Sunday, December 10, 2017

Reducing the Federal Deficit - A Monumental Approach

This past week President Trump reversed protection for millions of acres in two national monuments in Utah.  Bears Ears National Monument and Grand Staircase Escalante will be halved as a result of the major surgery just performed by the Chief Executive.  These moves will likely result in job security for scores of environmental lawyers.

Teddy Roosevelt is growling in his grave.

As expected, there were howls from the left, most of whom have probably never visited the sites.  How many people are against opening up the Arctic National Wildlife Refuge for drilling who have never been to Alaska?  Keep in mind that the folks who actually live in Utah, and the legislators who represent them, argue that they should have control over their own lands.  Shouldn’t they have the right to determine the fate of their own state and to resist federal encroachment?   Should the feds compensate states for the economic losses that they suffer when lands are deemed to be federal monuments? When do the feds have the right to ‘trump’ states’ rights?

I was shocked to learn that the vast majority of Utah land is controlled by the feds. 

Imagine the reaction if the location that Amazon chooses for its 2nd headquarters were suddenly designated as national monument.  Do you think that state would welcome this federal intrusion?  More likely, would be rioters with pitchforks in the street.


Let's cash in from Old Faithful at Yellowstone Nat'l Park!

Now I admit, I am uncomfortable opening up monuments to development and energy exploration.  Parks and monuments are finite and I fear inexorable mission creep if we have a permissive stance in reducing their size.  But I admit, that my misgivings do not constitute a legal argument.  Keep in mind that Utah is not forced to develop these newly released lands.  If they wish to keep them unmolested, they are free to do so.

Perhaps, we should be looking to generate revenue from governmental protected sites?  This could amass cash that could be used for social programs, conservation efforts or even to provide Americans with tax relief.

As a pilot program, I suggest that the Bright Angel and South Kaibab Trails that descend to the base of the Grand Canyon be monetized.   At each mile marker, hungry and thirsty hikers would encounter Starbucks, Five Guys, a Home Depot Annex, Verizon Customer Service, a Lemonade and Smoothie Stand, Sushi Bar, an Army Recruiting Station, FedEx and Whole Foods.   Of course, these goods and services would not in any way detract from the hiking adventure.  If a visitor does not wish to engage in a commercial transaction, then he can simply walk on by.   But, should we deprive a hiker who wants to satisfy an urge for a Frappacino?

This strategy truly gets airborne when it is applied to all of our national parks and monuments.  If Teddy Roosevelt knew of this plan, would he call out ‘Bully!’ or just ‘Bull’!?

Sunday, December 3, 2017

Does Patient Autonomy Improve Health?

It used to be that doctors knew best.  We told you what to do and you obediently complied.  The world has changed and the paternalistic system of yore has given way to the shared decision model where patient autonomy is respected.  

The Old Way:  “Well, I’ll be setting you up for surgery soon.”

The New & Improved Way: “Let’s discuss all of the reasonable options with their respective advantages and drawbacks.  Then, you make the call.”

To paraphrase the mantra of Fox News:  Doctors Report – You decide!

Has our current fidelity to patient autonomy improved medical outcomes?  I have no idea.  It has certainly changed patient’s (and our) experience, but I do not know if it has improved patients’ health.   I wonder if doctors and patients who have experienced both systems believe that the current system have improved medical outcomes.


Has anyone measured if the new system is better?

Not every patient wants this level of authority.  I cannot count how often patients have asked me over the years to make the medical decision for them – which I do.  There is an argument that the professional is better equipped to make the right medical choice; but the question is who has the right to make that choice. 

My point is not for us to return to our prior paternalistic pattern, but only to pause and consider if patients have benefited under current norms as much as many believe.

I am certain that attorneys and various consultants can relate to this issue very well.  Lawyers today, for example, generally don’t dictate an edict, but present clients with a range of options depending upon cost, risk and tolerance of legal exposure and the facts.

Why not extrapolate to the next level?   Let the patient make any medical choice he desires despite our medical misgivings.  If a patient, for example, wants a colonoscopy, antibiotics, a heart catheterization or removal of the gallbladder – and they are fully informed of the risks and benefits – why should medical professionals obstruct them?  Doesn’t the patient come first?   

Isn't this how the marketplace works?  Customers buy what they want, not necessarily what they need.   Should I be prevented from buying a premium vacuum cleaner if my current one is adequate?  If I want a contractor to do some remodeling which makes no aesthetic or functional sense, should he turn the job down?  

Yes, you might argue that medical care is different than buying an appliance.   But, if we doctors can refuse an informed patient's request, then aren't we returning to the Era of Paternalism that we claim to have abandoned?





Sunday, November 26, 2017

Thanksgiving 2017




The nation pauses to give thanks for health and family and freedom.  As during any holiday or celebration, some of us are in the valley or have been there.  There is always a way forward, even if the pathway is obscured. 


We gather together.

The First Thanksgiving


We converse amiably.

'I'll kill you!'


We dine.

Blessed with bounty...



We talk turkey.

Pardon me?


Saturday, November 18, 2017

When Electronic Medical Records Crash

The computerized era has introduced all of us to a genre of errors that never existed during the archaic pen and paper era.   The paper medical chart I used during most of my career never ‘crashed’.  Now, when our electronic medical records (EMR) freezes, malfunctions, or simply goes on strike, our office is paralyzed.  Although I appear to the patients as a breathing and willing medical practitioner, I might as well be a storefront mannequin who appears lifelike, but cannot function.  We cannot access the patients’ records, write a prescription or enter a new office visit. 


Mannequins appear lifelife but don't function well.


Of course, like any business who faces this crisis, we expect instantaneous rescue from our IT professionals, as if we are their only client and they are permanently stationed in our waiting room just waiting for us to sound the alarm.

This is among one of the most frustrating aspects of EMR for medical professionals.   We simply don’t have the time or psychic reserve to absorb unexpected loss of computer service.  We are not playing computer games (although sometimes it feels as if we are.)  We have a live patient facing us as we face a blank screen.  It is frustrating and awkward.   The patients understand this reality as they undoubtedly have endured similar frustrations in their own lives.  

Yes, we resort to writing a note in longhand and scanning it into the EMR later, but this is problematic.  First, a scanned document cannot be ‘read’ by our EMR as this document is not ‘part of the EMR family’.  It can’t be tracked, as we do routinely with laboratory and x-ray data.  More importantly, I will be offering medical advice without any access to the prior medical record, which may span years.  If the patient has a complex, chronic condition with a history of extensive testing and medication changes, moving blindly could lead me into a blind alley or through a trap door.

I propose no solution to all of this.  No technological system can perform perfectly.  It’s another example of our ever increasing reliance and dependency on technology – more than we really need, in my view.  I have no choice but to accept EMR in my professional life.  But, there are opportunities when we can stand up and push technology back.

Do we really need Alexa to turn on our lights?

Sunday, November 12, 2017

Why Curbside Consults are Dangerous

One of the skills and stresses about being a doctor, is giving advice to or about patients we have never seen.  If readers think these are rare events, it happens nearly every day.  Often during weekend or evening hours when I am on call, my partners’ patients will call with questions on their condition or about their medications.  Radiology departments contact me during off hours with abnormal CAT scan results of patients I do not know.  Or, a doctor may call me during the day for some informal advice about one of his patients.  These physician-to-physician inquiries are called ‘curbside consults’, which are appropriate for simple questions that do not require a formal face to face consultations.

Physicians must be cautious when providing a curbside opinion on a patient he has not seen as even informal advice could result in legal exposure if the patient later files a medical malpractice claim.  Consider this hypothetical example.

An internist contacts a gastroenterologist for a curbside opinion on an elderly patient who had some mild rectal bleeding.  The internist suspects hemorrhoids and doesn’t want to refer the patient for a colonoscopy as the patient had one 3 years ago at which time hemorrhoids were discovered.  The gastroenterologist reassures the physician that the bleeding is probably from hemorrhoids, which is a very rationale conjecture.  But, it may be wrong.  The bleeding now may be from a colon cancer that was either missed on the last colonoscopy or has developed since.  The cancer won’t be discovered for another year.  Is the 'curbside' gastroenterologist responsible here?

I think so because, even though he hasn’t seen the patient, he has rendered medical advice directed toward a specific patient, rather than simply offer generic comments.  Indeed, the internist may have told the patient and his family that the 'curbside' gastroenterologist agreed that no testing was necessary.  Had the gastroenterologist pushed back against the internist and insisted on arranging for a colonoscopy or seeing the patient in the office, then the outcome may have been different.

Had I been asked for a curbside opinion regarding above inquiry, I would have been much more circumspect with my response, and ideally, I would have entered a chart note in my electronic medical records.  Memories of physicians and patients can fade over time.  I would feel more secure if my chart note recorded that I recommended that the patient be sent to me for an office consultation.

Some questions should never be answered ‘from the curb’.  I would not, for example, give informal advice to an internist about changing his patient’s medications for Crohn’s disease.

If I have any discomfort in responding to an inquiry on the phone, then I recommend an office visit when I can provide a thoughtful and informed opinion. 

Some inquiries are so innocuous that I respond readily even without entering a chart note.  These generic questions do not directly connect me to an actual patient.  To clarify, I will list a few examples.

What’s the proper schedule for the hepatitis B vaccine?
Is the generic for Nexium equally effective?
Are ulcers caused by stress?

There’s a skill set physicians need when we are advising strangers.  Sometimes, the skill is knowing when to remain silent or when to push back.  If you're not careful, it's easy to trip over the curb.

Sunday, November 5, 2017

Polypharmacy in the Elderly: Who's Responsible?

There's a common affliction that's rampant in my practice, but it's not a gastrointestinal condition.  It's called polypharmacy, and it refers to patients who are receiving a pile of prescription and other medications.  I see this daily in the office and in the hospital.   It's common enough to see patients who are receiving 10 or more medications, usually from 3 or 4 medical specialists. 

Of course, every doctor feels that he is prescribing only what is truly necessary.  If an individual has an internist, a cardiologist, a gastroenterologist, a urologist and a dermatologist which is not unusual - and each prescribes only 2 or 3 essential medicines, then polypharmacy is created.  Each day, the patient swallows a chemistry set.

First of all, I don't know how these patients, who are often elderly, manage the logistics of taking various medicines throughout the day and evening, before meals, after meals and at bedtime.  Who can keep track of this?  Nurses in the hospital can barely manage this overwhelming schedule.  This has to negatively affect one's quality of life as the daily calendar of events is predominantly pill popping events.  

Keep in mind that the drugs we doctors prescribe are not that smart.  Does the Nexium I prescribe to hundreds of patients only act on just the right amount of stomach acid to relieve the patient's reflux?  Doesn't the drug reach every organ of the body having potentially deleterious effects that we might not be aware of?  Could Nexium be interacting with other medicines in an unfavorable manner?  While we are quick to demonize stomach acid as an enemy of mankind, isn't the acid that Nexium is reducing there for a reason?  Are we smarter than a few million years of natural selection?

I'm betting on Darwin's theory.

Extrapolate the Nexium example above to a situation when 10 or 12 drugs are cruising throughout the body on a Fantastic Voyage journey, colliding with each other and smashing into organs far away from the drugs' intended targets.  

We also function in a culture where every symptom demands a pharmaceutical response.  While depression, hyperactivity and insomnia are real illnesses, can anyone dispute that the medical community is over prescribing medicines for these conditions?

I wonder how many folks who are suffering from unexplained nausea, balance issues, confusion, dizziness, falls, bowel disturbances and abdominal pain are actually getting a taste of their own medicine.   When they present these symptoms to their doctor, they may end up with yet another prescription thrown onto the pile, when the solution is to diminish the pile which is causing side-effects.

Challenge your internist and your specialists to verify that every drug is truly needed. Insist on the lowest dose that will accomplish the mission.  Are the doctors on your team communicating adequately with each other?  Is someone in charge? 

In my experience, the biggest risk factor for polypharmacy is polydoctor.   More medicines and more physicians aren't better medicine.  Primum non nocere, first do no harm, still deserves to be the mantra of the medical profession.  In medicine, less is more.  On your next visit, ask your doctor to please do less for you. 

Sunday, October 29, 2017

Patient Navigators Climb Your Mountain of Medical Bills

To accomplish certain tasks, we need a little help from our friends.  No one can do it all, although many of us are more resourceful than others.  Some folks are adventurous and dive into a new arena with excitement.  They may be tinkerers who aren’t afraid to play with new gadgets.  Sure, they might break some china, but they are apt to widen their skill set and enrich their lives.  Others, eschew this dive bomb approach and prefer to wade cautiously into new experiences.  Their comfort zones are narrower.  They never break the china, but their personal growth is likely more stultified. 

For some activities, we should simply call upon the professionals straight away.  Here are some examples of jobs that we should pay others to do for us.
  • Cut down a huge dead tree on our front yard.         
  • Replace damaged roof shingles.
  • Investigate why smoke is seeping out of the hood of our car.
  • Prepare our last will and testament from www.DIEWITHCASH.com or some similar website.

I realize that not everyone may agree with my examples above.  Many folks, for example, would have no hesitation to scamper up to the roof with a tool belt strapped on to do some reshingling.  Have at it.  If you ever spot a man on my roof, trust me, it’s not me.

If a job needs this tool, then keep your fingers and hire a pro.

There are some activities that we pay others to do, but we shouldn’t have to.  It’s not our fault.  Certain systems are so complex and byzantine that a normal individual simply isn’t equipped.  Why should most of us have to pay someone to figure out how much we owe the government in taxes?  I realize that this absurdity is employment security for the accounting and legal professions, but it indicates to me that the system is broken.  The system should be simple enough that we can calculate our obligations ourselves.

Similarly, shouldn’t understanding and paying medical bills be a simple process, similar to paying all of our other bills?  When I receive a plumber’s bill, leaving aside that his hourly rate might be higher than mine, I can easily understand the itemized services and how the total charge was calculated.  Not so with medical bills.  I’m a practicing physician and I cannot reliably understand my own medical bills. Medical bills occupy a unique universe, which is not governed by reason or logic.  I will assume that every reader has had similar experiences.

We need a modern day Rosetta Stone to decipher our encrypted medical bills.  Of course, we can always call our insurance company directly, which is guaranteed to be as relaxing and fun as undergoing a rigid sigmoidoscopy.  Also, don’t you love the musical phrase, “please listen carefully as our options have changed”?

Enter the new profession of Patient Navigators, an emerging occupation that helps the confused citizenry understand their medical bills.  We all know of many patients who have stacks of bills awaiting payment from physicians, hospitals, radiologists, pathologists, laboratories, emergency rooms, etc.,that would overwhelm the most rugged among us.  Grappling with medical billing is to tread onto a treacherous pool of quicksand with no bottom. Leaving aside the Herculean task of sorting through the morass, there is an inhumanity to expect sick or recovering patients to be forced into this maze of madness.

The existence and growth of the Patient Navigator profession is Exhibit A that medical billing needs to be reformed.  With all of the nonsensical ‘reforms’ that have been forced onto the medical profession, Obamacare missed a target that was overripe for real reform. 





Sunday, October 22, 2017

The Curse of Medical Records Documentation

Let me post a question that neither I nor readers can answer.
How much of what I do during the course of a day directly benefits patients?

Perhaps, I don’t want to really know as I would be dismayed at how much of my effort benefits no one. Ask a nurse who works on a hospital ward, how much of his or her effort is directly applied to patient care.  I would recommend that you have a double dose of antacid in hand – one dose for you and the other for the nurse. 

Just today, I was gently reproved by a hospital physician administrator for a lapse in one of my recent progress notes, which I write after seeing every hospital patient I consult on.  Which of the following transgressions do you think I was cited for?  Only one answer is correct.
  • I did not perform an adequate physical examination
  • I failed to address the results of an abnormal CAT scan
  • I neglected to write the time of day along with the date of the note.
  • I did not discuss the case with the patient’s family.
Just last week at our medical staff meeting, all physicians were told of the requirement to record the exact time, as well as the date, of our hospital visits.   This requirement, which is not new, is not to improve patient care.  It is a requirement imposed by the Joint Commission, which certifies that a hospital is complying with all rules and regulations.   I would like my readers to know that in over a quarter of a century of hospital practice, the visit times were recorded in 1-2% of all hospital notes of all physicians.  No physician has felt that the lack of recorded visit times negatively affected patient care.   Writing down the time may seem to readers to be just a minor irritant which takes only a few seconds.  It is, however, a symptom of documentation requirements that have run amok.

When the Joint Commission visits a hospital, the entire medical and administrative staff are on edge.  Why?  Because there are hundreds of requirements of dubious value that will be assessed  I support the Commission’s mission and recognize that many of the requirements are completely valid.  We want clean operating rooms, safe parking lots and a culture of respecting patients’ privacy.  But, trust me, many of the mandates from them can be trivial or absurd.


Colonoscopy Wildfire!

As an example, in our ambulatory surgery center where we do colonoscopies, we are required by the government to declare before every procedure if the patient is facing a fire risk.  Please do not ask me to explain this, as I am incapable.  Apparently, because we administer oxygen and use cautery, there is a flammability risk.

I want to reassure my current and future patients that to date our endoscopy center has been a flame free zone.  Moreover, the only instance where a firefighter was in our office was when he was getting a colonoscopy performed. 

The public would be shocked and outraged to learn how much of our time is spent racing on the hamster wheel, a difficult and timewasting exercise that yields no progress. 

Sunday, October 15, 2017

I'm Taking a Knee on Journalism

Thanks to NFL players, our national anthem is getting more attention than ever.  Keep in mind that many of us could not recite its words without error, and fewer of us have the range to sing it.  Even fewer can cite the historical event being described.  This is the latest, but not the last, example of a solvable issue that is being exploited to divide us.  I lament that so many of controversial issues ricocheting in the public square are similarly solvable, and yet remain combustible.

The media stokes these conflicts, in my view.  Listen critically to how CNN and other networks package and deliver the news.   Not only is the reportage suffused with editorial content and slant, but it sows overt division and partisanship by design.  

Consider the following two hypothetical questions from a TV reporter.  Which one would the network be likely to air?

“Senator, what is your plan for tax reform?”

“Senator, the leader of the opposing party attacked your tax policy as a cruel attack on working families.  Is he right?”

The 2nd example, in my opinion, improves television ratings at the expense of journalistic professionalism.   

Many cable ‘news’ broadcasts have become extended panel discussions where folks along the political spectrum talk over one another spewing forth predictable drivel in a rhetorical food fight.   Again, these performances may be spirited and entertaining, but they are actually a demonstration by the networks that conflict sells. 


Knees in the News!

The ‘take a knee’ issue has been morphed from its original intent to protest against racial injustice in the criminal justice system to venerating the anthem and the flag.  Of course, there was a pathway forward had calmer minds and listening ears prevailed.  Why solve a problem when conflict can advance your agenda?   Peoples’ positions can harden despite that they have lost sight of the actual issue before them.

Are NFL players who are ‘on the clock’ in uniform permitted to protest on the sidelines?  Although I am not an attorney, I am not certain that sideline player protesting is constitutionally protected, as would speech be in the public square.   Would owners be entitled to issue a restraining directive if the players' actions were driving away fans and profits?  Would a racist player be permitted to engage in a hateful gesture while in uniform on the sidelines?  Lawyers reading this post can enlighten us if an owner can lawfully require that all players stand respectfully during the anthem. 

 In our medical practice, if our staff all wore shirts with a message that stated, ‘I SUPPORT EUTHANASIA’, would the physician owners have a right to limit this speech?

Regardless of one’s view on the legality or propriety of taking a knee, this issue did not have to have sliced the country apart.   I am not hopeful in the short run. As long as our leaders profit from our divisions, and with the public’s insatiable appetite for conflict,  the end zone will remain far out of reach.

Sunday, October 8, 2017

Why Are You Seeing A Gastroenterologist?

I write to you now from the west side of Cleveland in a coffee shop with my legs perched upon a chair.  Just finished the last Op-Ed of interest in today’s New York Times.  Do I sound relaxed?

I rounded this morning at both of the community hospitals that we serve.  There is not a day that goes by that doesn’t have blogworthy moments.  If I had the time and the talent, I would post daily instead of weekly.   Read on for yet another true medical insider’s disclosure.

Gastroenterologists, as specialists, are called upon by other doctors to address digestive issues in their patients.  For example, our daily office schedule is filled with patients sent by primary care physicians who want our advice or our technical testing skills to evaluate individuals with abdominal pain, bowel issues, heartburn, rectal bleeding and various other symptoms.  The same process occurs when we are called to see hospital patients.   If a hospital admitting physician, who is usually a hospitalist, wants an opinion or a test that is beyond his knowledge or skill level, then we are called in to assist. 

The highest quality referring physicians are those who ask us a specific question after they have given the issue considerable thought.  Contrast the following 3 scenarios and decide which referring physician you would select as your own doctor.
  • “Dr. Gastro.  Just met this patient for the first time with a month of stomach aches.  Please evaluate.”
  • “Why did your doctor send you here?” queried Dr. Gastro to the patient.  “No idea,” responded the patient.
  • “Dr. Gastro, please evaluate my patient with upper abdominal pain. I thought it might be an ulcer, but the pain has not changed after a month of ulcer medication.  The pain is not typical of the usual abdominal conditions we see.  Do you think a CAT scan of the abdomen or a scope exam of the stomach would be the next step?  Open to your suggestions.”
Sometimes, we have to deduce the reason the patient is seeing us!
As readers can surmise, I favor primary care and referring physicians who give thought prior to consulting me.   There are many reasons today why primary care physicians pull the specialty consult trigger quickly.  Sometimes, busy internists simply don’t have the time available to deeply contemplate patients’ symptoms.   Physicians have also referred patients to specialists with the hope of gaining litigation protection by passing the patient up the chain, although the medical malpractice crusade has eased over the past few years.  Oftentimes, patients drive the specialty consultation process by asking to be sent to specialists. 

More often than you would think, we see patients in our office or in the hospital when neither the patient nor I have a clue why they are there.  This adds excitement to our task.  In addition to being diagnosticians, we must also serve as detectives, divining the reason that the patient is before us!



Sunday, October 1, 2017

Does Secretary Tom Price Deserve Forgiveness?

What is the explanation for Tom Price, a physician and current Secretary of Health and Human Services, taking private charter flights costing taxpayers hundreds of thousands of dollars?  Keep in mind that when Price was a conservative congressman from Georgia, he would have railed against such fiscal profligacy.  Is it hubris?  Entitlement?  Or, do folks who ascend to positions of power simply rationalize that such excesses are absolute necessities for getting the job done?

By the time this piece is posted, Dr. Price, an orthopedic surgeon, may have been surgically excised from the government without anesthesia. 

While his behavior is not quite Watergate, it was wrong.  And, if it was not wrong, it demonstrated impaired judgment.  And, if was not simply a repeated exercise of misjudgments, then it exhibited bad optics.  And, if it somehow passed the optics test, it was just dumb. 

Would Price have been able to explain these expensive charter flights to average folks, half of whom elected the president to drain the swamp?

I watched Price’s reaction to all of this in several interviews.  Yes, he agreed to pay ‘his share’ of the flight costs, which represented a small fraction of the total costs incurred.  He stated that his department would desist from private charter flights in the future.  He admitted that the ‘optics were bad’ and that previous cabinet secretaries have engaged in similar behavior without suffering repercussions.  He didn’t appear to me to be a man consumed with guilt. 

Sounding the shofar, a call to repentence.  

Personally, I don’t think that Price thinks that he did anything improper.  He never clearly states that he was wrong.  Admitting that he had an ‘optics issue’ is not the same as a confession.   Pointing out that prior government officials committed similar acts with impunity doesn’t sound like a man who knows he has done wrong. 

If he did feel that his flights were proper, then why would he pay back the government anything or stop future charters?    He could have resigned simply because the president was angry and displeased, without offering a pseudo-confession to a transgression he did not believe he had committed. 

Yesterday at sundown, ended the Jewish Day of Atonement, Yom Kippur.  This culminates a 10 day period of reflection and penitence.   We are instructed to beseech forgiveness from the people in our lives before petitioning the Almighty for absolution.  We cannot receive atonement unless we have first admitted our errors, repented for them and strive not to repeat them.  While I am not a rabbi, I doubt that the Almighty would grant us a pardon if we looked skyward and cried out:  “My Lord, forgive me for demonstrating bad optics!”

Sunday, September 24, 2017

Why Graham-Cassidy Bill to Replace Obamacare Should Fail

The Graham-Cassidy bill – the latest Repeal and Replace iteration - still has a pulse, but its prognosis is grave.   While we physicians generally avoid predicting outcomes, my sense is that this bill will be buried in the coming days.  I presume that once its passage becomes mathematically impossible, that the bill will be pulled.

Of course, failure to Repeal and Replace is a horrendous embarrassment and exposure of the Republicans who have been campaigning and crusading against Obamacare with religious zeal these past 7 years.   These patriots knew they could safely rail against the Affordable Care Act (ACA) – throwing red meat to their base – knowing that the bills would never pass while a Democratic president occupied the White House.   How ironic it is that now that the GOP have congressional majorities that they couldn’t get it done.  Not only could they not run the ball into the end zone, but they repeatedly fumbled at every opportunity into the hands of waiting Democrats. 

It seems to me that the GOP efforts to ram though a New & Improved health care program was all politics and very little policy.   The objective was to get a 'win'. Numbers were massaged.  Special deals were offered.  The non-partisan Congressional Budget Office was bypassed.  False promises were made.  Doomsday predictions were declared.  All this is public knowledge.  Imagine what was happening beyond our view. 

I have been consistently hostile to Obamacare, which I have regarded as a waystation on the path toward full government takeover.  Readers are referred to various rants on this subject in the Health Care Reform Quality category along the right margin of your screen.  But my animus toward the ACA doesn’t mean that I’ll support anything offered up as a replacement.


Someone deserves a thumbs up here.  

I didn’t like it when the Democrats passed the ACA without a single Republican vote.   This partisan victory created a chasm that divided the parties and the country which lives still.  While the Democrats will claim that no Republican would work with them then (really?), they could have made some compromises to draw in some GOP legislators and still pass the bill.  Was it simply beyond the Democrats’ ability or willingness to include tort reform in the bill, for example?  How different would our political landscape be now if both sides had contributed to health care reform?

I don’t have a firm opinion on the merits of Graham-Cassidy, but I do not like the process of trying to jam it through before the end of the month so the GOP can utilize the reconciliation process, where only 51 votes are needed, rather than 60 votes.   A decent bill should be able to withstand congressional vetting and inquiry and should be able to draw 10 or so Democrats on board, assuming naively that they would be permitted to vote their conscience. 

I think that Lindsey Graham knew in his heart that his closest friend in the Senate, John McCain was going to give the thumbs down again.   I give him a thumbs up for being the principled and heroic statesman that we so desperately need.  

Sunday, September 17, 2017

Why Are Drug Prices So High? Explanations Welcome

Most of us do not know the basics of economics, although we should.  It impacts every one of us every day that we are alive.  Yet, for most of us, once we get beyond the law of supply and demand, our knowledge of the subject starts to vaporize.  I can't explain fiscal or monetary policy.  While I regard economics as a science, it seems that experts routinely interpret data differently, which confuses beginners like me.  What are novices to think when one expert hails our continued job gains while another laments our anemic recovery?

The Puppeteers

I have a general feel for market forces.  If consumer demand for an item rises, then I will expect to pay more.  If I want to make a purchase at an independent appliance store, then I will expect to pay more in return for superior customer service.  If the item is manufactured in China, it will likely cost me less as this factory is not burdened with worker protections, environmental regulation and union wages.

The above common sense realizations do not compute in the medical universe.  My fees, which I do not control, are unrelated to supply, demand or quality of the product.  Moreover, medical costs are a mysterious enigma which confound physicians and our patients.  Why does the cost of a simple bandage for a hospital patient remind us of the defense department’s $400 hammer?  Why can’t I, a gastroenterologist, give a straight answer to the question, ‘how much does a colonoscopy cost?’

Reimbursement strategies in medicine are changing to a system that will pay physicians and hospitals for the ‘value’ of their service, rather than the quantity.  Like any slogan, it will sound appealing but will bring forth a bevy of burdens that will create foreseeable controversies and challenges.  Stay tuned.

Let me share an absurd medical economic observation that occurred a few days prior to this writing.  I received a phone call over the weekend from one of my patients who was suffering from a recurrence of C difficile (C. diff) infection and needed antibiotic treatment for this as soon as possible.  The drug of choice was Vancomycin (Vanco).  Physicians know that the cost of this medicine is often prohibitive.  The patient and I made phone calls to area pharmacies in an effort to find the most affordable option.  Let me juxtapose below results from two different pharmacies.

Pharmacy #1                  Pharmacy #2

Vanco Cost                        $110                             $2,500

Okay, my economist friends, explain this discrepancy to me, if you can.  Good luck.   

Would it make sense to you if a Big Mac costs $3 at one McDonalds and $500 at another? 






Sunday, September 10, 2017

Hospital Acquired Infections and C. diff. Is My Hospital Safe?

If any reader has heard of C. difficile, affectionately known as C. diff, than I presume you have had closer contact with this germ than you would have liked.  It’s an infection of the colon that can be serious, or even fatal.  There isn’t a hospital in the country that isn’t battling against the infection.  

We are not winning the war against this crafty and cunning adversary. 

We Need Better Weapons Against C. diff

While the infection is not new, the strength and seriousness of current strains of the germ have tilted the odds against doctors and our patients.  The infection usually is a ‘side-effect’ of antibiotic treatment, but it can also be contracted from infected surfaces and people that reside in hospitals and extended care facilities and nursing homes.  For example, nowadays a patient can be admitted to a hospital and pick up the germ from hospital personnel who are contaminated from contact with an actual C. diff patient.  For this reason, C diff patients are kept in a form of isolation to protect against spreading the disease.  When a C. diff patient is discharged, the room must be scrupulously cleaned.  Hospital housekeepers today have an incredibly important job for reasons that need not be explained.  While my intent is not to frighten readers, every room in your hospital has likely housed a C diff patient at one time or another. 
  • Imagine the consequences if hospital rooms are not cleaned fastidiously every time?
  • Imagine the risk to patients if personnel do not observe proper handwashing techniques?
  • Imagine the hazard from overuse of antibiotics which are a known risk of C. difficile?
C. diff is not a simple infection like a urinary tract infection that can be easily wiped out. It can be severe and stubborn. The germ has a spore form where it stays protected within a type of armor and can survive on surfaces for months.  This is why it is so tough for hospitals who are striving every day to destroy these millions of microscopic germs who resist attack and hide in waiting.  It’s not really a fair fight.

Some patients carry the infection for life.  Many have died from it.  It’s especially tragic when a patient battles against C. diff which resulted from antibiotics that were not necessary in the first place.  Think of this when your dentist insists on giving you antibiotics because you have a heart murmur of have an artificial joint, neither of which is supported by medical evidence.

There’s a new treatment called fecal transplantation, where healthy donor stool is introduced into the C diff patient’s digestive system and cures an infection that seemed to be chronic and incurable.  In my view, this is a game changer and I predict that every hospital in America will offer it in the forseeable future.
 
My advice?  Refuse any antibiotics advised by any physician, including me, unless the doctor makes a case for them beyond a reasonable doubt. 


Sunday, September 3, 2017

Labor Day 2017

Couldn't cover every tool or trade here, but a shout out to all.   All work is honorable.

Warm wishes from the Whistelblower.














Sunday, August 27, 2017

Jury Blames Talcum Powder for Ovarian Cancer - No Evidence Needed!

I have written about talcum powder previously.  Indeed, I have not only opined on the slippery substance, but I am also a regular consumer of the product.  Talcum powder has become magic legal dust that brings forth zillions of dollars to those who have been attacked by the poisonous toxin. 

Just last year, I informed readers of $55 million and $72 million judgments to cancer victims who used powder against the manufacturer Johnson & Johnson.  Earlier this year a Missouri woman was awarded $110 in damages. 

Recently, a jury in California, where the cost of everything is stratospheric, ordered J & J to pay damages to a victim of ovarian cancer.   The jury clearly wanted to send the company and corporate America a monetary message that went beyond the pinprick judgements that were issued against J & J last year. 

Readers at this point are invited to consider what would constitute reasonable damages if it were proven true that the product caused the cancer and the company knew of this risk and did not provide adequate warning to the public.   Make your guess before reading on.

Here are some price comparisons to test your sanity

Private Gulfstream Jet                     $70 million
Penthouse in NYC’s Plaza Hotel    $40 million
Alexander Hamilton Autograph             $1,000
Bentley Automobile                            $230,000
100 meter Superyacht                    $275 million
California Jury Award                    $417 million

You may resume breathing now.  Of course, the plaintiff’s attorneys were able to string  a circuitous array of dots that connected talcum powder to cancer in front of a jury who was likely more sympathetic to a dying victim than to a megacorporation.  But, sympathy is not evidence and being a successful company does not define negligence.   


Few strands of GW's hair is a bargain at $22,800!

This mega-judgment is rendered beyond absurd when one accepts that there is no convincing and consistent scientific conclusion that talcum powder is the responsible agent.  The studies have largely demonstrated an association, which are not designed to determine cause and effect.

What should product manufacturers do?  Should every package include a boxed warning that the product can cause misery and death just to cover themselves?   Perhaps, not. This would only give customers anxiety, pain and suffering.  Guess what would happen next?

Sunday, August 20, 2017

Yikes! There's Food Stuck in My Throat! The Steakhouse Syndrome Explained

While I typically offer readers thoughts and commentary on the medical universe, or musings on politics, I am serving up some lighter fare today.  Hopefully, unlike the patient highlighted below, you will be able to chew on, swallow and digest this post.  If this blog had a category entitled, A Day in the Life of a Gastroenterologist, this piece would reside there.

I was called to the emergency room yesterday to attend to an elderly woman who had steak lodged in her esophagus.  While this sounds life threatening to ordinary folks, it poses no mortal danger.  The airway is uninvolved and normal respirations proceed without interruption.

These patients, while fully alive, are rather uncomfortable. 

This is one of the tasks that gastroenterologists are routinely called to undertake, often at inhospitable hours.

Sometimes, these folks have known esophageal narrowed regions where food that is not masticated with enthusiasm can hold up.  On other occasions, a person with a totally normal esophagus tears into a steak like a famished wolf and forces down a mass of meat that has no chance of passing through.  Bar patrons who are inebriated and then grab a handful of chicken wings are prime candidates for an emergency room visit with a gastroenterologist when the wings just won't fly through.  And, if granny forgot to put in her dentures before biting into a chicken sandwich…


Don't bite off more than you can chew.


No one involved enjoys the experience, and the procedure has more risk that our routine scope examinations of the stomach and esophagus.   Usually, these episodes can be prevented with proper attention to making wise food choices and chewing well. 

How do we get the job done?  Basically, we serve as plumbers and use our usual scope instrument to unclog your food pipe.  (Reminds me of a joke when a customer complained to a plumber over his bill.  "I'm a doctor, " the customer said, "and I don't charge that much!"  The plumber replied, "I used to be a doctor also, but I wasn't earning enough money."

The curious aspect of this case is I asked the woman prior to the procedure if she has difficulty swallowing foods with regularity.  She responded that the only food that she has consistent difficulty swallowing is the type of meat she ate that day.

Can you guess my next question?

Sunday, August 13, 2017

The Heartbreak of Psoriais - Guilt by Association

I was asked this week for an informal opinion by someone who was advised by his dermatologist to take a biologic medicine for psoriasis.   Now, my knowledge of this disorder is barely skin deep, yet knowledge alone will not set you free in the murky world of medicine.  Knowing something is not as significant as knowing when to do something.


Can guacamole really cause cancer?  Read on.


Biologic medicines, which have surpassed in frequency the nearly omnipresent TV ads for erectile dysfunction, are expensive medications that have risks of serious, albeit uncommon, side effects.  And, unlike chemotherapy for cancer, which has a finite course, biologic medicines are administered forever, that is without a clear stopping point. 

The individual who questioned me was not suffering from insufferable psoriasis and was satisfied with the conventional topical treatments he has been using for years.  His dermatologist offered the biologic in an effort to reduce his risk of heart disease.  Let me try to explain.

If you GOOGLE psoriasis and heart disease, you will find a surfeit of hits claiming some kind of connection between the two conditions. However, if you GOOGLE any two items on any subject, you are likely to hit upon some ‘connection’.   I just randomly GOOGLED guacamole and cancer and sure enough, there is a 'connection'!  Presumably, the dermatologist accepted the psoriasis-cardiac connection to be one of causality, meaning that psoriais can cause heart disease.  Extrapolating beyond this FAKE NEWS, he assumed that treating the psoriasis would mitigate the risk of an adverse cardiac event.   It is exactly this false reasoning that so often gets patients into trouble.  The logic of the intervention seems sound, but it is entirely specious.

The facts are here that there is no proof that psoriasis causes heart disease.  Clearly then, it makes no sense to treat the skin condition hoping to prevent a complication for which there is no proof that psoriasis causes.  Psoriasis may be associated with or linked to heart disease, which understandably suggests to an ordinary patient that there is a strong connection where Condition A causes Condition B.  I address this fallacy several times each week when I am asked if heartburn medications cause hip fractures or dementia.  They are associated with these complications in a statistical sense, but have not been shown to cause the complications.

Say I publish a study showing that tall individuals are associated with high blood pressure.  This does not mean that height is responsible or that we should hope that our children remain short.


Do you think that this blog is associated with astute and discerning readers?   If so, can I write next week that reading the Whistleblower blog is powerful brain food?

Sunday, August 6, 2017

Will Genetic Engineering Save or Sink Humanity?

We cannot let the anecdote rule over us.   We don’t make sound policy if we are swayed by isolated emotional vignettes.  Of course, a vignette describes a living, breathing human being, but we must consider the greater good, the overall context and the risk of letting our hearts triumph over our heads when making general policy.  Consider these examples.

If an expensive drug treatment program keeps 5 addicts clean for 6 months, do we champion this success in asking for funding to be renewed while omitting that 400 enrolled addicts failed?

If an experimental medical treatment seems to be effective in one patient with a stubborn disease, should physicians lurch toward it leaving aside standard treatments which have been subjected to Food and Drug Administration approval and years of clinical experience?

If a high school student attends an SAT prep course and achieves a near perfect score, do we conclude that every student should enroll in this course?

It is natural to be drawn to a shiny object, but on closer review, the shine often tarnishes quickly.

Earlier this week, we learned of an astonishing scientific breakthrough that seems utterly fantastic and futuristic, even though it has actually occurred. Scientists amended the DNA of human embryos to correct a mutation - a genetic defect - that causes a very serious medical disease.   This suggests that with additional research and testing that embryos who otherwise might be destined for misery could be rescued. 

We will hear heartwarming and breathtaking anecdotes that, if considered in isolation, will generate excitement and support. 

Would you argue against the following headlines?

Embryo with fatal cystic fibrosis mutation saved.

Tay-Sachs embryo rescued from fatal outcome.

Hemophiliac embryo expected to live normal life.

As is always the case, there will be ethical mission creep, despite the usual bromides that “scientists and research institutions will conform to the highest ethical standards”.   The fact that there is a fortune to be made in the genetics industry can be expected to alter the direction of our ethical compass.  And, while the initial rollout will be discussing how genetic intervention can reverse the course of devastating and fatal diseases, does anyone believe it will stop there?  Once the concept has been normalized, other medical conditions will be targeted.   The creep will be inexorable.  Boundaries will be shattered.


Einstein said 'God does not play dice with the universe.'

Should we?


Who doesn’t want a perfect child?  Over time, how will all of us regard the disabled community or even folks of average intellect and ability?  Will a disabled person be defined as anyone who is imperfect?

Beyond medical mission creep, I believe there is a very serious risk that genetic engineering will be used to achieve non-medical results. 

Imagine that you are new parents.  If medical science could perform a procedure that would add 20 IQ points to your child, would you pursue it?  Would you submit to a minor DNA tinker that would produce an excellent athlete or a musician?  See where I'm going with this?

Are you really ready for the curtain to rise on the Genetic Engineering Show?  I'm not.  To me, all this sounds like coming attractions of a horror show.






Sunday, July 30, 2017

Is America Ready for a Single Payer Health Care System?

Each morning, as I read the newspapers in view of 3 birdfeeders, I send excerpts of news morsels to various individuals in an effort to stimulate a dialogue on issues of the day.  I am mindful how deluged we all are with a tsunami of unsolicited material.  I will not contribute to the cyber pile-on.  First, I’ll never forward an article that I have not read in full.  Secondly, I will send an item to an individual only if I have judged beyond a reasonable doubt that this person will feel that the time investment in the material will be judged to be time well spent. 

I engage in an active colloquy with one of my good pals, who is among the millions of Whistleblower readers who ponder these posts each week.  To my knowledge, he has never left a comment on the blog, which is somewhat unexpected of this rather voluble individual.   As he has opted to remain anonymous, I will not ‘out’ him here, although perhaps this post may be the catalyst to morph him from spectator to participant.

More than once this past week, my pal has importuned me for my view on a single payer health care system.  I shall do so now, in this very public forum.

Readers are aware of my views on our current health care system.  For those yet unacquainted with my insider’s view of the health care reform, I refer you to the Health Care Reform Quality category on the right side of the screen where you can digest several edifying entries. 

We already have a single payer model in this country.  It’s called Medicare and it is wildly popular with enrollees.  A single payer system can be regarded as a Medicare-for-All program.

I have written many times that I believe that Obamacare was designed to be an interim measure until a full and complete government nationalization of our health care system could be accomplished. How ironic it would be if single payer emerges because the GOP majority who favor private sector solutions can't bring a bill to the president's desk. 


Single Payer Health Care Will be a Heavy Lift

I will support a single payer system, if the following features can be guaranteed.

  • Universal access for every American.
  • Fair and reasonable compensation for physicians and health care professionals.
  • Pays physicians and health care institutions in a reasonable time period.
  • Adequate number and distribution of primary care physicians.
  • Eliminate the dreaded ‘prior-auth’ for prescriptions which tortures physicians and our patients.
  • Reforms an unfair medical practice tort system.
  • Reforms medical education so that students are not routinely saddled with 6 figure debts.
  • Incorporates innovations to reduce over-diagnosis and overtreatment which bleeds the system and harms patients. Both patients and the medical profession are culpable here.
  • Affordable medications understanding that the pharmaceutical industry needs a profit motive to spend hundreds of millions of dollars of research to develop treatments for cancer, arthritis, dementia, diabetes and various chronic illnesses.
  • Defines clearly what medical care is not covered by the plan.  Everyone wants coverage for experimental treatment regardless of the cost for an afflicted family member, but this is beyond possible.  We cannot pay for every conceivable medical test or treatment, even if some experts regard it to be ‘promising’.  What should the standard be?  Perhaps, FDA approval might be a starting point for this discussion.
  • An impartial appeals process that is fair to all parties and issues a decision in a timely manner must exist.  Fund promising clinical trials so that patients who have exhausted conventional treatment, can altruistically help to generate new medical knowledge.
  • Ensures that patients, physicians and hospitals who contact SinglePayerCare can reliably and promptly reach a living, breathing human being who can answer the question or solve the problem without dropping the caller into a labyrinth of horrors.
  • While the costs to patients must be reasonable, they need to have some ‘skin in the game’ in order to serve as a break in what is now a runaway train of unnecessary medical care.
  • Medical quality must be championed and fairly measured, which would be a departure from current sham and scam ‘quality metrics’ that are in place.
  • Futile medical care should not be provided even if demanded by patients and their families, although I recognize that this is a sensitive issue.  Families understandably ‘want everything done’ as they cling to vain hopes.  And, while I don’t mean this to be callous, it’s easier to request a service when someone else is paying for it.
  • Has proper incentives and access to primary care so that routine medical issues are not clogging up our emergency rooms. 
  • Separate medical institutions’ economic interests from the public interest.  I surmise that the United States has the highest per capita of CAT scan machines on the planet.  Would private hospitals and nursing homes willingly surrender control or even ownership to the federal government to serve the greater good?  (You may laugh now.)
Single payer?  Bring it on!   I think, however, that this would be a very heavy lift.  We have a Medical Industrial Complex (MIC) riddled with waste and conflicts of interest and very powerful players who are making a fortune off the system.  Perhaps, if we were designing our health care system de novo, we would establish a single payer system, as other nations have done. 

Think of the health care reform issue as we do term limits for our senators and congressmen.  We all know that it’s a good idea, but it will never happen.  Legislators, like those in the MIC, do not seem capable or willing to place our interest over theirs. 


Sunday, July 23, 2017

After Hours and Weekend Medical Care - The Doctor's Perspective

Today's patients must adjust to seeing many physicians, many of whom are strangers.   If you need a doctor on the weekend, at night or just need a ‘same day appointment’, you may very well not be seen by your physician.  This is not your father’s medical practice.  The days of the physician house call have vanished.   There are many reasons responsible for this evolution (?devolution) in medical care.  Patients have by and large adjusted to this new reality.

Housecall with some Old Fashioned Bloodletting

We physicians have had to adjust as well.  Formerly, we took care of our patients exclusively, with rare exceptions when we were out of town.  If you went to the hospital, we were there.  Same day appointment needed?  We squeezed you in.   There was no nurse practitioner to pick up the slack.  While I’m not making a judgment on the mediical merits, physicians of yesteryear were more devoted to their patients and their profession than they were to their own lifestyles, a fact that their families would attest.  Times have changed.

Nowadays, physicians regularly see patients whom we do not know.  Consider that for a moment.  On a regular basis, doctors treat patients whom they have never seen.  While this challenge is obvious from the patient’s perspective, it’s not easy for us either.  In my own practice, this experience usually occurs on the weekends when I am covering my partner's hospitalized patients. This is much more complex than if I were seeing my own patients whom I know well.  Here’s why.
  • I have no personal relationship or rapport with the patient or the family.  If I have a serious recommendation, such as surgery, will I have sufficient credibility?
  • I may be reluctant to aggressively intervene on a Sunday morning, opting instead to tide the patient over until Monday, when my partner who knows the patient will be back on the case.  This phenomenon of a benevolent stall is commonplace when a doctor is temporarily on the case.  
  • Although I may be ‘in charge’ of the patient on the weekend, I am not as knowledgeable of the nuances of the medical situation as would be the doctor of record.  For example, if I palpate a patient’s abdomen on Saturday morning, and it is tender, it may be very difficult to ascertain if it is worse or better, as it was someone else’s hands that were on the belly on Friday.  Additionally, doctors who are active on the case have knowledge of the patient that can never be recorded in the medical record.
When a patient meets me for the first time, he may be wary as I have not yet earned his trust.  I understand this.  Similarly, when I see another doctor’s patient for the first time, it is harder for me as the covering physician.  How could it not be?   I'm not sure that patients reliably recognize this, assuming that the covering doctor can cover it all.

We covering doctors do our best on the weekends, but it’s not ideal.  In a perfect world, every physician who sees a patient would know all.  But, the medical world must operate in an imperfect system and with imperfect professionals.  If patients and physicians both accept this, then our doctor-patient relationships will be more robust.  Let's all keep our expectations in the real world.  

Sunday, July 16, 2017

Obamacare Nearly Repealed & Replaced! 2+2 =7!

Everyone likes R & R.  In fact, I’m enjoying some R & R right now as I sit lounging on the backyard deck.  I have a full frontal of 3 birdfeeders who are all being attacked by avian assaulters.  It’s a microcosm of society – Lord of the Flyers, if you will.  The hummingbirds are working their wings off for a sip of nectar.  The finches politely share space on the feeder.  The male and female cardinals hang together – true love birds. The blue jays bully all the other birds away.  And, the lazy squirrels simply hang out below capturing seeds that the birds above spill to the ground.



The Bully


Senate Majority Leader Mitch McConnell is trying hard to get some R & R also.  Doesn’t he look like he needs it?  Poor guy.  The R & R on his agenda is not exactly like my backyard, bird gazing Rest and Relaxation.  The senator from Kentucky’s R &  R is Repeal and Replace!

The senator is a trained lawyer and must be skilled in logic, reasoning and interrogation techniques.  I have a sense that mathematics was not one of the senator’s stellar academic disciplines.

Here’s the situation:
  • There are 52 Republican senators
  • Two Republican senators are on the record as unwilling even to let the bill proceed for consideration. (52 – 2 = 50)
  • Within the past week, 10 Republican senators have raised serious concerns about the senate’s health care bill.  (50 – 10 = 40)
  • None of the 48 Democratic senators will support the bill.
  • Any Democratic senator who uses the word ‘repeal’ even by mistake will be sent to GITMO by Senator Chuck Schumer.
  • The bill’s public approval rating is a whopping 17%.  Great political cover for legislators who vote Aye!
  • Senator McConnell needs 50 GOP votes so Vice President Pence can push the bill into the end zone.
Can any of my brainiac readers with mathematical acumen show us simpletons a pathway to 51 votes?


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