalanche of breaking news to respond to me.  In times past, ‘Breaking News’ meant that the Germans surrendered, Truman beat Dewey or that Neil Armstrong planted his feet firmly on the lunar landscape. 

I also wrote twice to CNN asking how many minutes of commercials occupy Wolf Blitzer’s hour long ‘news’ show.   I got the same non-response as referenced above.  I’m sure I am now blacklisted there.   My guess is that the minutes of commercial time would shock us all.   I’m surprised that the network hasn’t started introducing the commercials with Wolf howling ‘Breaking News! New Floor Cleaner Wipes the Competition!’

So many commercials are devoted to health issues.  Many of them are for prescription drugs.  Interesting how the pharmaceutical companies are flooding the airwaves, internet and print hawking products to a public who cannot purchase them by themselves, as they might do with a TV set or a mattress.  They are coaxing the public to lean on their health care providers, aka doctors.  Enter the phrase:  ‘ask your doctor if Proctobomb is right for you.'

General Ambrose Burnside

Hair in All the Wrong Places

I heard a commercial today about some kind of laser device that could sprout hair on a bald and desolate scalp.  I was struck that the ad touted 93% significant hair growth from users.  I admit that I did not read the study, but I am skeptical that it would be characterized as rigorous scientific inquiry.  Moreover, I wonder who funded the study, or if the physician investigators  benefited by participating.  Once again, I am not leveling actual allegations of conflicts of interest, only that I am suspicious they exist when a commercial product is championed in a single study for an incurable condition..

I’ve read thousands of medical studies, and a 93% benefit is nearly unheard of in conventional medical reports.  Even treatments that are established and proven therapies rarely reach such a high bar.  Such a stratospheric level of performance should arouse skepticism that the study is misleading and deceptive.

Most of us who are follicularly-challenged would walk through a minefield for the promise of 93% significant hair growth.   Here’s the catch.  Who defines what significant hair growth is?  Recognize that as the definition of significant hair growth is relaxed that the success rate increases. For example, if  significant hair growth is defined as a few new limp saplings, then the company can boast a success that will not be visible to the customer or anyone gazing at his pate.

Think of how success rates in medical reports can be massaged to lure physicians and patients.  If a drug or device company announces  a huge success rate, make sure that what they are measuring really matters to you.  Just because they claim it’s Breaking News, doesn’t make it so.

Thoughts on Labor Day 2018

All work is honorable.   

Sometimes, when I ask a patient what his occupation is, the response begins with, ‘I’m just a…”.  I’ll have none of it.  There is no ‘just’.   Most of the people who keep this country afloat are anonymous folks who put in an honest and decent day’s work.  Some use a keyboard and others use a hammer.  Some use a shovel and others use a colonoscope.  Some arise when we are still asleep and others start work after we have retired.  Some use their hands with skill and precision and others offer professional advice.   Some design a building and others build it.   Some create and others consume.

But, why should these words matter here?  After all, I am just a blogger.