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. 


Sunday, April 9, 2017

Health Care Reform 2017 Solved!

Have you noticed over the past several weeks that reforming the health care system must be slightly more complicated that we were told?  The promise that Obamacare would be repealed and replaced on Day 1 seems to have been met with a few minor obstacles.  In other words, it’s dead in the water.

Whose fault is it?  It’s like Agathe Christie’s Murder on the Orient Express [Spoiler alert!] – everyone is guilty!

The Freedom Caucus stiff-armed the Speaker of the House.  The GOP House moderates dissed the Freedom Caucus.  President Trump learned that being the leader of the free world is not quite the same as being a CEO of a private company.  If the repeal plan was adjusted to capture a few more hard line GOP members, then moderate GOPers jumped ship.  The Democrats gloated at the GOP’s failure, although their smiles became slightly more taut once Judge Neil Gosruch was confirmed to occupy the GOP’s 'stolen' Supreme Court seat. 

Remember John Boehner?   He’s the happiest man on the planet!

Now, I don’t pretend that the Whistleblower can reform the health care system in a blog post, although I don’t think my results could be worse than the GOP controlled House of Representatives.


Health Care Reform - Searching for Low Hanging Fruit

As a medical insider, consider a few issues listed below that would save zillions and improve our health.  They are not controversial.  Why then, aren’t we pursuing ideas that every medical professional supports?  Perhaps, one of my erudite readers can enlighten us, as I am stumped.   
  • Tens of millions of dollars are wasted on unnecessary antibiotics, which result in serious side effects and are creating superbugs. 
  • We are spending too much money on end-of-life and futile medical care.
  • Every physician who is breathing orders CAT scans, stress tests and colonoscopies that are not truly necessary.
  • Patients are punctured much too often for blood tests, particularly in the hospital when multiple specialists (like me) are on the prowl.  Most patients need only occasional blood tests.
  • Patients, particularly our elderly, are overmedicated.  The length of some of their medication lists are staggering.  Any wonder they are routinely sent to gastroenterologist to explain their nausea and other side-effects?
  • Whatever happened to watchful waiting?  Does every complaint that a patient brings to the office have to result in test or a prescription?   How often does a patient’s medical issue simply resolve on its own?
  • The PSA, prostate specific antigen has single handedly harmed more men and wasted more money than perhaps any other screening test.  Despite mountains of evidence supporting my contention, the diehards are still hanging on.
That was a quick list of some very low hanging fruit.  I’ll wager that if all of them were implemented, that we could reform the entire system and have enough money left over to subsidize obscenely high drug prices.   The absurdity is that the above bullet items would be supported, if not championed, by every reasonable physician, informed patient and health care policy pro.  Here’s the riddle.  Why do we persist in behaviors that we all agree are destructive?   Why do we keep furiously digging in the same hole that leads nowhere?






Sunday, April 2, 2017

Is My Doctor Up to Date?

Professional training and development are critical.  Police officers, educators, orthodontists, painters, chief executives, musicians and chefs all need ongoing training to remain current.  Job requirements evolve, and we must adapt.  An accountant who hasn’t kept up with new or anticipated tax law changes might not account for much when computing your tax obligation or refund.

Physicians need to be dedicated to ongoing professional development as much as any other occupation.  Patients often wonder if their doctor is up to date.  Does your primary care physician know about new medications for your condition?  Does your orthopedist use the latest medical hardware when replacing your hip joint?  Is your anesthesiologist using the same old laughing gas to put you asleep?  Is your dermatologist’s knowledge of his field only skin deep?

In the medical profession, there has been a paradoxical emphasis on reducing professional training.  Here’s what I mean.  In hospitals, it is no longer true that every patient relies upon a registered nurse, or R.N., for nursing care.  Now, lower level personnel such as nurses aides and other care assistants are frequently utilized.  I’ll let the reader surmise what motivated this hospital ‘reform’.  Nurse practitioners now roam the hospital wards, technically under the authority of a physician who is seeing his own patients in an office miles away.  Why see your own primary care physician, when the ‘minute clinic’ on the street corner is open for business.  These clinics are conveniently housed in pharmacies so that any antibiotics prescribed, which we hope and pray are truly necessary, can be purchased on site. 

Who should be doing your colonoscopy?  Do you prefer a trained gastroenterologist, or would you be satisfied with a nurse who has been trained in how to technically use the instrument, as some cost cutters have advocated?    Even a casual reader might appreciate that competency in a colonoscopy, heart catheterization or knee arthroscopy extends far beyond the technical requirements of the procedures. 

Gastroenterologists are similar to Navy SEALS.  We both train to a knife’s edge and do all that we can to stay razor sharp.  To my patients, I want to reassure you that staying current in colonoscopy is my life’s mission.  The training manual pictured below is never out of reach.  Feel better?


Sunday, March 26, 2017

Beware of Joining a Clinical Trial - Medical Research Must Come Clean

From time to time, friends, patients and relatives ask my advice on participating in a medical experiment.  My response has been no.  More accurately, once I explain to them the realities of research, they don’t need to be persuaded.  They back away.

Here’s the key point.   When an individual volunteers to join a research project, the medical study is not designed to benefit the individual patient.  This point is sorely misunderstood by patients and their families who understandably will pursue any opportunity to achieve some measure of healing for an ailing individual.  I get this.  In addition, I believe that these research proposals are often slanted in a way to suggest that there may direct benefit that the patient will receive.  I am not accusing the medical establishment of uttering outright falsehoods to prospective study patients, but there are two powerful forces that may incentivize investigators to recruit patients with undue influence.
  • The Medical Research Industrial Complex is a voracious beast that needs a steady diet of new recruits.  In other words, the beast must be fed.
  • Investigators have bias favoring their research and truly believe that the new drug has a real chance of helping study patients.
The truth is this.  In general, research projects are designed to generate new knowledge that will be used to help patients down the road, not those in the study.  Of course, I cannot state with absolute certainty that a study patient won’t realize a favorable result, but this serendipitous outcome is not the study’s planned yield. It should be viewed as a happy accident.  This is why the study is properly called a research experiement.

Napoleon Has Stomach Pain.
Should He Join a Study?

Beware of the packaging.  If your mom or dad has Alzheimer’s disease, of course, you would be susceptible to the following hypothetical pitch.

Is someone you love struggling against Alzheimer’s disease?  Our Neurological Institute is fighting hard against this disease and is now testing a new drug to help conserve memory.  Call for confidential information. 

Recently, in France, 90 volunteers took a study medicine testing the safety of a psychiatric medication.  One volunteer is now dead and others have suffered irreversible brain damage.  We don’t know the underlying facts yet.  While a horrible outcome is not tantamount to guilt, this is a terribly troubling event that must be sorted out. We will find out soon enough if the French study subjects were given all the information they were entitled to, and if the investigators and others behaved properly.  The investigation that must be full and fair.  A conclusion of c’est la vie won’t be enough.

If you want to join a medical study to serve humanity – and not yourself – then you are free to make an informed choice.  Be mindful of the risks including those that are not known. 

Helping others is a praiseworthy act.  So is telling the truth.


Sunday, March 19, 2017

Medical Marijuana Use - Ready, Fire, Aim!

Promoting medical marijuana use is hot – smokin’ hot.  States are racing to legalize this product, both for recreational and medical use.  In my view, there’s a stronger case to be made for the former than the latter. 

Presently, marijuana is a Schedule I drug, along with heroin, LSD and Ecstasy.  The Food and Drug Administration (FDA) defines this category as drugs with no acceptable medical use and a high potential risk of addiction.  Schedule I contains drugs that the FDA deems to be the least useful and most dangerous.  Schedule V includes cough medicine containing codeine.

On its face, it is absurd that marijuana and heroin are Schedule I soulmates.  I expect that the FDA will demote marijuana to a more benign category where it belongs.  It will certainly have to if marijuana is going to be approved as a medicine. 

There is no question that some advocates favoring medicalization of marijuana were using this as a more palatable route to legitimize recreational use.  The strategy was to move incrementally with the hope that over time the ball would cross the goal line.  We have seen this same approach with so many other reforms, legal decisions and societal acceptances, many of which we take for granted.  Consider gay marriage and women’s role in the military as two examples of goals that required a long journey to reach.

Marijuana has had no personal or professional role in my life.  I do not object to responsible recreational use and would support such a measure.  To criminalize marijuana use while cigarettes, chewing tobacco and alcohol are entirely legal seems inconsistent and hypocritical.  Is smoking marijuana more dangerous than riding a motorcycle?

Paradoxically, I have hesitancy at this point to endorse medical marijuana use based on the fragmentary data that supports its efficacy.  If you ‘Google’ this subject, and you believe what you read, you will conclude that marijuana is the panacea we’ve been waiting for.   It helps nausea, neuropathic (nerve) pain, glaucoma, muscle spasms, Crohn’s disease, multiple sclerosis, epilepsy, Hepatitis C, migraines, arthritis, Alzheimer’s disease, cancer and numerous other ailments.  Do we accept so readily that one agent can effectively attack such a broad range of unrelated illnesses?  It sounds more like snake oil than science. 

Cure is Just a Puff Away!

Shouldn’t high quality medical studies demonstrate benefit before we sanction medical marijuana use?

The medical profession and our patients should demand that all our medicines be rigorously tested for safety and efficacy.   I realize that there is huge public acceptance that marijuana is real medicine.  Not so fast.  Let the FDA evaluate marijuana as it does for all medications and treatments.  I do not think we should relax our professional standards just because the public is willing to inhale without evidence and entrepreneurs want to cash in.

If you had a chronic disease, would you expect your doctor to offer you a medicine with definite risks but no proven benefit?  Why would you accept it and why would he prescribe it?  

Sunday, March 12, 2017

Why Are Drug Prices So High?

Why are the costs of prescription drugs so high?  While I have prescribed thousands of them, I can’t offer an intelligent answer to this inquiry.  Of course, all the players in this game – the pharmaceutical companies, Pharmacy Benefit Managers, insurance companies, consumer activists and the government- offer their respective bromides, where does the truth lie? 

While I don’t fully understand it, and I don’t know how to fix it, we all know that the system is broken.  More than ever before in my career, I am seeing patients who cannot afford the medicines I prescribe for them.  In the last few weeks of this writing, 3 patients with colitis, a condition where the large bowel is inflamed, called me to complain about the cost of their new medicine.  The annual cost was in the $2,500 - $3,000 range, which is way out of range for normal folks.  While I was only focused on the colitis drug, many of these patients face prohibitive costs over multiple medicines.  All of these patients had medical insurance, thought it didn’t feel like it to them. 

Medicine or Retirement?

Should sick patients be given the added burden of price gouging?

I'm not an attack dog against PhRMA.  I've expressed sympathy on this blog and elsewhere that it costs pharmaceutical companies a fortune to design, test and market new medicine.  R & D is not cheap.  If we want this industry to take risks developing tomorrow's drugs, then they deserve a profit high enough to justify the investment.  Nevertheless, from the prescribers and the consumers points of view, the system is out of balance and needs to be recalibrated.  

I reviewed my colitis patients' formularies, which is the list of medicines that patients' insurance companies cover.  If a drug is labeled as a ‘Tier 1’ drug, then the cost to the patient is the lowest.  The higher the Tier #, the more the patient will pay.  This is how the insurance company ‘guides’ physicians to prescribe cheap drugs.  Of course, the insurance company will never say that the patient can’t receive an expensive drug.  That’s a decision, they claim with a straight face, that’s between a patient and the doctor.  Give me a break.  Ordinary folks, especially retired people on fixed incomes, are confined to lower Tier medicines.

I have no issue with the Tier system as long as there is at least one Tier 1 drug that can do the job.  If there are half a dozen heartburn medicines that are equally effective, I understand if an insurance company makes one of them Tier 1, their preferred choice.  This happens when the insurance company gets a special discount on this particular medicine.  

With regard to my 3 colitis patients, the only Tier 1 drug was one that came on the scene decades before I was born.  The standard colitis medicines that every gastroenterologist would have prescribed were all upper Tier. My patients had no choice but to accept an inferior drug. 

If any reader can explain why our drug prices are the highest in the world, can you also explain why insurance companies are not practicing medicine?



Sunday, March 5, 2017

Should Attorney General Jeff Sessions Resign?


For me, the test of fairness, which many of us fail, is if we would have the same view of events if the situation were reversed. 

An employee approaches his boss requesting a raise, pointing out that he has not had a raise in 2 years, while other colleagues have received pay increases.  The boss responds that while his performance was highly satisfactory, the colleagues who did receive pay raises demonstrated sterling reviews.  The employee believes this decision is unfair, and suggests there may have been some favoritism at play.   The fairness test here is what would the employee do if he were the manager.

A nursing supervisor is told that two nurses on a hospital ward are unable to report to their shift.  Each nurse has to carry a heavier patient load for that shift.  These nurses believe that they are entitled to additional compensation as their already heavy work load has been increased.  This request is denied by the hospital’s administration.  I wonder if the hospital administrators would agree with their edict if they were the overworked nurses on that shift.  Would they still agree that no additional pay for additional work is downright fair?  Can't you just hear them saying that if they were these nurses that they would welcome the opportunity to be saddled with extra work and would refuse any offer for additional comp.  (Readers are invited to laugh at this point.)

Events always look a little different when we swap places. 

The Attorney General of the United States, Jeff Sessions, is the newest star performer on CNN and other networks this week.  He gave misleading responses during his confirmation hearings when asked if he had any contact with Russian officials during the campaign.  In addition, he did not correct his misstatements afterwards until his 2 meetings with the Russian ambassador were disclosed.  He has been accused of lying and deceiving congress, an allegation that he denies.  He claims that he misunderstood the question and had no intent to mislead anyone.


Public Enemy #1?

Personally, I am not satisfied with his inaccurate testimony and subsequent silence    Did he lie?  I’m not sure.  If so, it would seem to be a poor choice since telling the truth of the two meetings could have been justified and explained.  

Many Democrats are screaming for his resignation and for a special counsel to be brought in to assess the situation independently.   I suggest that the reasons behind these two Democrat requests have nothing to do with Sessions’ behavior, but deserve a larger context, which I’m sure my readers will acknowledge.

We all know that when there is an independent counsel that the investigation always morphs into a mega-mission creep that extends far beyond the initial target.  That’s why political partisans always zealously request this measure when the other party is under attack, but push back hard when they are in the crosshairs.  

Now for the fairness test.   Remember when the Democrats were screaming and whining when independent counsel Ken Starr was on the attack?  His mission started with Whitewater but was incrementally expanded and extended to the Monica Lewinsky affair.  I think the Democrats had a valid point that his investigation became untethered.  However, is an independent counsel only fair when your opponents are being targeted?

As for Jeff Sessions resigning, I think this is transparent partisanship.  How would the Dems react if the situation were reversed?  The experiment has already been done.  Remember when Loretta Lynch, the Attorney General had a near hour long meeting with Bill Clinton on the tarmac while Mrs. Clinton was the target of an FBI investigation?  Quite a long time to be discussing golf and grandchildren.  

How many Democrats called upon her to resign or face a special prosecutor?   Have they passed the fairness test?

Of course, many partisan Democrats will point out the the Lynch affair is 'completely different' from the Sessions matter.  How stupid do they think we are?

I'm taking aim at the Democrats here, but I fully acknowledge that the GOP also fails the fairness test regularly.  


Sunday, February 26, 2017

Do Doctors have a Right to Free Speech? Hippocrates Weighs In.

Free speech is one of our bedrock constitutional rights.  The debate and battle of what constitutes lawful free speech is ongoing.  The issue is more complex than I can grasp with legal distinctions separating political speech, commercial speech and non-commercial speech.  And, of course the right of speech does not permit the free expression of obscenity or ‘fighting words’, along with some other exclusions.  And, there is no right to free speech in a private work place, where an employee can be fired for speaking his or her mind.  While worker in a private shop may claim that he had a right to call his boss a flippin’ jerk, he would likely find that he suddenly has an abundance of free time to contemplate his prior utterance.

Leaving aside the First Amendment, physicians have always enjoyed free speech in our offices.  We ask our patients questions of the most private and intimate nature.  And, they answer us.  We ask such questions because, under appropriate circumstances, we need the information in order to provide our best medical advice.   We ask about specific sexual practices.  We ask about prior or current substance abuse.  We ask if patients are alcoholics.  We ask if patients are suffering from abuse or neglect. 

While we may not invariably receive truthful responses from these inquires, often we do.  Patients trust us to respect their confidentiality, which has been embedded into medical culture and practice since the time of Hippocrates.

And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.

Hippocrates -2500 years before HIPAA!


His admonition holds true nearly 2500 years later.  How’s that for meeting the test of time?

In 2011, the Florida Republican legislature, with the approval of the governor, passed a law that restricted physicians from inquiring of their patients about gun ownership and safety.  Physicians found to be in violation risked loss of their professional licenses or fines.  Nearly two weeks ago, an appeals court struck this silly law down.  Not only was such a law an obvious encroachment on physicians’ First Amendment rights, but also posed a barrier preventing doctors from doing their jobs.  Should a pediatrician, for example, be prevented from asking a parent if firearms in the home are properly secured?  This is not a political or partisan issue – it’s a medical and safety issue.

Of course, the appeals court got it right in a case that I regard as a judicial lay-up.  But, how did such a ridiculous law get passed in the first place?



Sunday, February 19, 2017

Do Judges Legislate from the Bench? What's Your Ruling?

Judge Neil Gorsuch, President Trump’s nominee to fill a vacant seat on the Supreme Court of the United States, will face a contentious vetting process in the U.S. Senate.  I expect the sausage-making process to be an opportunity for political grandstanding where bombastic bloviators will spew forth partisan pabulum.  Look for a senator, for example, to point out that the judge did not clean up after his dog when he was in the 7th grade.  “If we can’t trust you to clean up after Sparky, then how can we trust you to mind the Constitution?”

We read and hear about the scourge of judicial activism (JA), where judges invent laws rather than interpret existing law, as they are charged to do.  The antidote to judicial activism is judicial restraint (JR), when judges exercise modesty and base their rulings on the intent of the framers or on the words in the statute.  If, for example, the statute does not specify that “the puppies shall be saved”, then it is not for the judge, who may be a dog lover, to take on canine rescue as a ‘pet project’.

Let me define JA and JR more clearly for readers who do not wallow in the judicial universe.

Judicial Activism: A ruling that is disliked by various individuals and interests.
Judicial Restraint: A ruling that is celebrated by various individuals and interests.

If a judge rules for your cause, then he or she is a titan on the bench.  If however, you did not receive your desired judicial outcome, then the judge is an activist hack who is legislating from the bench.  I am generalizing, of course, but you get the point. 


A Den of Activism?

How has the judicial branch been performing?  A lot better than the other two branches, in my view.  Here’s some rough polling data.

      Approval Rating
Trump                            38%  (2017)
Congress                        28% ((2017 –  Surging -up 9 points in 1 month!)
Supreme Court             42% (2016)

Let’s not read more into this than the numbers merit.   Negative poll numbers do not mean that an individual or an institution is not performing well.  It simply means that the public is dissatisfied.  If Congress, for example, passes a law eliminating the deductibility of home mortgages, which may be a sound public policy measure, don’t look for an upward spike in poll numbers.

Hopefully, this blog, at least from time to time, polls well with readers.  What’s your ruling?  Of course, if I don’t like it, I will merely label you as an Activist Reader!

Sunday, February 12, 2017

Communication Between Doctors and Patients - Words Matter

Here’s a quote that readers will not readily recognize.

It is a pity that a doctor is precluded by his profession from being able sometimes to say what he really thinks.

I’ll share the origin of the quote at the post’s conclusion.  How’s that for a teaser?  I'll give you a hint below.

Author of the Quote as a Young Child

Physicians by training and experience are guarded with our words.  To begin, we are never entirely sure of anything, and we should make sure that we do not convey certainty when none exists.  This is why physicians rarely use phrases such as, I’m positive that..., I’m 100% sure…, there are no side-effects…

Because of the uncertainties of the medical universe, sometimes we sanitize our own concerns when we are advising patients and their families.  We may see an individual in the office with unexplained weight loss and a change in her bowel pattern.  While we may fear that a malignancy is lurking, we would be wise to keep our own counsel on this impression pending further study.  This patient, for example, may be suffering from a curable thyroid disorder. 

Words matter.  We all have heard how patients and families can dwell on one or two words uttered by a physician, who may have spoken at some length on a patient’s condition.  In these cases, the families may have inferred more serious news than the physician intended.  Doctors need to be mindful of this phenomenon when we are communicating.  Which of these messages would you prefer to receive on your voice mail?

“Please make an appointment to review your biopsy results.”

“Your biopsy results are benign.  Please make an appointment so we can discuss them further.”

On other occasions, physicians may opt to leave out certain words or suspicions.  Why unload anxiety on folks before the truth is known?  Additionally, not every patient wants the whole truth administered in a single dose.  These scenarios demonstrate the advantage that a physician has when he has an established rapport and relationship with his patient. 

Conversely, I don’t feel we are helping patients and their loved ones when we overly sanitize the medical situation in order to postpone an unpleasant physician task or to create hope that may not be realistic.  There’s a balance to be attempted, and I still struggle to achieve it. 

The quote that started this post was published 90 years ago, not by a doctor or a nurse.  I stumbled upon it when reading The Murder of Roger Ackroyd, one of the greatest works by the master of mystery, Dame Agatha Christie.


Sunday, February 5, 2017

Should Patients Order Their Own Lab Tests?

Knowledge is power.  Increasingly, patients are demanding and receiving access to levers in the medical machine that would have been unthinkable a generation ago.  I have already opined on this blog whether the informed consent process, which I support, can overwhelm ordinary patients and families with conflicting and bewildering options.  Television and the airwaves routinely advertise prescription drugs directly to the public.  Consider the strategy of direct-to-consumer drug marketing when millions of dollars are spent advertising a drug that viewers are not permitted to purchase themselves.  The public can now with a few clicks on a laptop, research individual physicians and hospitals to compare them to competitors.  The ‘Sunshine Act’, an Obamacare feature, publicizes payments to physicians and hospitals by pharmaceutical companies and other manufacturers.


"Sunlight is said to be the best disinfectant"
Every physician today has the experience of patients coming to the office presenting their internet search on their symptoms for the doctor’s consideration. “Yes, Mrs. Johnson, although it is true that malaria can cause an upset stomach, I just don’t think this should be our first priority.”
There are now laws that permit patients to order their own lab tests such as cholesterol or glucose.  Even registered nurses working in intensive care units are not permitted to order these tests without a physician's authorization.  Ordering diagnostic tests and medical treatments has always been under the purview of a physician or highly trained medical professionals.  Who interprets the results?  The patient?  The lab tech who drew the blood? The cashier at the retail health clinic?  A policeman?  A hospital custodian?
I had an office visit with my own physician to discuss how best to manage my own cholesterol level.  While this discussion did not have the drama of cardiac bypass surgery, it took time to consider the risks and benefits of various options along with my personal and family risk of cardiac disease.  My point is that even two medical professionals had to navigate through an issue that had more complexity than one might think.  Understanding the significance of a lab result takes nuance and medical judgment.
Patients already purchase all varieties of heartburn medicines over-the-counter, that years ago were out of reach.  Should we permit patients to buy antibiotics, blood pressure medicines, ‘statins’ for elevated cholesterol and anti-depressants? Why not?
Think of all the money the system would save.  A depressed individual, for example, doesn’t have to waste time and money with a psychiatrist.  He already knows he’s depressed. He can proceed directly to the Mood Aisle of the local drug store and get the pills he needs.  Wouldn’t it be easier and cheaper if patients could just buy antibiotics themselves for those pesky colds and flus?  No office visit or time off work for a doctor appointment. The fact that antibiotics don’t combat colds and other viruses never seemed to deter their use. 
Eventually, patients can order their own colonoscopies, stress tests, cardiac catheterizations and gallbladder removals.  Perhaps, we will see the creation of AmazonMEDPRIME.  Feeling a little chest tightness?  Just click the app, and the Cardiac Cath Mobile will be at your door in 30 minutes or less.    


Sunday, January 29, 2017

Probiotics Promote Digestive Health - Is There a Germ of Truth

Several times each week, I am asked about the value of probiotics.  Many of my patients are already on them, based on a personal recommendation or an advertisement.  As a gastroenterologist, I routinely treat patients with all varieties of diarrhea conditions, such as irritable bowel disease, ulcerative colitis, Crohn’s disease, lactose intolerance, celiac disease and the highly feared gluten sensitivity.  Many of them arrive in the office with a probiotic in hand waiting for me to pass judgment.  These patients look to me as a Digestive Supreme Court Justice as they sit on the edge of their chairs waiting for my ruling in the case of Probiotics vs Disease.  

First, let’s all be clear on what a probiotic is.  Probiotics are bacteria that provide health benefits when consumed.   Stop a moment and consider how bizarre this concept is.  Physicians have been fighting germs since the days of Louis Pasteur.  We have taught the public for generations how important personal hygiene is.  We are counseled not to eat under-cooked food from fear of contracting a food borne illness.  Every hospital in the country is stressing hand washing to all personnel to protect patients from infection.  Many of us won’t leave the house without a hand sanitizer bottle. 

In other words, germs are bad – unless they are probiotics!  In the latter case, billions of germs are deliberately ingested in order to relieve symptoms and treat diseases – an ironic shift in classic germ-fighting medical practice. 

Germs - Friend or Foe?

Are Our Intestines Germ-free?

Hardly. Our intestines are filled with zillions of bacteria.  Miraculously, during health these germs are not able to penetrate through the walls of intestines to reach internal organs which would cause a severe infection.  These strains of bacteria within the bowel all live together in balance providing health benefits to us.  They aid in digestion and immunity.  Some of these germs create vitamin K, which we use to maintain a healthy clotting system.  

When this bacterial neighborhood, which is called the intestinal biome, is disrupted, then disease can set in. For example, when we take antibiotics to attack ‘bad germs’, such as for a pneumonia or a urinary tract infection, the antibiotic also upsets the ‘good bacteria’ within our intestines.  In addition, many digestive diseases have an intestinal biome that is out of balance.   When the biome isn’t balanced, then the whole body is under a strain.

How Do Probiotics Work?

Here’s the theory in simplified form.  When the community of beneficial germs within our bowels is disrupted from antibiotics or disease, probiotics can get the biome back into balance.  Scientists are not entirely sure how this happens, but probiotic research is in high gear to understand how they work and who should receive them.  The theory is that bringing the biome back to its normal state restores health and relieves symptoms. 

What do I tell my patients with digestive conditions regarding probiotics?  I tell them the truth.  The supportive science is rather thin, but many of my patients feel better on a probiotic program.  We don’t know precisely which probiotic works best for a specific patient or disease, or how often to dose them.  Importantly, we believe that they are safe, but I would be very reluctant to recommend them to someone with compromised immunity.

If you have digestive symptoms and are contemplating a probiotic, here are 3 steps to consider.
  • Open the jar.
  • Open your mouth.
  • Open your mind to the belief that these germs can heal you.




Sunday, January 22, 2017

Repeal and Replace Obamacare - STAT!

Am I referring to Obamacare here or Obama himself?

I am glad that we have a new president.  Like most of the country, I was ripe for a change of direction and a new approach to foreign and domestic affairs – and we are certainly getting that.  New readers here might erroneously suspect that I voted for Trump.  I didn’t.  For the first time in my presidential voting history, I wrote in my choice for our top two office holders.

I have written multiple posts on my unfavorable views of Obamacare since it was jammed through congress without a single Republican vote.  (Do I sound slightly partisan here?)  Interested readers are invited to peruse posts on this blog within the Health Care Reform Quality category, if you dare.

There are two kinds of people who oppose Obamacare
  • Folks who believe it is wrong on policy grounds
  • Folks who wield it as a political cudgel to bash Obama.
Some opponents are a hybrid of both of the above.

I was also suspicious that the Affordable Care Act (ACA) was always an interim step preceding a full nationalization of our health care system.  Obama is on the record favoring such a policy during his 2008 campaign.  If Obama could have achieved this politically in one step, he would have.  The ACA represented the political upper limit that he could achieve, hoping that this would make a full would bring us within reach of a government takeover.   Some conspiratorial skeptics believe that the ACA was designed deliberately to fail so that private insurance companies would have to abandon it – as they have.  Then, the beneficient government would have to step in to rescue Americans who needed medical coverage STAT!  While I offer no opinion on this wild charge, there were many smart people who averred when the ACA was delivered to us, that the numbers would never add up. And they didn't.


Derailing the Obamacare Runaway Train

It is my belief that government is simply not equipped to assume control of the entire health care system and operate it at the highest level of quality possible, while controlling costs.  Remember how smoothly the healthcare.gov web site release was?  Do you think this would have happened if Google, or Facebook was in charge?  Which company do you have a higher opinion of in terms of quality and efficiency, the Bureau of Motor Vehicles or Amazon?  If folks want to have a government insurance plan like Medicare, I am fine with this.  But, give us access also to the free market.  I like choice because competition breeds excellence.  When FedEx came onto the scene, it forced the U.S. Postal Sevice to really step up, which they have. 

And, we all know that the plan’s proponents were somewhat less than truthful.  Feel free to GOOGLE Jonathan Gruber to become reacquainted with his 2014 comments which make reference to stupid American voters and other niceties.  How long did it take the Obamians to admit that the statement, “If you like your doctor, you can keep your doctor”, was known to be false from the outset?

Let’s face it.  The ACA promised us quality and cost control and in my view it has failed on both counts.  I do congratulate the president here, as I have previously, for taking on the challenge of health care reform.  Republicans over several presidential administrations failed to seriously confront this challenge.  And the plan does cover more Americans, which we all agree is a necessary goal.  But, the collateral damage of this achievement warrants a new direction, admitting that it may not be possible to uproot the entire tree.    

The replace part is going to be tougher than the repeal part.  Will the GOP take a lesson from their adversaries and jam it through without a single Democrat vote?

Sunday, January 15, 2017

Insurance Company Helps Patients Who Don't Speak English

When I was a kid, it was fun to get mail.  Now, not so much.  My mailbox at home is a receptacle for junk mail, various solicitations for services I will never need, and bills.  Office mail is not much more fun.  Each day I look through the stack and separate them into 3 categories.
  • Important stuff
  • Garbagio
  • Not sure

The latter category is the most vexing.  Some stuff is cleverly designed to appear important when, in reality it is drivel and nonsense.  We’ve all seen this stuff.  Sometimes, the envelope will include a teaser label, such as ‘Time Sensitive Material’, or ‘Signature Required’.   Once I have been duped to open up the envelope, I’ve lost the game.  Then, I am forced to scan the printed page as fast as my retinas can process the image with the hope that in a few nanoseconds I can send the page sailing into the waste bin.  Sometimes, however, even after reading the entire page, I simply can’t determine if the document merits calling an office meeting to discuss the contents or if it should be simply burned, with the ashes scattered over Lake Erie in a solemn ceremony.  One must choose wisely when facing these conundrums.  If a document is shredded instead of scanned into a patient’s chart, the potential consequences are simply too grisly for me to detail here on a blog that children can access.

I received a notification from a pharmaceutical company indicating that the heartburn medicine I prescribed so casually to an elderly patient was not the ‘preferred agent’.  These was a form letter which demonstrated the same level of warmth and human emotion that one expects when you call the Internal Revenue Service for assistance.  But, there was a 2nd page in the envelope, appears below.  Kindly note that I was able to technically reproduce the image here without the assistance of a 13-year-old child. 


This letter, sent to the patient, advises that customer service agents at WellCare are available to discuss the issue with the patient.  I am not certain if my patient intends to contact them, but my own experience is that making these phone calls is about as fun as undergoing oral surgery.  But, what struck me was all of the languages contained in the letter, many of which I could not recognize.  At the bottom of the letter is a Yiddish translation.  Yes, Yiddish.  Yes, the moribund language that many of our grandparents spoke.  I can’t speak it or read it, but I can recognize it.  Obviously, WellCare must include so many Yiddish speakers that they need to include this language in their correspondences.  My guess is that not a single Yiddish speaker is a WellCare customer.

Maybe, I am wrong and that Yiddish is roaring back.  Kudos to the linquists at WellCare for providing their customers with this essential service.  I may politely suggest that they include hieroglyphics on future mailings.  Why should these folks be left out?

So, was this letter worth saving?  Probably not, but I just couldn’t part with it. 


Sunday, January 8, 2017

Is Informed Consent Overrated?

Physicians now practice in the era of patient autonomy.  Most agree that the era of medical paternalism should not be resurrected.  During those days, doctors simply told patients what to do, and patients complied.  The informed consent process then was a shadow of what it should have been.  In general, physicians did not proffer medical options and alternatives for patients to ponder over.  They were told, ‘you need a hysterectomy’.
Sometimes, I think we physicians today have over-corrected for past arrogance.  Yes, I believe in informing patients, but I often wonder if many patients today really only want us to tell them which path they should pursue.  Even the most informed patients are not medical professionals who can grasp every medical nuance or ramification of a decision.  It can be vexing for them to choose among different medical options that are presented to them in an effort to meet our obligation to apprise patients of all reasonable treatment alternatives. 
Consider this scenario.
"You can proceed with surgery to treat your condition or try a new medication instead. The medication has risks and if doesn’t work, you can certainly have surgery.  Keep in mind that if surgery is delayed while you are trying the medication, it is less likely to be effective.  Additionally, the medical center downtown is doing experimental treatment for your condition.  Finally, some experts advise against any treatment, advocating watchful waiting instead.  What is your decision?" 
Not an easy labyrinth for a normal patient to navigate through.
Such a presentation is often followed by a patient asking, ‘what do you think I should do?’


What should I do?
I’m not advocating depriving patients of information they are entitled to in order to make rational health decisions.  I believe in informed consent and have written many essays supporting it on this blog and elsewhere.  However, I often believe that this process overwhelms patients and their families with competing choices that torture and confuse them.  As a statement of fact, many patients today are only seeking our best recommendation, even though physicians today go much further in an effort to meet our ethical obligation and to protect against a medical malpractice charge.  

I am very interested in what readers think on this issue.  Inform me, please.

Sunday, January 1, 2017

Happy New Year 2017!

The Whistleblower wishes all readers all good things for the coming year.  2017 will launch us into uncertain times where many of us are a mélange of hope, worry, fear, resignation, optimism, anger, skepticism, validation and self-doubt.  Will the ship of state sail straight and true or will we find the nation steaming off course into dangerous waters?   I suspect that it will not be simply one path or the other.  There will be times when we will stray and other times when we will more closely hit the desired target.  This is how every government, and indeed every person, lives and breathes.


Off Course or On Target?


We can accept the inevitable zigzagging with the hope and belief that the overall trend will take us forward. 

Let us celebrate our successes and exercise some forbearance when we or others miss the mark despite good intentions.

This blog enriches and challenges me and I hope it brings some small measure of delight to all of you.  Please continue to let me know (with forbearance!) when I have missed the mark.


I wish all of you well.

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