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?


Sunday, March 11, 2018

Insurance Company Denial of Emergency Care - Part 2

Last week, I opined about a decision by Anthem to deny paying for Emergency Room (ER) care that it deemed to be non-emergent.  My point was that insurance companies should not be obligated to pay for routine, non-emergent care, recognizing that we need a fair and reasonable method to define a medical emergency.   In my view, payment should not be denied to a patient who reasonably believes he needs ER care, even if the symptoms are (hopefully) found to be innocent after a medical evaluation.

For example, if a patient develops chest pain at 10 o’clock p.m., and is worried about an acute cardiac issue, he should call 911.  If the ER determines that chest pain is simple heartburn, it would not be reasonable for Anthem to deny payment for this ‘non-emergent’ condition.   We’re all a little smarter after the fact once we know the outcome.

Some medical complaints, however, are never medical emergencies.  If you want ER care for a runny nose, a cough or a sore knee, and you proceed to the ER, explain why you think your insurance company should pay for this. 



Coronaviruses Cause the Common Cold 
True Emergency?

Emergency Rooms must accept every patient who seeks care there by law.  A patient cannot be turned away regardless of how trivial the medical issue is.

One approach would be for every ER to have two tiers of service – Tier 1 for true emergencies and Tier 2 for all the rest.  Some ERs have such a system, but I think this should become the standard of care.  The Tier 2 facility could be equipped to provide efficient, low cost care for appropriate medical issues.  ER personnel are already highly skilled in triaging patients and could direct incoming patients toward the correct Tier. 

Here are the benefits.
  • Patients with minor complaints would be seen without waiting for hours while ER personnel attended to truly ill individuals.
  • Tier 2 facilities would be designed to provide lower cost care.
  • Tier 1 could operate more smoothly since patients with routine medical issues would be siphoned off.
  • There would likely be an overall cost savings to the health care system.
Ohio legislators are already threatening legislation to attack Anthem’s ER denial of care policy.  As a gastroenterologist, this craven political grandstanding nauseates me.  Politicians, who spend a career spending other people’s money irresponsibly, aim to lecture a private company who wants to exercise reasonable cost restraints.  Give me a break.

Would Anthem and her sister companies cover Tier 2 care?  Could they assert that since the patient was determined in the ER to have a non-emergent condition that the care should be on the patient’s dime?  I’m not answering this question, I’m merely posing it.  I do think that the present system when a patient expects or is entitled to any ER care being covered needs to be reformed.

When insurance companies pay millions of dollars for unnecessary care, guess who’s really paying for it?

Sunday, March 4, 2018

Insurance Company Denial of Emergency Care


We live in an era of demonization.  Political adversaries are not opponents, they are villains.  Commentary that contrasts with our views is labeled ‘fake news’.   Presumption of innocence?  R.I.P.  Civil discourse has become a quaint memory.  Why would one debate respectfully when today’s tactic is to talk over and demean your adversary? 

On the morning that I prepared this post, I read an article reporting that one of Ohio’s largest insurance companies, Anthem, is denying payment for non-emergency care provided at emergency rooms  (ERs).   In my view, this article was slanted, unfairly tilting away from the insurance company, an easy target to attack.   I think that a typical reader would conclude that the company was greedily trying to claw money away from sick customers.  An anecdote was offered describing a denial of payment for emergency care for abdominal pain that did seem improper, although there were no medical facts provided.

I felt that the journalist did not adequately present the insurance company’s motive and point of view.
Of course, I expect true emergency care to be covered.  And, I do not expect ordinary folks to reliably distinguish between a medical nuisance and an emergency.  Patients are not doctors. But, there should be some standard in place.  There should be a version of a reasonable person’s belief that an emergency is present. 


Insurance Companies are Easy Targets


Consider the following points.

  • Insurance companies are businesses and must be run responsibly, just like your business and my medical practice.  You may believe you are entitled to every imaginable medical benefit, but someone has to pay for it.
  • Many emergency room visits are clearly for non-emergent reasons.  This wastes health care dollars, leads to medical overutilization and clogs up emergency departments.
  • Insurance companies should object to paying for expensive ER care that could have been rendered elsewhere. 
  • A patient who presents to an ER with complaints such as a cough, a headache or stomach distress will likely undergo significantly more testing than would typically occur in a primary care physician’s office without an improved outcome. 
  • Do we expect an insurance company to pay for an ER visit for a splinter?
  • Do we expect an insurance company to pay for an ER visit to evaluate a child’s cold?
  • If a patient is offered an appointment at his physician at an inconvenient time, and he opts instead to proceed to the ER, should the insurance company be expected to pony up?
  • What would our position on this issue be if we were insurance company administrators?
I read (but cannot verify) that $40 billion are spent each year in this country on unnecessary ER care. Do you think there might be a better use for these funds?

It’s easy to vilify corporate America.  The pharmaceutical and insurance industries have large targets on their backs.  But, just because we can hit the target easily, doesn’t mean that our aim is true.


Sunday, February 25, 2018

The Americans with Disabilities ACT (ADA) and Food Allergies - Cleveland Enters the Arena

Reasonableness is like pornography - hard to define, but we know it when we see it.  (with a nod toward U.S. Supreme Court Justice Potter Stewart.)

It’s interesting how folks classify themselves on the political spectrum.  Most individuals regard themselves as moderate, independent and reasonable, regardless of their views and positions.  Try asking an extremely  partisan political conservative how he classifies himself and you will hear terms such as ‘family values’, ‘mainstream’ and ‘pro American’.   A politician on the far left is more likely to describe himself as ‘Progressive’, rather than as a 'liberal fanatic'.

The point is that unreasonable people believe that they are reasonable.

I read an account of an episode that occurred last week in Cleveland that hinged upon the legal meaning of the word reasonable.   A 16-year-old boy with various allergies joined several friends at an expensive restaurant.  Without providing advance notice to the restaurant, the young man started opening his own food that he had brought with him so that he might safely dine with his friends. The restaurant levied a $15 plating fee, which apparently is their policy and compensates them for the economic loss from a BYOF (Bring Your Own Food) patron.

The agiitated child texted his parents from the table which sparked a crescendo of anger and chaos.  Lawyers became involved in the contretemps, always a sign that tranquility is just around the corner.  Accusations of discrimination were hurled against the restaurant, who ultimately decided to waive the fee as a courtesy.  Everyone involved had a negative experience.  

In my view, all parties fumbled clumsily and repeatedly.  This dispute is similar to the childhood squabbles that we parents have resolved thousands of times in our kitchens and backyards.  Of course, the kid’s parents (or the kid) should have called in advance so the restaurant could be prepared and could also communicate and discuss its BYOF policy, which during this calm converation, might have been waived.  Surely, a phone call between two reasonable people could have resolved this riddle wrapped in a mystery inside an enigma.  (with a nod toward Prime Minister Winston Churchill.)  And, of course, the restaurant might have used a softer touch rather than light a fuse.


All Could Have Been Avoided With a Simple, Old-fashioned Phone Call


The Americans with Disabilities Act (ADA) requires an establishment to make a ‘reasonable’ accommodation to disabled patrons, visitors and clients.  We all support this law which has helped to emancipate and mainstream disabled Americans and others.   A reasonable accommodation does not mean any accommodation, however. 

The ADA would classify a serious allergic reaction as a disability.  Would the law require a restaurant to permit an allergic patron to bring in his own food?  Would a plating fee be permitted or might this be regarded as a discriminatory violation?  What if several diners with allergies came each day packing their own lunch boxes?  Would this be areasonable accomodation from the restaurant's point of view?   Could lactose intolerance or gluten sensitivity be claimed as disabilities?  (Don’t dismiss this possibility of DMC - Disability Mission Creep.  Recall, that a woman recently tried to board an airplane with her comfort hamster to keep her calm!)

I reached out to Mary Vargas, a Washington, D.C. lawyer, who was quoted in the newspaper article, and I am grateful for her patient explanation of some of the relevant legal points.  If there are any legal errors in my analysis in this post, they are mine, not Mary's. While attorneys perform a critical societal role, I suspect that Mary would agree that this issue should have been easily solved internally In a manner that would have satisfied all parties.

It’s not easy to screw up a situation where everyone should have emerged a winner.  But when you season a situation with anger and entitlement, be prepared to take cover.   

How would you have handled this situation if you were the restaurant?  What if you were the kid?  All reasonable responses welcome.

Sunday, February 18, 2018

Overuse of Colonoscopy - Scoping out the Reasons

In our practice we have an open endoscopy system, as do most gastroenterologists. This means that other physicians – or patients themselves – can schedule a procedure with us without seeing us in advance for a consultation.  Of course, we are always pleased to see any of these patients for an office visit in advance, but many patients prefer the convenience of accomplishing the mission in one stop.  This is reasonable for patients who truly need our technical skill more than our medical advice.

Our office screens these procedure requests in advance to verify that no office visit is necessary.  While this process works very well, it is not infallible.  There have been times when a patient arrives to our office poised for a colonoscopy with accompanying medical issues more complex than we had expected.

No vetting procedure is failsafe.  Have you seen the TSA statistics when they are tested in identifying dangerous items hidden in luggage?  Even though our trained personnel vet the procedure candidates, no process can capture every issue.  Also, sometimes patients forget about a medical condition or risk factor or medication, even when questioned about them. 

In addition, there have been occasions when patients arrive prepared for an endoscopic intrusion into their alimentary canal, when the procedure may not be truly indicated.  Keep in mind that the timing of a medical test often depends upon medical judgement.  For example, capable gastroenterologists may have differing opinions on whether a colonoscopy for a particular patient makes sense.


Colonoscopy - It's Alimentary!

Recently, a patient whom I had never met arrived for me to do a colonoscopy.   He had enthusiastically swallowed the liquid dynamite which had the desired cleansing effect.  I presume he took a day off of work and had a driver with him.   My review of his records demonstrated that he was about 2 years too soon for this procedure.  The reason he scheduled the exam is because his prior gastroenterologist’s office sent him a computer-generated letter that he was due for a colonic violation.  In other words, the patient was following his doctor’s advice.  

I speculate that the reason that the computer issued a Notice to Appear was that the prior gastroenterologist experienced a ‘click malfunction’ and clicked Return in 3 Years by error, rather than have correctly requested a Return in 5 Year recall.  While this may sound egregious, ask your doctor how many screw ups he has committed on electronic medical record (EMR) systems.   Indeed, EMR has created a new niche for medical malpractice attorneys to sue physicians and hospitals.

So, I have a patient before me who endured a night of purging, who has missed work and has a driver with him.  But, he is 2 years early.  What should I do?

Sunday, February 11, 2018

Why Did CMS Contact My Office? Medicare Fraud?


In our society, there are absurdities that simply defy reason.  In the past week or so, I have read about an individual who was denied the ‘right’ to bring a peacock on board a plane for comfort.  Just this morning, I read of a women who was cruelly denied to fly with her comfort animal – a hamster.  Readers are invited, if they dare, to use their preferred search engine to discover the tragic denouement regarding this hapless hamster.


'Let me comfort you.' *


If a person needs a peacock, a snake, a pig, a kangaroo or a pterodactyl for airborne support and comfort, then perhaps flying is not for you.  The rest of us have some rights also.  Rent a car.
The medical world has its own exhibits in the Theater of the Absurd.  Here’s our latest performance.
Our medical practice received notice last week from The Centers for Medicare & Medicaid (CMS) that we owed the federal government money.  Apparently, according to federal brain trusts, we had billed a patient under Medicare when we were not entitled to do so.   I’ll let readers choose from the following explanations for the government’s accusation.
  • A random audit demonstrated that we had never seen the patient.
  • The patient was dead at the time we claimed we had treated him.
  • A whistleblower (love that term!) had contacted CMS regarding our fraudulent billing practices.
  • CMS routinely sends out letters like this knowing that some medical practices will simply pay on demand rather than take on the Mother of All Bureaucracies and risk an audit of their billings over the past century.
  • There was an unconscionable error in our electronic claims submission to CMS.   We used the abbreviation Ave. in the patient’s street address in direct violation of CMS policy that dictates that acceptable abbreviations for streets include Dr., Blvd., and Rd, but that Avenue must be spelled out.
Have you made your choice?  I’ll be you are incorrect.  Sure, you may have accumulated a decent measure of knowledge and wisdom in your life, but this is no match against the brainiac feds.  They asserted that we were wrongly paid for medical services because when we claimed to have seen the patient he was already stone cold dead. 

While actual facts support that the patient was quite alive on the encounter date, try explaining that to a federal bureaucrat who believes otherwise.  The patient did, in fact, pass away a couple of weeks ago, months after we saw him.   However, when his death certificate was prepared, the incorrect year of 2017 was inserted instead of the correct year.  The scientific term for this event is call a typographical error.  The government now believed that this patient entered the hereafter a year ago.  Therefore, all social security and Medicare payments made on his behalf last year must be returned to the government.  We should support such fiscal responsibility by our government knowing how wisely they spend our money.

Of course, this will all get straightened out by his poor family, who are still mourning his loss.  They will have fun with lots of phone calls, long wait times, maddening phone menus, letters, forms and maybe even an attorney.  The whole affair has stressed me out.  Where’s my hamster?




Sunday, February 4, 2018

Top CEOs Aim to Disrupt Health Care Market.

Since the infamous memo released this week by the chairman of the House Intelligence Committee has taken up so much oxygen, other newsworthy events were relegated to a lower priority by the media.  In my view, many of these second tier issues deserve Page 1 coverage, but our media in general has decided that potential or actual scandal must lead their coverage. 

Can anyone defend, for example, the prominent and repeated coverage that Stormy Daniels has received?   If CNN received a lurid videotape of Stormy and the president on the same day that North Korea declared that it wanted to denuclearize their country, which would be the lead story?  The editors would be agonizing!


Tell the truth, would your rather be reading about Stormy?*

A bombshell announcement in health care came this week when when 3 titanic corporations stated they aimed to reform health care coverage from within.  Amazon, JPMorgan Chase and Berkshire Hathaway will combine their resources, ingenuity and mammoth leverage to bend the cost and quality curves in opposite directions.  While this will undoubtedly be good news for their million or so employees, will it be good news for the rest of us?  Hard to say.

Amazon inspires a range of emotions in businesses and individuals across the nation.  Their economic triumph is iconic, but this success has had great costs for businesses and individuals across the country.  Have you seen many small hardware stores, book shops, music shops, clothing retailers or any of the small businesses that used to be dotted across the land?   If you want a closer glimpse of the culture of working at Amazon, I suggest that readers view the 2014 documentary Amazon Rising, or peruse a 2017 book called Nomadland, by Jessica Bruder, which chronicles what life is like inside Amazon’s walls.
Just today, I read about an Amazon patent that can track workers' location and even what they are doing with their hands, unwelcome technology for workers who have nasty habits.

I have no doubt that these companies can fashion a health care system that would correct many of the health care system’s deficiencies at large.  Here’s why.
  • They have unlimited cash
  • They are aiming to provide coverage to employed people, and do not need to address the uninsured or unemployed.
  • They have stratospheric expertise in finance and technology.
  • They can exert enormous leverage over insurance companies, hospitals and the pharmaceutical companies. 
  • If they can track where an employee’s hands are, imagine how they can track health care expenditures and outcomes and have incentives in place.
  • They are large and rich enough that they could self-insure their employees, which would whittle away administrative costs. 
What is less clear, is what the effects of this disruption would be to the health care system at large.   Would hospitals and insurance companies and drug companies who are excluded survive?  Would medical costs on the rest of us be raised in order to offset the Trio’s discounts?   Is their true intent, despite their denials, to become a profit center for medical care in the United States?  

I thank readers who have made it this far.  Those who didn’t likely clicked off in search of a morsel on Stormy.  I'm sure that Amazon is tracking them.

*Photo credit:  Glenn Francis
Attribution :  © Glenn Francis, www.PacificProDigital.com


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