Sunday, May 19, 2019

Why Patients Avoid Colonoscopies - A Plea to Choose Wisely.

                                                            
Exercising good judgement can mean the difference between life or death.  Life can be unforgiving of the choices me make.  As we all know, many life events are beyond our control and understanding.  But, there is much we can do to shape our personal paths to a brighter destination.

Consider some of the choices listed below that many folks make every day.  Are any of them familiar to you?
  • Texting while driving.
  • Riding a motorcycle.
  • Riding a motorcycle without a helmet.
  • Lifting an object that we know is too heavy for us.
  • Getting into a car when the driver has had one too many.
  • Driving a car when we have had one too many.
  • Giving your social security number to a caller who is promising you a tax refund.
  • Responding to an email from Nigeria alerting you to a wad of cash waiting for you.
  • Using your date of birth as your password for your on-line bank accounts.
  • Rushing through a yellow light so we won’t be late for a movie.
  • Eating street food in a foreign country that appears undercooked.
  • Skipping a ‘flu shot’ and other recommended vaccines.
  • Getting chest pain for the first time after shoveling snow and decided it was just heartburn.
Get the point?

All of the above activities can end tragically depending upon the choices we make.  But, they can easily end well for us.  Every day, we confront forks in the road when we must make choices.  Sometimes, we choose the wrong road.  Sometimes, we make no choice at all.  The point here is that we have a choice. 

A Velocycle - Safer than a Motorcycle

I see this issue in my gastroenterology practice.  I’ve done about 30,000 colonoscopies in my career, a number so large, that I can barely believe it myself.  Fortunately, the results of nearly all of them are normal or show benign findings.  Telling a patient and their family that all is well after the procedure is a pleasure that hasn’t changed over the years.

But, not every colonoscopy result is innocent.  As you might imagine, I have confronted a lot of colon cancer in my career.  When I discover one, I am aware that life for that person and his loved ones is about change profoundly.  Life changes in an instant.

While colon cancer affects the patient and his family most deeply, it’s a heavy day for the gastroenterologist also.  We are human beings.  What makes the day even darker for us is when the patient had faced a fork in the road, but made the wrong choice.  Consider the following examples which I have seen repeatedly in my practice.
  • A patient turns 50 but chooses not to have a colonoscopy, against the advice of his doctor.
  • A patient has rectal bleeding and ignores it.
  • A patient was told of hemorrhoids years ago.  Rectal bleeding develops and he assumes that his hemorrhoids are active again.  He does not consult his physician.
  • A patient’s bowel changes, but he decides that this must be a side-effect of new medication.
  • A patient has a large colon polyp removed by his gastroenterologist.  He is advised to return in a year for another colonoscopy, but he does not do so.  He is too busy.
Colon cancer, unlike so many other cancers, is a preventable disease.  I am not suggesting that modern medicine can prevent every case of colon cancer.  It can’t.  I am stating that the majority of colon cancers that I have discovered were in people who did not choose wisely when they should have.  They ignored.  They denied.  They delayed. 

Time after time, I have seen intelligent people who have had rectal bleeding for months before they decided to see me. 

Every expert will attest that the earlier colon cancer is diagnosed, the better the prognosis will be.  But more importantly, timely colonoscopy can prevent the disease altogether.

I haven’t made perfect choices at every fork in the road that I’ve faced.  But, when I turned 50, I did the right thing.

We can’t control everything.  But, there is much that we can control.  For example, you have chosen to read this post.  How you decide to use it is your choice. 


                                                                                        

Sunday, May 12, 2019

Charity Encourages Generous Donations - New Standard for the Industry?


This really happened.  The vignette I present now occurred 3 days before its posting on this site.  My good friend Bill invited me to a fundraising dinner to support a Jewish organization.  I declined the invitation, but told Bill that I would be pleased to make a donation to support a cause that was important to him.  I connected to the website which led visitors quickly to the Donate page.  Charitable enterprises want to make it as easy as possible for you express your generosity and separate you from your funds.  Haven’t you noticed that every museum visit leads to the gift shop? 

I quickly filled in the credit card information and then scrolled down and typed $50 in the Customized Donation window.  This box allowed donors to designate their own amount, bypassing the default listed uber high dollar amounts that appeared higher up on the page.  The entire process expended about 3 minutes and ended when I clicked on the Donate Now button.   It’s the same process that we all use to purchase items on line.

Immediately, I received an e-mail receipt, which I opened for no clear reason as I generally ignore these notifications.  At first glance, I noted a donation amount of $18,000 which, of course, was incorrect.  On closer inspection, as my pulse rate quickened, this is exactly what the receipt claimed was transacted. Most likely, I thought I must be suffering from some transient blurry vision from over-caffeination, a previously unknown complication. But, squinting failed to change the number.  I did not panic, because I am a medical professional, who is steeled to maintain my equipoise when unexpected turbulence confronts me.  This is when seasoned pros must let their training and muscle  memory kick in.  In other words, I panicked.  



At least they thanked me!


I called Visa, whom I regarded as culpable, or at least guilty of contributory negligence, by facilitating this fraudulent transaction.  After exposure to the highly personalized menu tree, and hitting the zero on the phone repeatedly until my index finger was nearly calloused, a human-sounding voice emerged that claimed to be emanating from an actual human.  I was grateful to have discovered an escape from the menu tree, a labyrinth that can keep clients and customers trapped for months or longer.  Most of these lost souls go mad simply from being forced to hear, ‘Please listen carefully as our options have changed’, at high volume and without pause.  Visa-man advised me that I had no recourse available with them; I needed to take it up with the charity.

A few nanoseconds later, I phoned the charity and immediately was greeted by a voice mail.  When would I hear back?  What if the call came while I was doing a colonoscopy?  Should I answer anyway?  (I was leaning 'yes' on this.) What if the religious charity didn’t consider my donation as a human error, but as a divine stroke for which I would be rewarded in the hereafter?  Would I risk selling my soul for a mere $18,000? (I was scared to lean yes on this one.)

In less time than it seemed, a rabbi called and promptly and courteously returned me to the status quo ante.  He made me whole.  How did this escapade happen?  He explained that the Donate page was defaulted to donate 18 grand, and unless this box is unchecked by the donor, this will be the amount transferred.   I congratulated the rabbi on having such an effective donation process, and he assured me with a laugh, that he would attend to the glitch. 

We have all clicked on the wrong box or sent a text message to an unintended recipient, which can result in amusing or serious consequences.   In this case, my ‘error’ wasn’t one of commission, but of omission.  I failed to ‘opt out’.

Physicians, at least honest ones, can relate to this anecdote.  In the electronic medical era, how many of us have placed an order on the wrong patient?  Wouldn’t it be a shame if a doctor ordered a colonoscopy on Bill by mistake?

Sunday, May 5, 2019

Why Smart Doctors are not Enough

I’ve delved into the issue of medical judgment more than once on this blog.  I have argued that sound judgment is more important than medical knowledge.  If one has a knowledge deficit, assuming he is aware of this, it is easily remedied.  A judgment deficiency, per contra, is more difficult to fix.
 
For example, if a physician cannot recall if generalized itchiness can be a sign of serious liver disease, he can look this up.  If, however, a doctor is deciding if surgery for a patient is necessary, and when the operation should occur, this is not as easily determined or taught.  

Medical judgment is a murky issue and often creates controversies in patient care.  Competent physicians who are presented with the same set of medical facts may offer divergent recommendations because they judge the situation differently.  Each of their recommendations may be rationale and defensible, which can be bewildering for patients and their families.  This is one of the dangers of seeking a second opinion, as this opinion may not be superior to the first one.  Patients have a bias favoring second opinions as they pursue them because they harbor dissatisfaction, or at least skepticism, with the original medical advice.  If the second opinion differs from the original, it reinforces their belief that the first advice was inferior.  
Second Opinions Can Cause a Tug of War

Here are some scenarios which should be governed by medical judgment.

A 70-year-old woman with severe emphysema uses an oxygen tank.  She has never had a screening colonoscopy.  Professional guidelines suggest that screening begin at age 50.  Does a colonoscopy make sense for her considering her impaired health?

A 40-year-old man has had 1 week of stomach pain.  This started 10 days after he took daily ibuprofen for a sprained knee.  The physician suspects he might have an ulcer.  Should this patient undergo a scope examination to make a definite diagnosis?  Should the doctor prescribe anti-ulcer medication without determining if an ulcer is still present?  Should the ibuprofen be stopped if the patient states he has significant pain without it? 

An 80-year-old woman had some recent dizziness and nearly fainted.  The doctor sees her in the office two days later and questions her carefully.  He suspects that the patient was simply dehydrated.  Should the doctor simply reassure the patient or arrange for a neurologic evaluation to make sure that a more serious condition is lurking?  

Of course, you want your doctor to know a lot of stuff.  More importantly, you want a physician who can give you sound and sober advice.  Knowledge and scholarship are important physician attributes, but healing demands more.  At least, that’s my judgment. 


Sunday, April 28, 2019

End of Life and the Medical Profession


Physicians and nurses deal with the deepest issues of the human condition – life and death.  Our profession brings new life into the world and does our best to bring comfort and peace at the journey’s end.  It is a profound and emotional experience for medical professionals to be with a patient and family when life ends.

There are other professions who routinely confront loss of life.  Law enforcement personnel, paramedics, firefighters and soldiers all are exposed to events that most of us would never wish to experience.

The medical profession and society is struggling to preserve our humanity in a 'cut & paste' world where one's worth is determined by the quantity of twitter followers.  

Hugging a child.  There's no 'app' for this.

On my very first day of medical internship in Pittsburgh, I was called by a nurse to pronounce a patient dead.   I had never seen the patient before.  The only deceased individual that I had any close contact with was the cadaver we studied in medical school.  I entered the room and did not know what I was supposed to do, never have been given any training or guidance on this responsibility.  I learned an important lesson then.  New interns know nothing.  Experienced nurses know a lot.  Ask for their help.  An arrogant intern will be permitted to sink.  The humble intern will be rescued.

This was an elderly patient from a nursing home and this outcome was anticipated.  The nurse patiently guided me through the requisite steps.  I performed this function multiple times throughout my internship and residency, but the only actual memory of these events is with that first patient on my very first day.  It imprinted upon me, much as the first day that I was introduced to the cadaver as a first year medical student in anatomy class. 

Being present with patients and families at profound moments is a privilege and a responsibility.  As we are all suffocating from dehumanizing technology in every sphere of our lives, there are experiences still that cry out for our humanity.   If you or someone you loved was facing difficult medical choices, who would you want in the room with you?  A physician, who might deliver wisdom and compassion or Alexa?

Sunday, April 21, 2019

Musings on Religion


There is a confluence this weekend of holy days from two venerable monotheistic religions.  Today is Easter, which represents the anniversary of the resurrection of Jesus Christ, a foundational theological principle of Christianity.   Christians await the Second Coming, when they believe that Jesus will return to establish a world of peace and justice.

Passover, which began on Friday evening, celebrates the iconic and gripping tale, chronicled in the Book of Exodus, of the emancipation and liberation of the Jews who were enslaved under a cruel Egyptian regime.  The yearning for freedom and resistance against tyranny carefully documented in the Torah, is truly a universal template that is relevant to this very day. 

Jews Crossing the Red Sea Leaving Bondage Behind

The religions are so deeply intertwined.  While I am neither a Christian nor a scholar, I have taken some effort to study the New Testament so that I might gain some understanding of this ‘offshoot’ of my own religion.   Indeed, true scholars of Christianity teach that it is not possible to understand Christianity without having a deep understanding of Judaism.  When one considers that Jesus, his disciples, the pharisees, the priests and other figures highlighted in the New Testament were all Jews, it is obvious that understanding their birth religion is a prerequisite to understanding how and why Christianity developed and thrived. 

Consider some fascinating queries.  Did Jesus eat matzoh on the Passover?  Was the Last Supper a Passover meal?

I am not naïve and am well aware of the deep hostility that Jews have suffered from Christians both centuries ago and in recent times.   There has been a rapprochement, but the work is not finished.  And, my own house is not yet in order.    Many Jews and others are troubled by the principles and actions of the current Israeli government.  I presume these leaders, like Jews throughout the world, were at Passover meals, called Seders, this weekend, when they read about the plight of their subjugated ancestors. Did the ancient Exodus narrative offer them any perspective on current events?  In our own country, ignorance and prejudice against Islam has been used for malign purposes.

Many believe that religion has caused far more harm than good for humanity.  As we gaze around the world today, their argument is very plausible.  Where do we go from here?   Who will reach across rather than turn away?    Who will listen with an open mind and an open heart?  

Must we all wait for an apocalypse, described in Revelation, or a series of catastrophic plagues, as appeared in Exodus, for a peaceful world to emerge?   Is there anything we can do now?





Sunday, April 14, 2019

Step Therapy - Pharmacy Benefit Managers are at it again!


Among the many tools that insurance companies wield to save money is a technique called ‘step therapy’.  This is a technique that exasperates patients and physicians.  Here’s how it works. 
A patients comes to his doctor with a medical issue.  The doctor, who presumably has a decent measure of medical training, experience and judgment, decides to prescribe a medication, in an effort to ameliorate the patient’s distress.  Let us call this magic elixir Pill A.  The doctor zaps this prescription to the pharmacy at the speed of light using the ever trustworthy electronic medical record.  The satisfied patient leaves with the mistaken impression that his cure is just around the corner.

Here’s where the fun begins.  Of course, the patient may receive the typical denial as Pill A is not on the formulary.  Keep in mind that an insurance company’s denial doesn’t mean the patient can’t fill the prescription.  Insurance companies would never interfere with a physician’s medical judgment.  The patient is still free to take the prescribed drug.  The fact that it costs $2,200 per month is but a trifle.   If Pill A costs a fortune and the insurance company’s alternative Pill B is cheap, then can we really argue that insurance companies are not practicing medicine?

Physicians in Asylum Driven Mad by Step Therapy

In the above example, usually Pill A and Pill B are medically equivalent, so the cheaper drug delivers the same benefit.  Sometimes, however, the doctor’s preference is medically superior.  Either way, the process burns up hundreds of hours per year for physicians and our staffs. 

Step therapy is when Pill A is denied because the doctor has not tried different types of medication first, which are not equivalent and are often inferior.  In order to get Pill A to be covered, the doctor must demonstrate that he has tried other medications first, and that they were not effective.  So, under this genius system, a patient receives drugs that cost money and likely won’t work.  After enduring this experiment, the  insurance company may ultimately cover the medicine that should have been prescribed in the first place.  Usually such approval is for a limited time guaranteeing that the physician can look forward to a sequel in the near term.  

Imagine if a patient suffered a serious side-effect from one of the step therapy drugs that the doctor knew was a waste of time.

I’ve argued on this blog on the need to reduce overutilization and to cut costs.  A fundamental premise of this blog is that less medical care can increase medical quality.  Step therapy managed to both increase costs while it cuts quality, not an easy feat.

We need to step up and step on step therapy.

Sunday, April 7, 2019

Why I Fired Two Patients From My Practice



You're fired!  We've all heard this directive that was popularized by our current chief executive.

It is much more common for a patient to fire a physician than it is for a doctor to cut a patient loose.  Yet, I sent 2 of my patients termination letters in the month prior to my penning this post, which represents a firing surge on my part.  This has been a very rare event in my practice.  Since physicians are patient advocates by training and practice, we tend to extend leniencies to our patients, giving out 2nd and 3rd chances routinely.  But, the doctor-patient relationship is not unbreakable and both sides have responsibilities to maintain it. 



The Doctor-Patient Relationship Should be a Partnership - not a Duel.

Here are some reasons that patients have offered justifying seeking a new physician.  Keep in mind that these given reasons represent patients’ perceptions, which may not necessarily represent absolute truth.
  • Poor or absent communication.
  • Inattentive or rude staff.
  • Unreturned phone calls.
  • Habitual physician tardiness.
  • Diagnostic delay or error.
  • Dismissive attitude toward chronic medical complaints.
  • Insurance coverage change - not a true 'firing' but a common reason to change horses.
  • Suggestion that patient’s complaints stem from anxiety or depression.
  • Refusal to order requested diagnostic testing.
  • Rushed office visits.
  • Arrogance toward complimentary and alternative medicine. 
  • Unavailable timely appointments. 
Here’s why I sent two patient pink slips.

Patient 1:  I saw the patient in the office and scheduled her for diagnostic tests at our local community hospital.  This appointment time requires a commitment from me, the endoscopy department and the anesthesia personnel to be available at the appointed hour.  After the patient cancelled for the 3rd time, we declared ‘no mas’.

Patient 2:  He is on a medication for colitis that suppresses the immune system.  This requires that he periodically check in with me for office visits and laboratory studies.  He missed his appointment and was due for his blood tests.  We called and wrote reminding him that I needed to see him.  He declined.  I wrote him a personal letter requesting that he make an appointment or I that would need to sever him from the practice.  When we didn’t hear from him, we followed through.  

It’s challenging enough to take care of sick patients who are playing by the rules.  When a patient decides to make his own rules, and can’t be coaxed back into reasonable compliance, then the doctor-patient relationship may traverse the point of no return. 

When a patient fires a doctor or a physician dismisses a patient, there is an opportunity for reflection and growth.  Just like in the business world, a person who is fired should want to know why the action was taken so that he can learn from the experience, rather than simply blame the boss.  Conversely, an experienced manager will want to understand why an employee has given notice.   

On those occasions when a patient has left my practice, I have tried to understand if I or we fell short.  Sometimes we have and we do our best to learn from the experience. 


Sunday, March 31, 2019

The Mystery of Medical Insurance Coverage


“Does my insurance cover this?”

I cannot calculate how often a patient poses this inquiry to me assuming wrongly that I have expertise in the insurance and reimbursement aspects of medicine.  If I – a gastroenterologist –  do not even know how much a colonoscopy costs, it is unlikely that I can speak with authority to a patient’s general insurance coverage issues.

Of course, patients assume that we physicians have an expansive expertise of the medical universe, both in the business and the practice of medicine.  Often, friends and acquaintances will informally present a medical issue for my consideration that is wildly beyond my limited specialty knowledge, and yet they expect an informed opinion.  “Hey, aren’t you a doctor?”   Yes I am, but if you think a gastroenterologist – a Colonoscopy crusader – can advise you on your upcoming hip surgery, psoriasis treatment retinal detachment, or cardiac rehab, think again. 

And, I likely know more about psoriasis treatment than I do about the enigma of insurance coverage.  I have to check with our billing expert to understand my own medical coverage and I’m in the business.  And, at the risk of appearing as a simpleton to my erudite readers, I cannot aver that I fully grasp the meaning of the E.O B. (Explanation of Benefits) forms that I receive for my own care that purport to explain exactly where my insurance company responsibilities end and mine begin.

Imagine for a moment that you are an actual physician as you counsel a patient who is sent to you for a screening colonoscopy.  (To assist you in this role play, a screening colonoscopy means there are no symptoms or any other abnormalities that would justify the procedure.  A screening study is done on patients who are entirely well as a preventive medicine exercise.  In contrast, if a patient has a symptom, such as pain or bleeding, then the colonoscopy is considered diagnostic and not screening.) You advise your 50-year-old patient that his screening colonoscopy will be fully covered by insurance. The patient is happy.  However, during the screening colonoscopy, a polyp is discovered and removed.  Indeed, removing polyps is the mission of the procedure.  However, polyp removal automatically changes the procedure from screening to diagnostic.  And, guess what?  Now, the procedure may not be free and the patient may be subject to copays or diving into his deductible.  When the patient receives his E.O.B, and properly decodes it, he is no longer happy.  Then, our office is likely to receive a phone call.


Can Sherlock Holmes Deduce the Cost of Colonoscopy?


This is but one example of the Medical Insurance Industrial Complex.  Even our most seasoned patients are no match against this machine.   It’s not a fair fight.  They make the rules, change them at will and serve as the referees.  And, if the insurance company ruling doesn’t fall your way, relax, you can certainly appeal. This process is about as pleasurable as undergoing a rigid sigmoidoscopy.  The appeals process is not for the faint of heart.  You must have the patience of Job, the fortitude of a Navy SEAL, accept rejection gracefully, welcome irrationality, regard a dropped phone connection as an amusing event and have several consecutive hours available typically at times most inconvenient for you.  On reflection, perhaps the sigmoidoscopy is the more pleasant option. 


Sunday, March 17, 2019

Why Our Medical Practice Won't See Nursing Home Patients

Our practice will no longer see nursing home patients in our office.  If a nursing home patient is already established with us, then we will see him; but, we have decided not to accept new patients.

Of course, we believe that these individuals – like the rest of us – deserve medical care.  This demographic not only deserves care, but has the greatest need for medical services.  Our practice will see every person who wants to see us, including the uninsured. 

Why, then, would a welcoming practice like ours close our door to new nursing home patients?  We just couldn’t take it anymore.

These patients, who often have serious physical and mental challenges, would typically arrive to our office accompanied by a driver, who naturally has no medical knowledge.  The patient often had no awareness of the reason for the visit.  The ‘medical record’ consisted of a nearly indecipherable list of medications of uncertain accuracy.  Typically, no reason for the visit was documented, or there might appear a scrawl - ‘stomach problems’ - not quite a road map that a consulting gastroenterologist can follow.  I would then, in the middle of my practice day, call the nursing home in search of a nurse (or nurse’s aide or secretary or janitor) who might enlighten me on what my focus should be. This task is about as fun and efficient as calling the IRS customer service line with a tax question.  Often, the nurse who might actually know the reason for the visit is off that day or works a different shift.



Why Should We Have to Work Wearing a Blindfold?


It took several years before our practice declared ‘no mas’, but our level of exasperation finally exceeded our patience.  Our repeated attempts to improve communications  were not successful. 

Here’s what didn’t happen.
  • The patient’s doctor or nurse would call us in advance to discuss the case so that we might gain information that would make an office visit worthwhile. 
  • We are contacted in advance and we advise that a diagnostic test or blood tests be performed prior to the office visit.
  • We are contacted in advance and, after discussing the case, request certain prior medical records to be sent prior to an office consultation.   If a patient is having rectal bleeding, for example, I want to review the prior colonoscopy records.  Perhaps, a repeat procedure is not necessary.  
  • A family member accompanies the patient to the office visit.  I am not judging folks here, and family members may live out of town, but I was always surprised that these ailing and elderly patients rarely arrive with a family member who could play a critical role of providing (or obtaining) medical knowledge and advocating for their loved one. 
This has been a vexing issue.  If you were sending an elderly patient, perhaps demented, to a doctor, why wouldn’t you give that physician a full briefing so that he or she could do a decent job?  Even when we are sufficiently informed, the task is challenging.  But, we shouldn’t be asked to work blindfolded in the dark.

Sunday, March 10, 2019

Quality Indicators in Colonoscopy - A Three-pronged Test for your Gastroenterologist


One thing that gastroenterologists know about is stool.  But, I’m not referring to that kind of stool in this post.  Follow along.

When we do a colonoscopy, for example, we are relying upon stool, or more accurately a stool, as in a three-legged stool.   This metaphor illustrates that the three legs must be equally strong or the stool will not stand.  The three pillars of support that a colonoscopist needs include:
  • Knowledge
  • Skill
  • Judgment

All 3 Legs Needed


As the gastroenterologist guides the colonoscope along your long and winding colon, he may discover a lesion.   He needs knowledge to identify the intruder.  Is it a cancer or a benign polyp?  Could it be Crohn’s disease or some other form of colitis?  Is it a normal structure that simply appears atypical? Obviously, the more experienced the gastroenterologist is, the more likely he will be able to identify the abnormality. But, every gastroenterologist, regardless of experience, confronts lesions he has not seen before. 

The gastro specialist must have the requisite technical skill, not only to perform the colonoscopy properly, but also to manage any lesions discovered.  Removing colon abnormalities requires an assortment of techniques and instruments.  What good is having the knowledge that can identify a lesion if you don’t have the skill to remove it?  Would we permit a cardiologist to perform a cardiac catheterization on us if he couldn’t insert a stent if a narrowed artery was discovered?

Most importantly, the gastroenterologist needs judgment.  In my view, this ‘leg of the stool’ is what distinguishes good physicians from truly seasoned medical professionals.  Medical judgment, in my judgement, is much more difficult to learn that knowledge or skill.  By definition, judgment is subjective.  There is no medical bible to consult that can confidently advise what constitutes the optimal judgment in a particular circumstance.  There are so many variables.  This is why a patient could consult several specialists regarding a medical issue and receive differing opinions all of which might be ‘correct’.  The facts don’t change, but the physicians’ interpretations of those facts and consideration of the overall medical context, may lead to opposing recommendations.  One physician might advise repair of a hernia which is causing discomfort while another may counsel against it because the patient has severe emphysema and has high operative risks. 

Consider how many U.S. Supreme Court decisions are decided in 5 to 4 votes.  The facts are the same for all 9 justices but their decisions often vary profoundly.

Two hours before writing this, I performed a colonoscopy.  I discovered a medium sided polyp right at very end of the colon at the spot where the appendix is connected.  I had knowledge of the lesion and had the skill to remove it.  But, I was concerned that resecting it – a simple task I’ve done for decades – might cause a complication by injuring or puncturing the appendix.  Primum non nocere, or first, do no harm, is medicine’s sacred mantra.  Perhaps, another gastroenterologist would have removed the lesion without any consequence.  His patient would not need any surgery to remove the lesion, as my patient might.   The patient will return to my office in a few weeks.  I thought that he was entitled to a sober discussion of the options while he was awake and alert, rather than sedated on a gurney. 

Sunday, March 3, 2019

Medical Practice Hassles Torture Patients and Doctors

We do most of our colonoscopies in our ambulatory surgery center (ASC), which is attached to our office.  We are proud of the work that we and our staff do every day and are grateful for the outstanding feedback that we consistently receive from our patients.  Some insurance companies will not cover procedures in our ASC so these patients must get ‘scoped’ at the hospital instead.  For many of them, this means required blood tests a few days in advance of the procedure, which we would not have required for an ASC procedure.   On the procedure day, the patient and the driver will enjoy spending hours in the hospital for parking, checking in, interviews with various medical personnel, the procedure and the recovery period.  And, since it is a hospital, delays are inevitable.  Not only does this experience take hours longer than it should, but we are mystified that an insurance company would take on the expense for a hospital test that we could do more efficiently and cheaper in our ASC.  Can you make sense out of this?

It is typical for a physician’s prescription for a patient to be ‘denied’ by an insurance company.  Such denials, of course, are never issued by a medical professional, but are form letters kicked out automatically if the physician’s preferred drug is not included in the insurance company’s sacred formulary.  Appealing a denial – which we will attempt – is just as smooth and stressless as calling the IRS for questions on your tax return.  It is designed this way so that physicians and patients simply give up.  What physician has the time or fortitude to make several phone calls to hear repeatedly, ‘please listen carefully as our options have changed…”  Sometimes, my recommended drug is denied because my patient has not first tried a different medication, which I did not prescribe because it is not indicated for my patient’s condition.  Should I prescribe the wrong drug so that few weeks later when it is not effective, I can then hope that the correct medicine will be approved?  Can you make sense out of this?



The System Can Make Doctors and Patients Batty


Some insurance companies will only permit me to prescribe a 30 day supply of a medication.  Some of these medicines need to be taken indefinitely.  Why should these patients have to make 12 stops to the pharmacy every year?  Why can’t I prescribe a 3 or 6 month supply?  Can you make sense out of this?

A patient comes to me for a screening colonoscopy.  His insurance company covers this preventive service.  I do the exam and find a polyp, which I remove.  This changes the definition of the procedure from screening to diagnostic.  Why does this matter?  Because the insurance company may require that the patient pay a greater share for a ‘diagnostic’ procedure?  In other words, the patient gets penalized because his gastroenterologist removed a polyp, which is the goal of a screening colonoscopy.  Can you make sense out of this?


If any reader can make any sense out of these real life medical absurdities, then the medical profession needs you STAT.  You are much smarter than we are.

Sunday, February 24, 2019

Insurance Company Denies Coverage for Drug - Part II


Last week, I related a vignette where a routine medication refill was denied by a patient's new insurance company.  The patient had developed symptoms 2 weeks after he ran out of the medication. I surmise that 100% of gastroenterologists surveyed would have agreed that refilling the medication was the next step.

So, even though the best medical option was to refill the medicine that we know has worked, the new insurance company won’t cover it and the patient cannot afford to pay retail for the drug. (As a separate point, I challenge anyone including those with PhD's in economics to explain retail drug pricing.)  The patient did his best to navigate the insurance company’s website and found a colitis medicine that is covered, but it is medically inferior.  Should we just cave and prescribe it to save money and a hassle?  Is this an issue that we want on our sick patients' agendas?  How would you like to face surgery and be told that the newer clamps and scalpels are out of network, but there are some rusty tools in the back that are fully covered?

I tried using our electronic medical record to ascertain if there were effective alternative colitis medications that would be covered, but neither me nor my staff could get a straight answer on this.   If we were to call the pharmacist to ask which colitis medicines were covered, which we have tried in the past, we would be told that we would have to officially prescribe each drug individually in order to determine its coverage status.  Doesn’t that sound fun and efficient?

Does this vignette show medical care at its finest?  How much time do physicians and our staffs burn up on tasks like these?   Does this anecdote reinforce the notion that insurance companies’ mi$$ions are to protect profits and not patients?

Do we want sick patients and physicians to have to fight just to get medicines approved?  Shouldn’t they be focused on health and healing?   Keep in mind that my patient was not seeking exotic or experimental treatment.  He only wanted the medicine that he and I knew could keep him well which is approved by the FDA for his condition. 



Beware the Medicare for All Express!


If an avaricious shoe manufacturer decides to hike prices, no customer will be harmed.  If the insurance industry, however, aims to maximize their profits, folks can get sick or worse.  If this industry doesn’t reform itself, then at some point others will do it for them.  Wouldn’t they be wiser to earn some good will with their customers and the public rather than create an army of enemies? 

Who will be there to defend private insurance companies once the Medicare for All Express gains momentum?   If insurance companies won’t do the right thing for the right reasons, perhaps, self-preservation will motivate them to do better. 





Sunday, February 17, 2019

Insurance Company Denies Coverage for Drug


A patient came to see me recently with a suspicion that his colitis was recurring.   In general terms, colitis describes a condition when the large intestine is inflamed or irritated.  Typical symptoms are diarrhea, abdominal cramping and rectal bleeding.  This patient was concerned as his last 3 bowel movements were diarrhea.  He had been on a medicine called mesalamine, a safe and effective treatment for colitis, but he ran out of it 2 weeks ago.  While he was taking the medicine, he felt perfectly well.  So, his bowel change developed 2 weeks after he ran out of his medicine. 

For readers who like to play doctor, choose among the following options:
  • Schedule an urgent colonoscopy to verify that nothing has changed since his colonoscopy 6 months ago.
  • Observe the patient without any treatment to give him time to heal himself.
  • Recommend probiotics to restore his digestive health.
  • Refill the mesalamine at his usual dosage.
  • Request a 2nd opinion because the case is mind boggling complex.
  • Prescribe an antibiotic because most cases of diarrhea are caused by an infection.
I thought that the most reasonable option was to reunite the patient with mesalamine, which had been extremely effective.  Moreover, since the symptoms developed after a 2-week medication hiatus, this suggested that his colon was pleading for a medication refill.  The patient, who is not a doctor, also thought this was the optimal choice, since he attempted to refill the mesalamine on his own prior to seeing me.  However, he had new medical insurance and their response to the routine refill request was DENIED!

My Staff and I became Gerbils

Next week, I’ll share how we responded to this frequent and frustrating development.  Don't get your hopes up.   It was a gerbilesque experience. We all felt like we were running on a wheel, expending lots of energy and effort, but with no traction. 

Sunday, February 10, 2019

Blockchain


First there was Bitcoin, a cryptocurrency that utilizes blockchain, a decentralized system of data collection and transactions that we are told will defy hacking.  (Wasn’t the Titanic said to be unsinkable?)   We read that cryptocurrency and other blockchain functions will be a societal gamechanger, much like the internet was when Al Gore invented it some years ago.

My own state of Ohio will now accept Bitcoin as payment for commercial taxes. 

And, of course, there are many other cryptocurrencies mushrooming around us.  In my life, many innovations seem to be solutions in search of problems.  I don’t find my current methods of transacting business – cash and credit cards – to be so onerous that I am screaming for a new way to conduct commerce.  But, I will admit that I have security concerns about my credit card number and other highly personal data being ‘safely stored’ all over the internet.  Some years ago, I enjoyed the thrill of being a victim of identity theft, which in gastrointestinal terms, is about as pleasurable as a rigid sigmoidoscopy.  Just contacting the 3 credit agencies in the quest to reach living breathing human beings is a task that separates the weak from the robust. 

Northeast Ohio is prepared to invest over $100 million to attract and cultivate blockchain investors.  Will this create a Blockchain Bubble?  We will see.  Initial investors in Bitcoin hit the jackpot.  But for many others who didn’t time their investments at a propitious moment, they lost big.

There are many aspects of our personal and professional lives that could utilize blockchain.  And, like any new innovation, we don’t have to understand it to benefit from it.  Do we really know how our routers at home work?  Of course, whenever a new disruption breaks in on the scene, many existing businesses and organizations will be threatened.  Consider Amazon, the Mother of All Disrupters.  Bitcoin, for example, could assume many functions of traditional banks and perform them better, more securely and at less cost.  If cryptocurrency can really deliver, then those under threat will have to adapt or they will be run over.  Those players who are not adaptable will become obsolete.  Typewriter repair is no longer an occupation.


Who Can Fix This?


In my own profession, blockchain could offer incredible benefits.  As a physician, the notion that I could easily access all of a patient’s medical data from my office would be a gamechanger.  And, every new medical event would be instantly and securely added to a blockchain.  The HIPAA police would become unemployed, another blockchain casualty.  Imagine how this would affect medical care in an emergency department.  Physicians, with access to the entire record, would be less likely to order medical tests if they could determine that they had already been done elsewhere.  And, beyond the medical advantages, I’m sure the billers, coders and insurance companies would also be hitching rides on the Blockchain Express.

Patients and I today are often frustrated that even in our digital era, I do not have easy access to their electronic records, which often exist in different medical systems and institutions.  Wasn’t electronic medical records supposed to solve this? 

Will blockchain become the coin of the medical realm?  Has this post induced you to invest in cryptocurrency?  My advice?  Buy a CD instead. But, stay tuned. 

Sunday, February 3, 2019

Hospitals Seek Donations from Patients


Many organizations solicit private donations from benefactors and philanthropists.  Is there a stadium in the country that does not bear the name of a prominent donor?  There are also anonymous donors who are not cursed with egos that require their names to be emblazoned in giant font on a building’s façade.  But, most donors want recognition which is often used as an incentive when soliciting the donation.

Donors understandably receive perks and privileges that ordinary folks will never be offered.  If you give a ton of money to a theater, you might receive prime season tickets as a gift.  If you make a sizable donation to a symphony orchestra, you may be invited to a private event to meet the conductor and leading musicians.  If you make a robust financial contribution to your city’s art museum, you won’t have to worry about competing for limited tickets to view the visiting Picasso exhibit.  You may very well have your own private tour.

There is nothing venal about any of this.  If you give money, then you get stuff.  But, sometimes this quid pro quo is improper and unethical.  For example, if I donate to a campaign, and the candidate wins, am I entitled to a higher level of constituent service?  (Of course, this example is hypothetical, as no politician would ever confer special favors to a donor.)

The New York Times reported recently a donation scheme in my own profession that I found to be ethically problematic.  Hospitals across the country determine which of its hospitalized patients are wealthy and then contact them asking for money, sometimes while these folks are still in the hospital!  The article states that physicians and nurses – actual medical professionals – have played a role connecting patients with hospital fund raisers. 

First of all, there is an unseemliness to trolling through public data on sick patients to ascertain their history of political donations and property records to determine if they have sufficient net worth.   This stealth review of data sounds more like the skulduggery that we have all learned is part of Facebook’s culture.   It is possible that a grateful patient who is approached and then gives a mighty donation might not enjoy any future special treatment from the institution.  But, it is also possible that the donor, like the example of a museum donor I cited above, might be given a higher class of service.  While we expect to reward donors to cultural and educational institutions, would we condone a donor to a hospital receiving special treatment which might include better medical care?  Shouldn’t all patients receive the same level of quality?  Do you think it might be possible that a donor would be more likely to get a private room, get access to the best surgeon, get a complaint resolved expeditiously, get phone calls to the hospital returned promptly or get better access to appointments after hospital discharge? And, if a potential donor declined to contribute, particularly if his doctor initiated the solicitation, might this affect the doctor-patient relationship?



The MD Whistleblower Stadium

If you want to give your life meaning by donating to a worthy endeavor, consider donating to this blog.  Imagine the prestige and fulfillment of having a post named after you. 


Sunday, January 27, 2019

Diagnosing Sleep Apnea - Leave it to the Amateurs!

It seems that there is an epidemic of obstructive sleep apnea (OSA) out there.  Snoring, a harbinger of OSA, seems to have captured the national attention, at least judging by the ubiquitous ads I am subjected to hourly on the radio.  Gastroenterologists routinely inquire about the presence of OSA in our patients as this may increase the risks of sedation and anesthesia. 

Most patients with OSA are undiagnosed.  Many of them are not aware that the condition troubles them, but experts warn of potential long term consequences if the condition is not treated.  The diagnosis is classically made after an overnight sleep study when the patient is monitored.  I have equal confidence in the diagnostic skills of those who sleep in the same room as the individual at home.  For example, if a patient’s wife tells me that her husband regularly (and fortunately temporarily!) stops breathing during sleep, I think that the diagnosis has been securely made.  In these cases, I am unsure how an overnight sleep study would alter the treatment plan, but I suspect that most sleep physicians would still recommend it.


Why is everyone so tired?

The usual treatment is for the patient to don a clumsy and noisy helmet apparatus called CPAP while sleeping.  Many patients find this remedy to be worse than the disease and have eschewed this recommendation.   I expect that technological innovation will make progress on this front.

I offer readers an interesting side note on one of the warning signs of OSA – snoring.  I find that patients often regard snoring as if it were a moral failing.  For example, if I ask a patient if he snores, he may point to his wife in the exam room exclaiming, “you should hear how loud she snores!.   This scenario has repeated itself over the years and always amuses me.   Snoring isn’t a vice that needs to be minimized by pointing to a fellow sufferer.

Sleep is important and most of us don’t get enough of it.  Wouldn’t life be better if an afternoon siesta became a daily routine in our culture?  

Sunday, January 20, 2019

Physician Weight Loss Tips

Although I have confessed that I am not a seasoned expert in this field, here are some tips and pointers I’ve gleaned over the years.


Slow and Steady Wins the Race!

  • Avoid gimmicks.  We’ve all seen ads and telemarketing pitches that promise to melt off pounds by the hour.   These products are very effective for the companies, but not for you.  They don’t work.  Yes, you may enjoy some short term weight loss for as long (or short) as you can stay motivated, but the chance of keeping the weight off is vanishingly small. 
  • You don’t have to be perfect.  Allow yourself some backsliding and seek continued motivation from these events.  The path to your successful destination may include some zigzagging.
  • Weight loss medications don’t work well.  Of course, the notion of a pill solving any medical problem is seductive, but the history of weight loss medications includes an array of side effects and relatively modest results. 
  • Bariatric surgery, including gastric bypass procedures, has made great strides in recent years.  I have seen many successes and failures in my practice.  These procedures will not work unless the individuals have made the difficult mental commitment to a profound life changing procedure that will be present every day of their lives.  In my view, these procedures should not be casually or prematurely entertained.  Is a candidate for surgery unable to lose sufficient weight in any other way?   If the candidate couldn’t stay motivated to stay on a diet, will they have the motivation to make surgery a success?
  • I recommend partnering with a professional, such as a dietician, to offer guidance, support and accountability.  If not, recruit a family member or a friend to serve as your coach.
  • You will not exercise the weight off.  Patients lament to me all the time they can’t understand why their weight stays the same or even creeps up despite their walking and exercise routines.  To burn off serious weight, a person would have to intensely exercise for hours and hours each week – far beyond the capacity and willingness of almost all of us.  From a weight loss perspective, a more successful strategy is to restrict the calories that are coming in rather than burn them off after they have been swallowed.  In other words, eat less. 
  • Set reasonable and achievable goals for yourself.  
Achieving sustained weight loss is hard.  If it were easy, all of us would be skinny.

Sunday, January 13, 2019

Memorial Sloan Kettering in Bed With Industry


Is there corruption in the medical profession?  Recall Captain Renault’s iconic rejoinder to Rick in Casablanca.

“I’m shocked, shocked to find there is gambling going on in here!”



In any enterprise with billions of dollars at stake, and when different players have competing interests which may not coincide with the public’s interests, there will be skullduggery.  How do you think our Defense Department and its relationships with vendors would look if we were able to shine a bright light on all its faces?  Do you think it’s possible that a weapons manufacturer might argue, through lobbyists and salesmen, that its weapons are essential to national security and superior to those of a competitor?   How about when a congressman argues for the continued purchase of military equipment manufactured in his district that military experts state is no longer needed?  And, there’s the quintessential and craven corruption of legislators refusing to close military bases in their districts that the military want to close down.

And, so it is with the Medical Industrial Complex where the arena is filled with jousting pharmaceutical execs, hospital administrators, insurance companies, the government, medical device companies, physicians, pharmacy benefit managers, politicians and the public – all competing to protect their interests.  Does this system seem optimal to achieve a greater good for society?

Recently, the Chief Medical Officer of the Memorial Sloan Kettering Cancer Center in New York City ‘resigned’ in the wake of disclosures that he failed to disclose financial relationships with outside health care companies.  In other words, it was a failure to disclose that ousted him, not the conflict.
 
Here’s my riposte to this.  The obvious weakness in our current disclosure policy is that the emphasis is on the disclosure and not the conflict.  Following nearly every medical article that I read, appears a long list of disclosures, often in small font, listing the various business relationships that the authors have with various companies.  Apparently, in the authors’ and the editors’ minds, the disclosures have provided them with adequate ethical insulation.  They argue that readers can weigh the disclosures when they assess the authors’ credibility. For example, if an article is extolling a new diagnostic test, readers may be informed that the author is a paid speaker for the company that manufacturers the test.  The actual conflict, however, remains. 

Over the past 10 years or so, practicing physicians and scientists have been so deluged with disclosures in our journals and at our professional meetings that we have become numb to them.  (How carefully do we listen to the safety presentation given by flight attendants prior to take off?)  The ongoing tsunami of medical disclosures have vitiated their potency, and as I stated above, do not address the actual conflicts. 

The connections between medical science and medical industry can create great benefits for humanity.  I accept and encourage this.  And, I’m all for full disclosure.   But, personal and institutional integrity must be paramount.  Oftentimes, the conflict itself should be disqualifying and no simple disclosure should be permitted to cure it.

Addendum:  The Chief Medical Officer who 'resigned' was immediately hired by... yes, you guessed it, a pharmaceutical company!  And, Sloan Kettering (SK) now prohibits its leaders from serving on corporate boards.   Can we assume this to be an admission that SK now recognizes that such business relationships are improper or did they simply feel the optics were uncomfortable.

Comments, confessions, and disclosures welcome. 


Sunday, January 6, 2019

Medical Device Sales Rep Kills the Sale

A few weeks before writing this, two device salesmen came unannounced to our small private gastroenterology practice.  They were hawking a product that could quickly and non-invasively determine how much scar tissue had formed in a patient’s liver, a useful tool for assessing patients with hepatitis and many other liver conditions. 

We are physicians, not entrepreneurs.  We do not regard the colonoscope as a capitalist tool.  Yet, these two salesmen were barraging us with facts and figures on how much money we could make off their product.  They knew the insurance reimbursement rates and could quickly calculate our practice’s return on investment depending upon our projected volume.  They recognized that the cost of their device would be beyond our reach and offered to sell us a ‘refurbished’ product at a huge discount.

Liver Sales Reps Ignored the Liver!

For a host of reasons, we were not interested in acquiring the device, which we could not afford.
Here’s what was so striking.  Not once did either of them mention, even by accident, that their product was a device that might help a human being.   These guys were so clumsy and so transparent that they weren’t even adept enough to feign an interest in contributing to the health of liver patients.  Of course, we would have seen right through this pretense anyway, but at least they would have gone through the motions with the hope that we might not have recognized their charade.

Afterwards, our office manager was deluged with e-mails beseeching us to reconsider our refusal, offering ‘new and improved’ calculations that promised us profitability.  And, borrowing a technique from late night infomercials, they now offered an even steeper discount on a newly discovered refurbished product that was a deal they advised that we should not pass on.

We have many sales folks who come to see us.  Of course, we understand that they are selling products.  But a true sales professional understands his customer, and these guys massively misfired.  We are physicians, not hedge fund managers who regard income generation as our primary objective.  How should salesmen sell to doctors?  When device or pharmaceutical representatives come to see us, they are best poised to sell us on how their wares can help our patients improve their lives.  The product that can sell itself, sells best.  

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