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 ClinicalTrials.gov, 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.

Sunday, May 6, 2018

Opioid Deaths in Ohio - Hell in the Heartland


We are working hard to bend the curve of the opioid crisis here in Ohio.  The cause of the crisis is complex and so is the remedy.  Statistics examining the last several months have not yet been released, but the trend over the past several years is very troubling.  When I first learned that Ohio was the epicenter of opioidmania, I was quite shocked, as I wrongly thought that this plague would spare the heartland.  In contrast, it seems the heartland is ground zero.  While I have no specific expertise in addiction medicine or sociology, here are my speculations on some of the contributors to the current crisis.
  • Aggressive marketing by pharmaceutical companies.
  • Deceptive marketing by pharmaceutical companies claiming non-addictive potential of their products.
  • Economic decline and hopelessness.
  • Increasing expectation by the public of a pain free existence.
  • Physicians prescribing opioids, rather than non-addictive alternatives, in response to a new prescribing culture for these agents.
  • Physicians writing opioid prescriptions containing more pills than necessary.
  • Increasing availability of affordable, illicit opioids.
 Ohio overdose deaths were 3613 in 2016 and 5232 for the 12 months prior to June 2017.



A popular bromide is to accuse the medical profession of spawning the crisis.  While my profession clearly bears responsibility here, I think the causes are multifactorial.  The reason it is so important to have a clear understanding of all the causes is that this is essential to successfully formulate a strategy to combat the epidemic. 

It is a much easier task to prevent addiction than it is to treat it.  While I support treatment efforts, experts have told me that the probability that an opioid addict can conquer the addiction is rather dismal.  We all have heard vignettes of addicts who are revived multiple times by paramedics with naloxone, who immediately afterwards return to their addiction.  If fact, some individuals have raised the question if there should be a limit on the number of times that an individual should be revived.  I am not supporting this effort, but merely reporting on it here.  However, city budgets have limited resources.   How might a city’s residents respond if someone died of a heart attack because the paramedics were treating an overdose victim for the 5th time?  

This is going to be tough work, but I think it’s a battle we must wage.  Moreover, I truly believe that real progress is possible and is ahead.   If we are all pushing in the same direction, then we can start to bend the curve. 





Sunday, April 29, 2018

A Rare Cause of Rectal Bleeding

‘I can’t stand the site of blood!’  We’ve all heard that adage.   Blood can provoke emotional reactions from even steely muscle-bound bodybuilders.  We gastroenterologists routinely receive fearful phone calls from patients who have observed even minor rectal bleeding.  Fortunately, in most of these cases, there is a benign explanation for the sanguinary seepage.

If blood repels you, then gastroenterology should not be on your short, or even long list of professions under consideration.  We confront blood every day.  Of course, blood is the elixir of life as it courses into every remote recess of our bodies.  But, when blood loses its bearings, takes a wrong turn, and emerges errantly from our gastrointestinal tract, then gastroenterologists - or G-men -are called in.   Indeed, searching out the site of blood leakage in patients is one of our primary diagnostic tasks.  You might say that blood is our ‘bread & butter’.

I recently evaluated a patient in my office that confounded me and my staff.  Collectively, we have seen thousands of cases of internal bleeding, and yet we had never seen such a case as this before.  Will our discovery be a game changer in my specialty?  Should I publish this case in a medical journal to alert other practitioners of our groundbreaking discovery?  Should I start out on the lecture circuit?

Here are the facts.

A young woman underwent a colonoscopy in my office to evaluate abdominal pain and other digestive complaints.  There was no rectal bleeding.  Yet, during the colonoscopy there was blood throughout her colon, an entirely unexpected finding.  Now, we physicians are trained to deal with unexpected eventualities, but we are as surprised as anyone when we confront an unanticipated situation. We like stuff to make sense.   Suddenly, I needed to add diagnostic considerations to explain this surprising finding.  I assiduously searched with my scope for the origin of the bleeding, but I could not identify any lesion.

At that moment, I realized what must have occurred.  This patient, against our instructions, must have mixed the laxative with a red beverage, which was now masquerading as blood.  I smugly shared this hypothesis with my staff and dispatched a nurse out to the waiting room to ask the mother about pertinent laxative details.  The nurse returned informing us that the patient mixed the laxative with a blue beverage.  My smugness evaporated.  What is happening here?

After the patient was recovering and awake, we inquired about any ingestions that she did not previously disclose.  At that moment, she offered a full confession.  At midnight, she reached for a snack that we will now add to the list of forbidden foods prior to undergoing a colonoscopy.  Mystery solved.



We considered having her wear a scarlet letter as penance for her culinary sin.

Sunday, April 22, 2018

Warning! Coffee May Cause Cancer!


Are you getting a little tired of being warned that all kinds of stuff you do is unsafe?  I wrote a post recently about Warning Fatigue with regard to our office’s Electronic Medical Record which I fear will emit a flashing Red Alert if I prescribe a patient an aspirin.

Now, I start every morning with a steaming cup of coffee.  In fact, there is one beside me right now, as I peck about my Dell keyboard to create this post.  My inner circle of intimates and those with whom I share a high percentage of DNA, are aware that I add something to the java, which is a rather atypical additive.  Curious readers may inquire further, although I cannot pledge here that I will make a full disclosure.   Persuade me to disclose, and I will give your request due consideration..

Recently, a judge in California ruled that various coffee companies, including Starbucks, must issue a cancer warning regarding a component of coffee called acrylamide  Violators would be subject to a mere $2,500 daily fine until the establishment complied.  Should Starbucks file for bankruptcy?  Or, better yet, can we sue the coffee companies if we become ill?  What about the fear of becoming ill?  Shouldn't that be compensable?

You might think that this warning could discourage sales since most folks, including me, are against cancer.  But, most folks, including me, shrug off dire warnings on substances and activities that have become part of our daily lives for hundreds of years.  And, calling something a carcinogen – which sounds scary – does not mean it is truly toxic. It may in theory pose a risk that is simply too infinitesimal to take seriously.  For example, if some laboratory rodents (the most unlucky creatures on the planet) are given the equivalent of 500 cups of coffee a day for a year, and they develop tumors, should we humans be concerned because some element of the java may be a carcinogen?

Arsenic in Disguise?


More confusing is to consider all of the putative health benefits of coffee, which even a rudimentary Googler such as myself quickly uncovered.   There are claims, for instance, that coffee can protect us against diabetes, Parkinson’s disease, dementia, depression and liver disease.  Perhaps, we should increase our coffee intake to protect ourselves.  

If we avoided every substance that an organization claimed to be risky and injurious, we would have to live in a hermetically sealed chamber receiving specialized feedings through a tube.  Doesn’t that sound like fun?

What if some organization decided that oxygen was toxic and needed to be avoided?  How long can you hold your breath?
                                                                                                                                               


Sunday, April 15, 2018

Why I Now Treat Hepatitis C Patients


In a prior post, I shared my heretofore reluctance to prescribe medications to my Hepatitis C (HCV) patients.  In summary, after consideration of the risks and benefits of the available options, I could not persuade myself – or my patients – to pull the trigger.  These patients were made aware of my conservative philosophy of medical practice. I offered every one of them an opportunity to consult with another specialist who had a different view on the value of HCV treatment.

I do believe that there is a medical industrial complex that is flowing across the country like hot steaming lava.  While I have evolved in many ways professionally over the years, I have remained steadfast that less medical care generally results in better outcomes. 



A Scouting Patrol of the Medical Indutrial Complex

There was an astonishing development in HCV treatment that caused me to reevaluate my calculus.  New treatment emerged that was extremely safe and amazingly effective.  Now, nearly all patients with HCV can be cured by taking pills – no injections – that only rarely cause side effects.  Over the past 2 years, I have had many successes treating patients who on my advice had declined prior treatment options.

If you now have HCV, how can you refuse a safe medicine that works superbly?

This has been a game changer and the pharmaceutical companies should be congratulated on these breakthroughs.  There are several outstanding drugs currently available.  Initially, a 12 week course of treatment cost about $1,000 a day, clearly a pricey option.  And, if you believe that every HCV patient in the country should be treated, which may be up to 5 million people, do a cost calculation which might crash your computer.

To those who demonize the pharmaceutical industry for sport, would such a monumental research effort have even been undertaken without the promise of a huge profit?  Would you take a huge risk in your business without the hope of realizing a robust profit?  It takes years and tens of millions of dollars to do drug development, and most of these efforts fail either along the way or after the drug has hit the market and safety concerns arise.  

I’m not suggesting that this industry is filled with Eagle Scouts.  We have all read about numerous excesses and even illegalities in the drug trade.  But, if we want real pharmaceutical breakthroughs, and not just another heartburn or hypertensive medicine, then we need to provide incentives for undertaking this research. 

Market forces have substantially lowered the cost of HCV treatment, but it is still expensive.

Patients come to my office already informed about current HCV treatment.  Many are referred to me by physicians expecting me to treat them.   The drugs are safe and effective and approved by the F.D.A.   Although I still feel we are overtreating, my arguments for holding back have been somewhat dismantled by the new pharmaceutical developments.  Am I now at the vanguard of the Medical Industrial Complex?

Sunday, April 8, 2018

Avoiding Drug Interactions and Side Effects - Be Warned!


Eons ago, there was a television show where a non-human character would yell out, ‘Warning’, Warning’, when he sensed imminent danger.   The series was called Lost in Space where we were entertained by a set of quirky characters on a cheesy set.  We loved that stuff.  It’s hard to imagine today’s millennials and younger folks being transfixed, as we were, with the deep television dramas of our day.  Who could match the subtle allegory and nuance of shows such as Green Acres or Gomer Pyle?  Some superficial viewers regarded The Andy Griffith Show as a homespun, idyllic view of small town America.  In truth it was a biting satire on the excesses and abuses of law enforcement in the 1960’s.


Robot and Dr. Smith


I am overwhelmed with the warnings that I receive in my work and in my life.  It seems that warnings, caveats and disclaimers are so omnipresent that they have lost their impact.  As I write this, I am seated in McDonalds, sipping a cold beverage that does not quite qualify as a nutritive elixir.  Had I chosen a steaming hot ‘cup of joe’, I’m quite certain that the beverage’s container would warn me that it contains a hot beverage.  Such a warning, of course, is of great benefit to the consumer, who would behave entirely differently equipped with the knowledge that his hot coffee is actually hot. 

With some regularity, when I prescribe a medication using our office’s beloved electronic medical record (EMR), a red warning flashes indicating that there is a potentially severe interaction with one of the patient’s current medications.  The intensity of the warning would suggest that I was prescribing cyanide or rat poison.   Our EMR allows me to bypass the warning and prescribe anyway, leaving this action memorialized in the EMR and available to plaintiff attorneys who might be in a position to query me on this decision, should an adverse medical event ensue. 

Now, I take these warnings seriously and would never place a patient at risk, unless the medical circumstances justified it, and the patient was properly informed.  My point is that many of these electronic warnings are hyperbolic, if not spurious.  Many times when I call a pharmacist – a human drug professional – in the presence of the patient, I am advised that there is no material risk.  In fact, the last time I did this just a few weeks ago, the pharmacist assured me that there was NO risk of an interaction.  I always document these conversations in the record and hope that the truth would set me free, if necessary. 

I cannot explain why the EMR’s software is set so sensitively.  I suppose I could investigate raising the threshold for issuing an apocalyptic warning, but then I might miss some actual legitimate warnings.

Do you think that all of the warnings we read, hear and trip over are issued to protect us or the companies and organizations that issue them?

Sunday, April 1, 2018

The Joy of Appealing a Medical Insurance Company Denial

A few weeks ago, I saw a patient with some gastro issues.  So far, nothing newsworthy here since I am a gastroenterologist.  I ordered a CAT scan colonography, a special CAT scan that is designed to view the colon in detail.  It’s the CAT scan version of a colonoscopy.  Why didn’t I simply perform a colonoscopy, which, unlike a CAT scan, would contribute to the Whistleblower Retirement Fund?  That’s an easy one.  Care to take a guess?
  • The patient refused to undergo a colonoscopy.
  • The patient had no insurance and I don’t work for free.
  • The patient is a ‘cat lady’ and loves all things CAT.
  • The CAT scan was a better tool than colonoscopy to explain her symptoms.
Playing Cat & Mouse with Insurance Companies

I expect that my discerning readers can identify the correct choice.  I ordered the CAT scan because it was the best option for the patient, which the insurance company summarily denied.  I called the insurance company (always a fun and amusing exercise) and spoke personally to a physician reviewer and explained my rationale, but his decision was immutable.  I asked if there was additional recourse available to me, and he advised that I could request a ‘peer-to-peer’ discussion, when I could discuss the case with another physician.  My suspicion was that this doctor no longer treats living, breathing patients.  He seemed to be reading off insurance company cue cards.  He projected less humanity than is present in the ubiquitous mechanical utterances of “Your call is important to us.  Please listen carefully as our menu options have changed…”

I will summarize the conversation in the following two bullet points.
  • Insurance Company Tool:  “We can’t approve the test as you have not provided any objective evidence that there is a problem in your patient’s colon.”
  • Me: “I agree.  That’s why I am ordering the CAT scan.   If I knew in advance what was wrong with her colon, thenI wouldn’t need to order the test.  Get my point?”
He then issued Denial #2.   Had I recommended that my patient undergo a colonoscopy – not the best choice for her – it would have sailed right through.  But, for reasons I ask readers to trust me on, this wasn't the right choice for her.  This patient will be seeing me later this month and I look forward to updating her on how her insurance company’s mission is to protect her health. 

If insurance companies care only for profits, then they should at least have the decency to tell the truth.  Look the patient in the eye, the person who’s been paying premiums for medical coverage, and tell her that you won’t pay for the test because their box-checking process has determined that it is not medically necessary.  What would happen if the patient decided to stop paying premiums because it wasn’t 'fiscally necessary'?  Since the insurance company denied medical care to a paying customer for care that her own physician believed is necessary, then I assume that they would continue her medical coverage even if she stopped paying her premiums.  Should there be one standard at play here?  You may start laughing now.

Comments invited. 


Sunday, March 25, 2018

Hepatitis C - Silent Killer or Innocent Bystander?


For a few decades, I did not treat patients with Hepatitis C (HCV) infection, despite aggressive marketing by the pharmaceutical companies and cheerleading by academics.  I was an iconoclast as most of my gastroenterology colleagues were HCV treatment enthusiasts. They argued that if the virus could be eradicated, that there was evidence that these patients could avoid some horrendous HCV complications, such as cirrhosis, liver failure and cancer of the liver.

I’m certainly against cancer and liver destruction, but I have thought that the evidence that HCV patients who vanquished the virus would be saved from these fates was somewhat murky.  Treatment proponents would argue that the medical evidence for thes claims is solid, but I wonder to what extent their favorable bias toward treatment influenced their judgment.  We physicians know that a doctor or a drug company will seize on  particularly studies that supports their views.  Studies that challenge their beliefs may be criticized for 'study design flaws' and other defects.  I am generalizing here, but we all know how we tend to pursue confirmation bias, seeking out sources and opinions that support what we already think. This is not quite a pursuit of the truth.

Additionally, there is a well-known phenomenon called publication bias when favorable treatment results are more likely to be published than negative treatment results.  In other words, a study that shows a drug is effective is more likely to be published than a study that shows a failed result. This means that physicians like me who read medical journals may receive an over optimistic view of drugs because of this cherry picking.

In my 30 years of practice, I have never had any of my untreated HCV patients develop any measurable deterioration of their liver status.   In fact, nearly all of them were asymptomatic and felt
entirely well. 



Illustration of the liver created 100 years ago.


Consider these facts:
  • Most patients with HCV are not ill.
  • HCV is not easily transmissible to other individuals.  It is spread via contaminated blood, such as with sharing IV needles.
  • The majority of HCV patients will never develop liver cancer or liver failure.
  • The majority oF HCV patient have had the infection for decades and remain well.
  • Until recently, HCV medications had very limited efficacy and had numerous complications.
Like all of you, I harbor my own biases.  I am a very conservative practitioner, as readers know well.  I am never among the first to jump aboard the New Treatment Train.

Until groundbreaking HCV treatment emerged in recent years, I had been unable to convince myself, let alone my patients, that they should accept a complex medical regimen that included injections, that didn’t work well and would make them feel sick.   

While my academic colleagues would have accused me of nihilism, not a single HCV patient in my practice has seemingly progressed.  (Of course, my academic friends would claim that many of my patients may have 'silently progressed' even though they still feel well.)   There is always a medical argument a physician can wield to justify his or her recommendation or belief.

I'm not claiming that my view here is the only legitimate one.  I do suggest that it deserves to be heard.

In an upcoming post, I will share why I have jumped, with some reluctance, into the HCV treatment arena. 

Sunday, March 18, 2018

Thousands of High School Students Protest Gun Violence - Should We Give Them a Free Pass?


This past week high school students across the country walked out of school for 17 minutes to show solidarity with the 17 fallen Florida students and their families. There is not a human being among us who disagrees with their mission, except for a few deranged and cowardly murderers.  These kids are crying out for more restrictive gun laws.

Although I will offer a controversial view below on the walkout, let me say with clarity and sincerity that I am proud of these kids.  Since the horror in Florida, I watched them speak to us with passion, poise and eloquence.  While many of us may not agree on the best path forward, we can all agree that we have great kids in this country.

These kids are right and have a right to demand to be safe. Schools have always been an oasis for our children, places where they are to be nurtured, educated and protected.  I know that there are many teachers who would serve as a shield for their students in any situation, as they have so nobly demonstrated. 


Safe in School

Some public and private schools have  authorized the demonstrations, assuring the kids that no disciplinary action against them would be taken.  Moreover, Yale, MIT, Dartmouth, UCLA, Harvard and other colleges have announced that no high school protester’s college application would be adversely affected by their participation. 

Many high schools have differing views on the propriety of the protest.  Here’s my concern.  If colleges and high schools are taking a permissive stance on this protest, because they support the cause, have they opened a door that will allow future students to walk through?

My personal view is that students should not be permitted to leave the school during school hours without permission in accordance with established school policy.   Students, like the rest of us, are free to protest and express themselves when school is not in session.  Why must the demonstrations occur during the school day?  If school policy is violated, then violators should be prepared for the consequences, which should already have been codified and known by all those concerned.  Many students opted to protest and were prepared to be held to account.

What if the students' message was not for more gun control?  Would we expect equal treatment?

How would high school administrators, school boards, teachers, students, parents and colleges react to the following protest themes?
  • Students walk out demanding that teachers be armed.
  • Students walk out demanding that an NRA spokesman be permitted to address the student body during assembly.
  • Students walk out protesting against teachers who have been advocating for stricter gun control during class time.
  • Students walk out to express their pro-life view and demand abstinence education.
  • Students walk out demanding an end to standardized testing alleging they are racially biased.
  • Students walk out demanding changes in the curriculum reflecting a more multicultural approach.
  • Students walk out protesting the FBI and law enforcement who missed so many opportunities in Florida to intervene and prevent a horror. 
I don’t think we should have an elastic policy that stretches when we support a cause but contracts when we oppose it.  True fairness is when we have the same tolerance regardless of the content.  Free speech, for example, doesn’t mean free speech only when we agree with it. 

How do you think the Academy, high school leadership and the press would have reacted if high schoolers poured out during the school day carrying signs and shouting in unison, Build That Wall!  Do you think that colleges and universities would be racing for the microphones to give these kids encouragment and a free pass?


Add this