Sunday, May 28, 2017

Memorial Day 2017



Freedom is not Free.


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

Sunday, May 21, 2017

Why My Patient Will Quit the Military

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

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

Scales Tipped Against Him

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

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

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

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

Sunday, May 14, 2017

Patients Who Drink Too Much

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

Preparing One for the Road

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

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

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

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

Sunday, May 7, 2017

Should Physicians Provide Futile Care?

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

The Liver - Alcohol's Enemy

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

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

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

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

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

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

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


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