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. 


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