Sunday, October 14, 2018

The Antidote to Big Box Medicine - Private Practice

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

Village Hall in South Orange, NJ

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

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

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

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

Sunday, October 7, 2018

When Diagnosing Colon Cancer Might be a Mistake

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

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

Are we really just shooting dice?

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

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

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

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

Sunday, September 30, 2018

Kavanaugh versus Ford: Who Really Lost?

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

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

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

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

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

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

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

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

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

Sunday, September 23, 2018

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

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

Atonement is a tough business and I admit that I am no expert.  Consider how challenging this process is.
  • Personal reflection.
  • Acknowledging personal flaws and transgressions.
  • Approaching those whom we have wronged to make it right.
  • Forgiving those who seek our pardon with grace.
  • Committing not to repeat our offenses if placed in the same circumstance again.
Sounds easy?   Hardly.  Changing our traits and actions are very difficult.  Why do you think so many of us have the same list of New Year’s resolutions every year? 

But, change is possible.

Here are some actions that many in the medical profession might seek atonement for.  I am judging no one here, and I admit that as I construct this list that I am not without sin.
  • A diagnosis is missed because a physician was not sufficiently diligent.
  • Privileged health information was inadvertently disclosed.
  • A physician is habitually late and is indifferent to his patients’ time.
  • A doctor disparages a colleague.
  • A physician fails to return phone calls from concerned patients.
  • A doctor berates one of his staff who made an error.
  • A doctor berates one of his staff who did not make an error.
  • A doctor modifies a medical record for the wrong reasons.
  • An impaired physician does not seek professional assistance.
  • A physician has a lapse in his bedside manner and doesn’t demonstrate the empathy the patient deserves.
  • A physician thinks of his own interest over the patient’s interest.

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

Sunday, September 16, 2018

Artificial Intelligence and Medicine - Is Your Doctor Obsolete?

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

Man vs Machine

Increasingly, we see functions executed by machines that were formerly performed by living breathing human beings.  Examples range from the mundane to the preternatural. 
  • Order food and drink from an iPad.  No server needed.
  • Driverless auto travel.   This may lead to a resurgence in prayer.
  • Pilotless air travel.  Hard times ahead for the Airline Pilots Association. 
  • Making precision tools – from 3D printers.
  • Gourmet meals created with a voice activated command.
  • Theater and film productions starring faux actors created on keyboards.
Will artificial intelligence invade the medical arena?  The question is only how deeply it will invade.  The role of the traditional physician is at risk of being marginalized as computer software hits the profession hard.  Sure, computers cannot palpate an abdomen or perform a rectal exam – yet, but they can listen to heart sounds with much greater accuracy than a physician with a stethoscope can.  Additionally, as most practicing physicians know, the physical examination is much less useful than the patient’s medical history, although our medical school teachers and mentors always preached how critical the physicians’ eyes, ears and hands were.  Most doctors know what’s going on most of the time after carefully listening to the patient’s story, the medical history.

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

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

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

Sunday, September 9, 2018

Breaking News! A Cure for Baldness!

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

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

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

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

General Ambrose Burnside
Hair in All the Wrong Places

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

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

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

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

Sunday, September 2, 2018

Thoughts on Labor Day 2018

All work is honorable.   

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

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

Sunday, August 26, 2018

When Should You Have a A Screening Colonoscopy? Preventive Care and Personal Responsibility

A man I had not met came to my office prepared for one of life’s most joyful pursuits – a screening colonoscopy.   Perhaps, this experience gives truth to the adage, ‘it’s better to give than receive’.
This man was 70-years-old and was about to undergo his first screening study of the colon, an exam that experts and others advise take place at age 50.  Let me do the math for you; he was 20 years too late. 

I performed my task with diligence and removed a large polyp.   While I believe that the lesion was still benign, we gastroenterologists prefer to discover your polyps when they are small.   Smaller lesions are nearly always benign and are safer to remove.

Afterwards, I chatted with the patient and his wife and I expressed some surprise that there had been a two decade delay of his colonoscopy.   (Readers would be amazed and amused at the creative excuses I’ve been offered over the years explaining delayed colonoscopies.  A popular one is “I’ve been so busy!”, as if this could justify a 5-year delay.)

At this point, his wife interjected and expressed that ‘no one ever told him to get it done.’  I interpreted this as an effort to defend her husband’s delay and also to give a poke to the medical profession, who must have been derelict in its responsibility to advise him.

‘Not so fast’, I thought to myself.   Of course, I was going to be polite and respectful, but a push back was in order.

'My doctor never told me smoking was bad for me.'

While I agreed with her that his primary care physician should have made a timely recommendation to pursue colon cancer screening (which for all I know may have happened), surely her husband was aware himself that he needed a colonoscopy.   The medical profession and numerous health organizations have been diligent and effective over the past few decades educating the public about colon cancer prevention   Folks don’t need a doctor’s advice or reminder on this any more than they do to wear seat belts or bicycle helmets. 

Personal responsibility is a virtue and a responsibility.   I don’t expect my patients to know how to treat Crohn’s disease and Hepatitis C.   And, I do my best to make sure that their colons don’t escape my attention.  But, it not all on me.   Would it be reasonable for a smoker today to keep puffing away because a doctor didn’t counsel about cigarettes' health risks?

Sunday, August 19, 2018

Opioid Contracts for Chronic Pain Patients Threaten the Doctor-Patient Relationship

A contract is an agreement stipulating the rights and obligations of the signatories.  In most cases, a contract is consulted when a dispute arises.  When all is proceeding swimmingly, the contract remains dormant in a file drawer or in a digital file.  In general, decent people resolve differences in the old fashioned way utilizing the twin arcane legal techniques of reasonableness and compromise.  Remember them?  Yes, it is possible to settle disputes without consulting an attorney.

Settling a Dispute without a Lawyer

I learned recently about the existence of Opioid Contracts, an 'agreement' between a patient and a physician regarding the use of opioids.  I have read through various OC templates and, although I have no law degree, they seem extremely lopsided in that one party seems coerced to accept numerous stipulations while the other – the doctor – serves as the enforcer.  Although many of these agreements require both the patient and the physician to sign and date the forms, there really are no requirements of the doctor, except to provide the prescription. The agreements basically catalogue a very long list of required behaviors that patients must agree to and be prepared to document.  Here’s a sampling.
  • I will agree to random drug testing.
  • I will agree to cancel any office visit at least 24 hours in advance.
  • Only 1 lost opioid prescription will be replaced annually.
  • I will agree to psychiatric care and counseling, if necessary.
  • I will treat the office staff respectfully.
  • I will store my medicines safely.
  • I agree to waive any right to privacy or confidentiality if any law enforcement agency is investigating alleged misuse of my opioid medicines. 
To begin, it is not clear to me why “agreeing to cancel any office visit at least 24 hours in advance” or treating “the office staff with respect” is so unique to opioid users that it is included in some OC’s.  Explain to me please the relevance with respect to the opioid issue.  Why shouldn't these terms apply to all patients?

Of course, I understand the rationale behind these contracts.  But, this coercive effort seems like OperationOVERKILL.  To me, it seems like a humiliating experience for patients and risks eroding trust and weakening the doctor-patient relationship.  I would think that preserving and enhancing this relationship would be particularly important in caring for these patients.

If these medical diktats are truly necessary for opioid users, then why shouldn't every patient sign an agreement promising to take all medicines as prescribed, never arrive to the office late, refrain from disparaging the practice, never request a refill on a night or a weekend and limit their phone calls to the office to one per month.   How would patients react to this?  One advantage of this approach is that it would clear out doctors' crowded waiting rooms.

I don’t object to the content of the agreements; but I think forcing a signature on a written 'contract' is unseemly and unnecessary.  Medical care should not be rendered as a transactional business matter.

Physicians often rightly complain that our work is treated as a business by insurance companies and others.  With regard to Opioid Contracts, who deserves the blame?

Sunday, August 12, 2018

Refusing Medical Care for Children: Religious Freedom or Child Abuse?

I read yesterday in Cleveland’s main newspaper about the tragic passing of a 14-year-old girl.  She had cancer.   Why would this tragedy have been reported on Page 1?   As sad as a loss of a child is from a medical condition, this is generally not of interest beyond the family, friends and loved one.  This case was different.  The parents refused the chemotherapy that her doctors advised.  They wanted their daughter treated with herbs and feared that standard medication would worsen their daughter’s already precarious condition.   The parents believed that chemotherapy would violate their religious beliefs.

The parents sought another medical opinion from Cleveland’s other premier tertiary care center, which affirmed the original medical advice.

About 2 weeks ago, the parents received a court order mandating that their daughter receive chemotherapy.  Shortly afterwards, the daughter, who was already on a ventilator,  developed serious medical complications and died.

This case is a tragedy for all involved, as well as for the community at large.  I was so disturbed about reading the details about a desperately ill child with overlying tensions between parents, who I believe loved their child, and the medical and legal professionals. 

  Courts Practicing Medicine Guarantee Pain and Heartache

Yes, I believe that parents have rights over their children’s medical care including the right to refuse treatment, one of our bedrock medical ethical principles.  This is why we secure permission from parents before performing medical tests and treatments on their kids. 

But, I do not believe that this right is absolute, and there is no simple standard formula that we can rely on to guide us..

It depends upon the stakes.   Refusing Nexium for your child’s heartburn is not quite the same as refusing surgery for a burst appendix.   It also depends upon the age and maturity of the child.  A 17-year-old Jehovah’s Witness may be capable of making an informed decision to refuse a blood transfusion.  I doubt that a 3-year-old Witness has this capability.  Should Jehovah Witness parents of a 3-year old be permitted to refuse a blood transfusion that the doctors feel would save his life?   Can a parent refuse recommended vaccinations for their children believing them to be harmful?  If the child becomes infected with a vaccine-preventable condition, what about the health risks to others who might be exposed to them?   Where do the individual’s rights end and the community’s rights begin?

Do children who have not reached an age of maturity and understanding have innate rights that merit protection that may override their parents' rights to direct their children's medical care?    

While it’s best if the family and the medical team agree on a plan, I realize that this is not always possible.  When the stakes are life itself, the issues become raw and agonizing.  The sure sign of a system failure is when the courts become involved. 

Sunday, August 5, 2018

TSA Under Fire for Quiet Skies Program: A Lesson for Doctors?

Consider these behaviors.   A newborn calf nurses from his mother.   A robin places a worm into the gaping mouths of her offspring.   Cats know how to hunt.

These behaviors are examples of instinct.  The creatures do not even understand why they engage in these acts.  They are inborn behaviors. 

Animal Instinct

Humans have instincts also.   Unlike most professional standards and qualifications, instincts cannot be easily quantified or tested.  But, under certain circumstances, they are invaluable assets. 

We learned last week that the Transportation Security Administration (TSA) has been pursuing a program called Quiet Skies, when passengers who have met certain criteria are monitored for various behaviors that might suggest that closer scrutiny is warranted.   I am making no comment here on the merits of the program, but I am supportive of TSA using instincts of air marshals as a tool to evaluate threats.   Some have criticized this as an infringement on passengers who are not under actual suspicion or been charged with a crime.   But, if we strip instinct and suspicion from the armamentarium of our security services, then what is it exactly that makes these folks actual professionals?  Do we want ‘box checkers’ or real pros?

Of course, most of the time suspicions will not be borne out.  This does not mean, however, that the tool is invalid or that the target should feel victimized.  Before, we cry ‘discrimination!”, let’s consider what the stakes are here.  This is not an improper search of your car trunk; it’s blowing up an airplane.

I related to this issue since seasoned physicians rely so often on our instincts and sixth senses about our patients.   Every physician has said or thought throughout his career, ‘something is not right here’, even if all of the objective data seem to line up.  I think patients understand this and want their doctors to use their intangible skills along with their stethoscopes.   Frankly, it is these skills, in my view, that are amply present in our very best physicians. 

While you can’t teach these skills, doctors over time do develop them.  While younger physicians have much to teach us experienced practitioners,  we have a few things to offer them, at least that’s what my instincts tell me. 

Sunday, July 29, 2018

Where Have All the Republicans Gone?

For a few decades, I have assisted tens of thousands of patients in making medical decisions.  While the stakes may be higher in making a medical decision, the process is the same as would be used in making any decision.   Gather the facts.  Weigh the options.  Consider the respective risks and benefits.  If applicable, consider additional issues that may tilt the decision, such as cost, family or professional impact, personal priorities or cultural norms. 

Obviously, two individuals may share identical medical facts but decide differently – and both decisions may be sound and correct.

Our politicians and government officials should use the same process when faced with a political decision or a vote.  But, they don’t.   Sure, they engage in a risk-benefit analysis, but in a rather twisted manner.

Politician contemplating a vote:  “What is the risk to me if I vote for or against?”
Same politician contemplating a vote:  “What is the benefit to me if I vote for or against?”

In other words, our politicians focus much more on their interest than on ours.  Perhaps, that’s why their approval ratings are underwater.

Consider how the establishment GOP have been responding to the president’s steady stream of rhetorical and behavioral malfeasance.  In general, the responses have included silence, acquiescence, tolerance, deflection and even outright defense.  Yes, there are occasional murmurs of discontent, but these seem more aberrational than a coherent broadside.

'Hear no evil, see no evil, speak no evil.'

Interestingly, the GOP individuals who have been consistent critics of the president are from those who are not running for reelection.  Thus, it may be that these folks discovered their principles only when they became unshackled from a future campaign and election - not exactly a profile in courage.

Even some senate Democrats who are up for reelection in 2018 have been very reluctant to criticize the president as they are from red states who support Trump.  

Here’s a different way to approach the risk-benefit equation for politicians who won’t express their outrage.   What do they risk by speaking their mind?   They would not be risking their health or their freedom.  They would not be risking a financial catastrophe.   They would not be risking the respect of their colleagues or their own self-respect.   Yes, they might be risking their job.  The worst outcome of calling out a demagogue is that the voters would toss them out.  Is that such a cataclysmic event that is worth one's personal integrity?   And all of them are so readily employable, although the prospect of leaving the public trough seems downright unbearable to them.

Consider the benefits of speaking true.   I won’t insult my readers my listing them, as they are self-evident.

If you suspect that I didn’t vote for Trump, then you are correct.  And, if you suspect that I voted for Clinton, then you are wrong.

There are circumstances when it is sensible to keep one’s thoughts to himself.   Maybe the issue is not that important or the stakes of speaking out are disproportionately high.   This is not the case for current legislators who look away.  The stakes to the nation and to themselves do not justify their silence.

Sunday, July 22, 2018

Doctors and the Opioid Epidemic

I am against all forms of bodily pain, both foreign and domestic.  I wish the world were pain free.  When I am suffering from even a routine headache, I want immediate relief just like everyone else.  The medical approach to pain control has changed dramatically even during my own career.  When I started practicing a few decades ago, the strategy was pain reduction.  We gave narcotics for very few indications such as kidney stones, heart attacks and severe abdominal pain after a surgeon evaluated the patient.  (The reason for this was so the surgeon could obtain an accurate assessment of the patient’s belly before pain medicine masked the findings.) 

The new goal is pain elimination which I believe is one factor that has fueled the overconsumption of opioids, although there are other factors present.  I admit that I am opining on this as an individual who is blessed to be pain free.  I do not pretend or suggest that if I were afflicted with a painful condition, that I would not want whatever it might take to bring me relief.  In medicine and in life, the world looks very different when you are a victim.   Your view on health care reform, for example, might ‘evolve’ if you or a loved one is suddenly uninsured. 

But patients’ rising expectation of eliminating pain and the medical professions willingness to join in this mission has exacted a great societal cost.  I am not blaming anyone here.  Of course, patients want pain to go away.  Of course, physicians want to relieve suffering.  Isn’t a doctor’s mission to make his patient feel better?

Could this really result from a doctor's prescription?

The consequences of this approach have exploded.  Narcotics and opioids are addictive agents.  Any individual who takes these medicines over time risks addiction, which is a new disease.  In fact, the addiction may very well be a more severe illness than the original medical condition. When OxyContin (oxycodone) came on the scene in 1995 the drug company recommended it as first line treatment for chronic pain as well as for musculoskeletal pain, two conditions that today would not be initially treated with opioids.  Over a decade later, the pharmaceutical company accepted a guilty plea in federal court and admitted that it trivialized the drug’s addictive properties, along with other deceptive practices. 

Consider this sobering statistic.  The United States is about 5% of the world’s population yet consumes about 80% of the world’s oxycodone supply. 

When a doctor is prescribing opioids to a patient, which may be entirely appropriate, the physician and the patient must be mindful of how carefully this must be monitored and the addictive risks of prolonged use.   We must guard against creating a new disease – which may be fatal – which may result from unrestricted or inadequately monitored pain medication use. 

Ohio announced new rules recently that would limit opioid prescription for only 7 days for acute pain.  While I generally resist politicians interfering with medical practice, with thousands of overdose deaths in our state every year, I understand their need to intervene.  

Many heroin addicts today can trace their affliction back to a doctor’s prescription, which was given for the right reasons. 

The medical profession and the scientific community needs to triple down on research to develop new drugs and techniques that attack pain but leave patients protected from the ravages and misery of drug addiction. 

Sunday, July 15, 2018

Liberals Attack Brett Kavanaugh and Trash the Neighborhood

We live in frustrating and angry times here in America.  If you are not aware of this reality, then you are:
  • a newborn
  • a plant or an invertebrate
  • in heaven
  • comatose
  • on a deserted island sans electronic devices or wifi
  • living outside of the Milky Way
Peruse the front page of any newspaper or turn on any cable news channel.   You will read and hear about conflicts, outrage, investigations, accusations, threats and denials because this is what we desire and demand.  If we rejected such partisan and inflammatory reportage, the media would modify their content.   I do not accept that the media simply reports what is truly newsworthy; they produce their product to appeal to market forces.  Is Stormy Daniel's news value proportionate to the coverage she has received?  The reason that rags like the National Enquirer are successful is because we read them.

Beyond our collective appetite for darker and salacious content, we are also participants in the various tribal and cultural conflicts that are ongoing with no resolution in sight.  In other words, it's not all the media's fault.  For many interest groups and organizations, the mission is not to compromise or accommodate, but to vanquish and prevail.  Issues are viewed as a series of zero sum games – if you win, then I lose.   Of course, this is absurd. 

Ruth Bader Ginsburg was confirmed in a 96-3 vote in the Senate in 1993.   She was a known liberal, but Republicans properly supported her confirmation as she was qualified to serve.  Liberal presidents nominate jurists who are aligned with their philosophies.  Indeed, this should be a major consideration of voters when casting ballots in presidential elections.  Qualified nominees should be confirmed.  President Obama’s 2 Supreme Court Justices received Republican support, as they deserved.  Recently, Judge Brett Kavanaugh was nominated to assume Justice Anthony Kennedy’s seat.   Although his qualifications and temperament are unassailable, he has been vilified as if he is the anti-Christ.  Just because the Republicans inexcusably deprived Judge Merrick Garland of a hearing, does not justify perpetuating the dishonorable misdeed.  I wonder had President Trump nominated Moses, King Solomon or Jesus, if they would be similarly and summarily rejected by political opponents.

Moses - Clearly not Judge Material

Let me offer readers an oasis, albeit a brief one, from the chaos and the depressing morass that surrounds us.

Go and see Won’t You Be My Neighbor, a film that chronicles the life and work of one of our nation’s treasures, Fred Rogers.   He was an extraordinary human being, who inspired us with his deep humanity, compassion and love.   I found myself near tears during several moments of the film, and I continue to reflect on him his weeks later.  He was an antidote to hate and intolerance.  He made a difference.  We need him now more than ever.  See the film and you will also yearn to join his neighborhood.  

In today's era, if Fred Rogers needed Senate confirmation, could he achieve it?

Sunday, July 8, 2018

Insurance Companies Protect Patients or Profits?

A patient came to see me with lower abdominal pain.  Was she interested in my medical opinion?  Not really.  She was advised to see me by her gynecologist who had advised that the patient undergo a hysterectomy.  Was this physician seeking my medical advice?  Not really.   Was this patient coming to see me as her day was boring and she was bored and needed an activity?  Not really. After the visit with me, was the patient planning to return for further discussion of her medical status?  Not really.

So, what was going on here.  What had occurred that day was the result of an insurance company practice that I had thought had been properly interred years ago. 

The Insurance Reform Hammer - Locked and Loaded.

The woman had pelvic pain and consulted with her gynecologist.  An ultrasound found a lesion within her uterus.  A hysterectomy was advised.  The insurance company directed that a 2nd opinion be solicited.  A second gynecologist concurred with the first specialist.  The patient advised me that the insurance company wanted an opinion from a gastroenterologist that there was no gastrointestinal explanation for her pain.  In other words, they did not want to pay for a hysterectomy that they deemed to be unnecessary.
  • We should applaud the insurance company for its diligence to protect the patient from an unneeded surgery.
  • We should recognize that the insurance company is focused only on promoting medical quality with no concern for saving the company money.
  • We should cite the insurance company for industry excellence for facilitating smooth and efficient medical care.
  • We should tell the obvious truth about what is actually going on here.
This woman’s treatment plan, as recommended by two gynecologists, was halted by a bureaucrat who likely had less medical training than they did.  I surmise that not enough ‘boxes were checked’ on the submitted paperwork to permit the recommended surgery to proceed.   The insurance companies, of course, claim fidelity to a medical quality mi$$ion.  How would they like to be subjected to the same absurd level of scrutiny and oversight that they wield over us?  When the reform hammer comes down on the insurance companies,  my patient might be holding up a sign or a pitchfork, but it won't be to stand up for them.

Sunday, July 1, 2018

Happy Fourth of July

Let's pause for a few moments, amidst the chaos and cacophony of a society tearing at each other, when we shout more than we listen, when we foment more than we forgive and when we hate more than we heal to recall the promise of a nation that was founded with noble ideals as it journeys to form a more perfect union. 
The Whistleblower 

”I am apt to believe that it will be celebrated, by succeeding Generations, as the great anniversary Festival. It ought to be commemorated, as the Day of Deliverance by solemn Acts of Devotion to God Almighty. It ought to be solemnized with Pomp and Parade, with Shews, Games, Sports, Guns, Bells, Bonfires and Illuminations from one End of this Continent to the other from this Time forward forever more.”

John Adams

Sunday, June 24, 2018

Do Insurance Companies Care About Patients or Profits?

Readers know of my hostility toward overdiagnosis and overtreatment.  I maintain that there is probably twice enough money as needed to reform the health care system if unnecessary medical care could be eliminated.  (Yes, I am including colonoscopies in this category!)   The challenge, of course, is that one person’s unnecessary medical care is another person’s income.  

One institution that is routinely demonized are medical insurance companies.  They are described as Houses of Greed who put profits ahead of patients by design.  Every physician who is breathing can relate tales of woe describing frustrating obstacles that insurance companies place before us and our patients.  When one of my patients receives a ‘denial of service’ notification, I am always prepared to discuss the patient’s case with a physician at the insurance company, as this provides an opportunity for me to explain the nuances of the case to a colleague. 

Take the following quiz now.

Which of the following tasks is most difficult to accomplish?
  • Getting an upgrade from ‘coach’ into first class of the plane for free.
  • Calling the IRS to get some personalized advice from a living, breathing human being.
  • Understanding your medical bill.
  • Solving your internet malfunction by consulting the company’s ‘FAQ’ page.
  • Reaching the medical director of a medical insurance company.
Alexander Graham Bell's First Call to Insurance Co Doctor
'Sorry, Wrong Number.'

I know that these companies have medical personnel on the payroll, but finding them requires assistance from intelligence professionals.  They likely arrive at work in disguise and work in a secluded office behind a door labeled ‘Maintenance’.  Years ago, while I didn’t actually connect with a live physician, I was afforded the opportunity to leave my phone number on a voice mail.  If the physician did deign to return my call, it was never at a time that I was available to converse.  Since I do procedures every day, round at the hospital and have a few offices, the probability of the physician reaching me with a single call was equal to the chance that you will be served Surf ‘N’ Turf on your next airline flight.

Yeah, I know I sound frustrated, and writing this blog post has released some of the pressure.  In fairness, there are many times that the medical community and the public take advantage of the insurance companies.  I will share some thoughts on this in an upcoming post. 

If you need to call a doctor, take my advice.  Don’t call the one who works for your insurance company.  Try something when the odds will be more in your favor.  Play the lottery.

Sunday, June 17, 2018

Ohio Limits Opioid Precriptions - The Journey Begins

I have written previously about the raging opioid epidemic here in Ohio.  Attacking and reversing this tidal wave will require many weapons, resources and time.  Opioid addiction is a crafty and elusive adversary that will be difficult to vanquish.  Our battle plan will have to be nimble and adjusted over time, much as military leaders must do in actual armed conflict.

Here in Ohio and elsewhere, physicians must abide by new prescribing restrictions.  Prior to prescribing a controlled pain medicine, doctors are required to check the patients OARRS report on line, which catalogues the patient’s prescription history.  This would alert us if the patient was receiving controlled medicines from various pharmacies that the patient might not disclose to us.  Physicians and the public are encouraged to seek non-narcotic alternatives for pain relief.  If opioids are prescribed for acute pain, there is now a limit on the length of opioid treatment that is permitted.  There are exceptions which require additional physician documentation.  The above restrictions do not apply to chronic pain or pain suffered by individuals with cancer or are in hospice.  Importantly, these rules do not apply to medication-assisted treatment of opioid addiction.

Cure for Addiction Advertised over a 100 years ago.

There has been opposition to the above regulations from patients with chronic pain who are having difficulty getting their pain medicine prescriptions filled.  They are being turned away by their doctors, or told to consult with pain management physicians who have expertise in this discipline.  These specialists are extremely busy and it can be very challenging for patients to secure a timely appointment with them.  For a patient with chronic pain, this can be a vexing and agonizing situation.  And, if this patient proceeds to the Emergency Room, these physicians may be understandably reluctant to accede to a patient’s request for controlled pain medicines. 

I think and hope that these issues will sort out.  One can’t expect that new reforms will be flawless from the outset.  Perhaps, the net we are using now to restrict pain medication use is overly wide, as many initial proposed solutions often are, but we will narrow it with more time and experience. 

There is no law, regulation or policy that does not cause friendly fire casualties or undesirable outcomes.   Our criminal justice system, for example, demands a not guilty verdict, even if an individual has committed a crime if a designated proof standard has not been reached.  Society has accepted a balance in the courts and elsewhere.  We reject using a wider judicial net that would capture more criminals but would ensnare too many innocents.  It's an imperfect system by design.

Since no system is perfect, we should not aspire to achieve this standard.  We have to tolerate some level of error and fallout.  Similarly, the medicines that doctors prescribe are deemed by the Food and Drug Administration to be safe and effective, but we all know that they are neither 100% safe nor effective.

Our opioid strategy is a work in progress.  Surely, we all agree on the destination.  But, the path to reach that point will be marked by many pitfalls, slippery slopes and difficult terrain.  

Sunday, June 10, 2018

Teaching Empathy in Medicine - Lessons from an IV Drug Abuser

We’ve all heard the excuse or explanation that ‘it’s society’s fault’, to explain someone’s failure.  We hear expressions like this often when an individual has committed a crime or simply failed to succeed.  Personal accountability is diluted as we are told that this person came from an imperfect home, had no role models or ample education.

These arguments are often wielded by those who have been favored with society’s blessings and advantages.

As readers here know, I am not politically liberal and regard myself as an independent who usually votes for Republican candidates.  I did vote for Senator Sherrod Brown, one of the most liberal members of the U.S. Senate, a fact that astonished friends and family, as I had concerns about the character of his opponent that I could not overcome.  I am proud of this vote. 

Were you born next to a ladder?

A 19-year-old female was sent to me to evaluate hepatitis C.  She was unemployed.  She had used intravenous needles years ago and resumed using them a few weeks before she saw me.  Hepatitis C was not the immediate medical priority here. 

I felt that I was facing an individual who inhabited an alternative universe from mine.  While I am speculating, I surmise that she faced choices through her life that I never had to confront.  What narrative, I wondered, could this young woman have had that would lead her to her present destination, where she would be self-injecting poison into her body?   I am not relieving her of personal accountability for the decisions that she has made.  Adverse circumstances do not guarantee failure.  Indeed, we all know phenomenal people who have overcome incredible adversity and long odds to achieve and inspire.  I wish that their methods were contagious.  The woman before me, at least so far, was not one of these individuals.

Perhaps, she came into this world unwanted and unloved.  She may not have had adults in her life to build her self-worth and to help guide her.  Maybe, education was a closed pathway for her.  What caliber peer group was available to take her in to soothe her rejection? 

My point is that it’s always easier to judge someone’s failures from higher ground.   Would many of us have reached higher ground if we weren’t born with a ladder that was set up beside us to ascend? 

I’m all for personal responsibility and accountability.   I’m also making a case for empathy, a virtue that has not always been as strong as it should have been in my own life.  

If our ladder breaks and we crash, how would we like to be treated?

Sunday, June 3, 2018

American Cancer Society Wants Colon Cancer Screening at Age 45

Until last week, colon cancer screening for most folks started at age 50.  Why 50?   Why hadn’t the colonoscopy coming of age been set younger to prevent the tragedy of a 45-year-old, or an even younger person, developing colon cancer?   In the past 2 weeks, I had to give a young patient and his wife the sad and serious news that he had colon cancer.  Because of his young age, he never received a screening colon exam, as we routinely do with 50-year-old individuals.  Is it time to make an adjustment?

Our colon cancer screening system is not perfect.  It is not designed to prevent every case.  There have been people in their 20’s who have been diagnosed with this disease, and there is simply no way to capture them in the system.  Experts in disease prevention must carefully analyze disease trends and behavior to find the sweet spot of when to begin screening.  And, money is part of this decision.  Let’s face it.  We don’t have unlimited resources to pay for every worthy medical benefit. 

Determining when to recommend mammography, and how often this test should be done, is a very similar issue.

What Starting Age for Screening is a Bullseye?

Colon cancer prevention experts had believed that age 50 was the proper starting point for screening.  Delaying until age 55 would leave too many people at risk, and starting earlier would save too few folks and wouldn’t be worth the cost or effort.  That is, until now.  The American Cancer Society (ACS) issued new guidelines last week recommending that colon cancer screening start at age 45, a radical change from established dogma.  The reason is that colon cancer in younger people has become more common.   Keep in mind, this recommendation did not emanate from a gastroenterology (GI) organization who might be expected to endorse any system that would benefit GI practitioners like me.   The ACS revised its colon cancer screening guidelines on the merits.  We await responses from other respected medical organizations on this issue.  And ultimately, insurance companies and the government will have to buy in to this proposal.

This bold recommendation, if universally adopted, will save lives.  Maybe yours will be one of them.

Sunday, May 27, 2018

Memorial Day 2018

I never served in the military.  My father served for 39 months during World War II, but was never in harm's way.  He was in the navy, stationed in California.   Had President Truman not ended the war in Auguts 1945, I think it is likely that he would have been sent to join in an invasion of Japan.

Because I have not served, and no one in my close circle is in the military, it is difficult for me to grasp the full depth and meaning of Memorial Day - a day that the nation honors and remembers its sons and daughters who have served, been wounded and have fallen.

Arlington National Cemetary

I try to connect with the experience as best as I can.   I watch, I read and I listen.  I recently watched Ken Burn's monumental documentary, The Vietnam War, trying to absorb its lessons.  But, I realize that I am still a spectator who will never comprehend the experience as the actual participants and their loved ones appreciate.

I have been honored to have served many men in The Greatest Generation.  One man fought in the Battle of the Bulge, one was wounded on Iwo Jima and another was in Pearl Harbor on December 7th, 1941.

While we can never fully repay the debt that we owe to our veterans and to those in active service today - nor do they ask for this - we can pause together to remember and honor them all.

Sunday, May 20, 2018

Are Clinical Trials Safe? The Risks of 'Medical Research'.

The day before I wrote this, I read about a ‘research’ fiasco where 3 individual were blinded after receiving stem cell injections into their eyes.  This ‘research’ was done in a physician’s office and cost each patient $5,000.   What a tragic outcome.  At least two of these patients discovered that this treatment was available by clicking on, a name that suggests government approval, which is not true.  Clearly, the name of this website is deceptive.  Neither the Food and Drug Administration (FDA) or the National Institutes of Health had any endorsement or sponsorship role here.  Moreover, press reporting indicates that these patients had scant medical evaluation prior to and following the medical procedure.

Note to readers:
  • Legitimate clinical trials generally do not charge patients for participation.
  • Legitimate clinical trials have intensive evaluation to screen patients for eligibility.  Many or most patients may be excluded because of specific requirements of the study.  Adhering to these requirements is what helps to make a medical study valid.
  • Legitimate clinical trials have a rigorous informed consent procedure.
  • Legitimate clinical trials have aggressive follow-up after the experimental procedure so that results and adverse reactions can be measured and recorded. 
  • Legitimate clinical trials aim to publish their results in peer reviewed journals.
Ophthalmologists have commented that injecting both eyes with an experimental treatment on the same day is an obvious deviation from acceptable  research practice.  Think about it.  Wouldn’t you want to inject only one eye at a time for reasons that need not be explained?

The Human Eye - Handle with Care!

 Like every doctor, I prescribe medications and treatments that are not approved by the FDA, a practice which the FDA supports.  Much of my advice is based upon my knowledge and experience, and may not be supported by sound medical evidence.  This is not because I am a quack, but because we don’t always have medical evidence for a patient’s particular medical issue.    Should we tell such a patient to return in a decade or two when the supportive evidence is available, or should we use our medical knowledge and judgment as best we can to address the current issue?

However, if I am prescribing a medicine to you off label, meaning for a purpose not officially approved by the FDA, I won’t call it ‘research’ or refer to it as a ‘clinical trial’.  It’s simply an ordinary day in the practice of medicine.  

Sunday, May 13, 2018

Who Should Get the Liver Transplant?

People with liver failure and cirrhosis die every year because there are not enough livers available.  Who should receive the treasured life-saving organ?  There is an organ allocation system in place, which has evolved over time, which ranks patients who need liver transplants.  Without such a system, there would be confusion and chaos.  How can we fairly determine who should receive the next available liver?  What criteria should move a candidate toward the head of the line?  Age?  Medical diagnoses? Insurance coverage? Employment status?  Worth to society?  Criminal record?

An artist's rendering of the liver from the 19th century.

Consider the following 6 hypothetical examples of patients who need a liver transplant to survive.   How would you rank them?  Would those toward the bottom of your list agree with your determination?
  • A 50-yr-old unemployed poet is an alcoholic.  He has been sober for 1 year.  His physicians believe he will not survive another year without a transplant.
  • A 62-yr-old prisoner has end stage liver disease from hepatitis C, contracted from prior intravenous drug use.  He has been showing serious medical deterioration and his physician is concerned that his demise approaches unless he undergoes a liver transplant.  He will be incarcerated for life.  He is taking college classes pursuing an undergraduate degree.
  • A 45-yr-old piano teacher has a malignant liver lesion.   Her physicians have advised a liver transplant. Although the survival rate for a liver cancer transplant is reasonable, it is lower than for sober alcoholics or hepatitis C.   There are no other effective treatments available.  Her prognosis with standard medical treatment is dismal.
  • A 40-yr-old has end stage liver disease of unclear cause.  Liver transplant would likely save his life.  He is self-employed and has no medical insurance. 
  • A 60-yr-old hedge fund operator needs a new liver to survive.  He is concerned that according to medical criteria, he will not be given a liver soon enough.  In exchange for a liver, he offers to donate $5 million to the medical institution to fund cutting edge research in treating liver disease.  This research has the potential improve the lives of thousands of individuals.
  • A 55-yr-old is trying to get a liver transplant for his child.  In exchange for preferential treatment, he will stipulate that several family members will agree to donate various organs upon death.
How should the ranking decision made?  What factors should be weighed?  Ability to pay?  Worth to society, assuming this could be calculated?   Probability of long term survival?

Every one of these 6 individuals has a right to receive a new liver, but some of them will be left aside because others will be judged to have a greater right to a transplant. When any decision is made that creates winners and losers, the system will be challenged and attacked by those who decry what they believe to be an unfair process and outcome.  It is for this reason that transplant policy be made primarily by those who are as free as possible from agonizing conflicts of interest. 

A conflict of interest understandably taints our views.  For example, we may be against paying ransom for kidnapped hostages, until our kid is taken hostage.

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