Sunday, October 20, 2019

Physicians and the Art and Power of Observation - Has This Bird Flown?

Medicine is for the birds, or it should be.  Hear me out.

A day before I wrote this, I was on the trail in northwest Ohio, binoculars in hand, trying to tell one warbler from another.  This was the final weekend of The Biggest Week of birding in Magee Marsh on the shore of Lake Erie.  Birders converged here from neighboring states and even from foreign countries to participate in this ornithological adventure.  My companion and I were new to the game.  Indeed, my birdwatching prowess had consisted of being able to successfully identify a blue jay at the feeder on our deck.  I had now entered a different universe.

There were serious birders afoot equipped with photographic and telegraphic equipment that looked like stuff that James Bond might have used.  Birds flitted about that heretofore would have generated no interest on my part.  When a rare warbler was spotted, the excitement raced through the birders like a brushfire, causing a crowd to gather to view the feathered phenom.  And, there were polite disputes among experts who were debating the true identity of the creature before them.  All in all, this was good clean fun.

Birders need knowledge and patience.  In addition, the most accomplished among them must have discerning powers of observation.  Here’s how I spotted a bird.  I simply came upon real birders who were all aiming their scopes and binoculars in one direction, and then tried to spy their target.  The skilled birder, the first on the scene, does not have this advantage.  He carefully scans the trees and foliage trying to find small birds, which are obscured by leaves and branches or camouflaged.  This looks easy, but it isn’t.  Many times, I had trouble finding the bird even when several birders next to me were staring at it.  This didn’t ruffle my feathers as I knew I was a few rungs below the beginner class.

You have to know what to look for, which is the distinguishing skill.  The pro knows the flora and which birds are likely to hang out there.  He sees the subtle moving of a small branch and knows this is not from the wind.  He knows the birds’ voices as individual arias, not as idle whistling.  He tunes out the visual and auditory static.

Easy to Spot 

Not so Easy

The power of observation used to be a honed skill of the medical profession.  Prior to the takeover of the profession by medical technology, physicians could deduce much simply by carefully observing the patient.  While medical educators may state that this skill is still valued, taught and practiced, this quixotic view isn’t part of the reality of medical practice today.  During my days in medical school, I recall learning from experts who could ascertain important medical information by examining a patient’s fingernails.  Palpating the pulse, and appreciating its nuances and subtleties, was an art, and not simply a means of determining the heart rate.  As a medical student, I watched Proctor Harvey, a giant in cardiology, use a stethoscope to hear sounds and make accurate diagnoses that are beyond the skills of nearly all of today’s physicians.   A patient’s speech, gait and skin often held important clinical clues for the physician detective.

I don’t’ think that medical quality is worse today because today’s physicians are not trained to observe.  Instead of observing, we test.   Nearly every heart murmur is subjected to echocardiography, as but one example.  The consequences of overtesting has been overblogged here at MDWhistleblower.  Readers know my serious concerns about overdiagnosis andovertreatment. Technology has both raised and lowered medical quality in this country.

I am wistful when I recall physicians and teachers from two generations ago, who could solve a case with their eyes and ears.  They would have been incredible birdwatchers. 

Sunday, October 13, 2019

Colonic Hydrotherapy. Is it Time to Bend Over?

From time to time, patients asks my advice on colonic hydrotherapy, vigorous sessions of enemas that aim to cleanse the body of toxins that are reputed to cause a variety of ailments.   The logic sounds plausible to interested patients.  Over time, toxins accumulate and leech into the body wreaking havoc.  Indeed, using the label ‘toxins’ already suggests that these are noxious agents.  If one accepts this premise, it is entirely logical that cleansing the body of these injurious agents would have a salutary effect.

Not surprisingly, the health benefits of hydrotherapy usually target very stubborn and vague symptoms and conditions that conventional medicine do not treat adequately.  It makes sense that if your own physician is not making sense of your chronic fatigue, for example, that you would entertain other options.  I get this.  Who wouldn’t want to enjoy having more energy, better concentration, an enhanced immune system or delayed aging?  But, in medicine and in life, just because one pathway seems blocked, doesn’t mean that an alternative pathway will be a better avenue. 

Let the Cleansing Begin!

The reason that I do no actively recommend hydrotherapy is because there is absolutely no persuasive and credible medical evidence that it is effective.  While their advertising materials may boast of ‘clinical studies’, there is no firm scientific basis for their claims.  And, these sessions can be costly as patients are often advised that several visits are necessary to address years of toxin build up.

If gastroenterologists did believe that the treatment works, we would be offering it in our ambulatory surgery centers along with our standard endoscopic amusement activities.  (A cynic might suggest here that if medical insurance covered these treatments, then we would!) 

It may very well be that practitioners of this treatment believe in the therapy and genuinely want to provide healing.  And, I have no doubt that many who undergo hydrotherapy feel better.  I’ll never talk a patient out of success from my or anyone’s treatment.  If a hydrotherapy patient were to tell me that his depression has eased, I would express great satisfaction over this.

I admit readily that I, along with every other breathing physician, prescribe treatments and remedies for which no supportive medical evidence exists.   We physicians may sanitize this fact by claiming that our action is an example of ‘the art of medicine’, but we are more likely hoping for the placebo effect.  

Physicians who deviate from evidence-based medicine shouldn’t casually criticize other practitioners who practice off the grid, particularly when patients have great faith in complimentary and integrative medicine.

However, all of us who claim to be healers should aspire for supportive scientific evidence for our recommendations, and we should admit to patients when such evidence is lacking. 

If you opt for periodic colonic cleanses, and you perceive a personal benefit, then be aware that you are engaging in an ‘art’, and not a science.  

Sunday, October 6, 2019

Treatment for Diverticulitis Revisited

Is there stuff that you do just because that’s the way you’ve always done it?   I’ll answer for you – yes.

In many circumstances, this makes sense.  For example, I stop my car at red lights just as I have always done.  I recommend that readers do the same as there is an underlying logic for this recommendation.  It is not simply a rote routine that has no rationale.   However, the particular order that we pour ingredients into a pot when making soup, may be more random than rational.   We follow the same order we always have, never pausing to wonder why or if there might be a better way.

And, so it is with many practices and procedures in the medical profession. Let’s return to the medical condition of diverticulitis, which I presented on this blog recently.  Follow the link, if interested.

For the last several decades, this disease has been treated in the same way – with antibiotics.  This means that physicians believe this to be an infectious disease – like strep throat – caused by bacteria.  But, the real reason I think that physicians like me prescribe antibiotics for this condition as because that’s the way we’ve always done it.

Changing established medical practices is like having an ocean liner make a U-turn.  It’s not easy.  For example, when I was a medical student, kids with red ear drums, or otitis, were routinely given antibiotics, assuming that this was a bacterial infection.  But, after a few decades, experts concluded otherwise.

Not Easy to Make a U-Turn

Similarly, I have a strong sense that the established treatment for diverticulitis may be revised.   The classic understanding of this disease was that this was a bacterial infection in the wall of the colon.  The theory was that a tiny puncture would develop in one of the diverticula, which are pouches that are weak points in the colon.  Germs from inside the colon would travel through the puncture site to the outside wall of the colon, which is usually sterile, and an infection would start.  We prescribe antibiotics and the patients generally recover well. 

But, should the antibiotics really get the credit?  What if these patients would have recovered anyway on their own?  I believe many of them would have.   In fact, many patients who have had diverticulitis, often have had episodes that recovered spontaneously without having seen a physician. 

In fact, a prominent gastroenterology professional society recently issued guidelines that expressed that not every case of diverticulitis requires antibiotic treatment.   It may take another 10 years for this recommendation to gain traction. 

I’m not abandoning antibiotics for diverticulitis in my practice yet.  But, I am following the issue closely in the journals.  There needs to be a better reason to do stuff than simple habit and routine – and that includes reading this blog.

Sunday, September 29, 2019

Value-based Pricing and Reimbursement in Health Care

I am a conservative practitioner in my specialty of gastroenterology.  Compared to peers, I order fewer scope examinations, prescriptions and CAT scans.  I’ve always believed that a more parsimonious practice of medicine would protect my patients better than would a more aggressive approach.  Sure, this also means that I spend fewer health care dollars on my patients, but this is not my primary motivator.  I practice in this manner because I am convinced that in the medical profession, less is more.

I am somewhat of an iconoclast as many of my colleagues for various reasons practice differently.  They might feel that my medical nihilism is depriving my patients of necessary testing and treatment. Patients over time tend to find physicians who share their philosophy.   Patients who believe that more testing and more medication is the pathway to better health will not be comfortable with a doctor like me.

But, change is afoot!  I predict that within the next several years, if not sooner, that my practice style will become normative.  Why would this occur?   Why would physicians who were heavy on the medical utilization gas pedal suddenly be pumping the brakes?  

It’s the reimbursement, stupid.   Soon, physicians and hospitals will be paid differently.  Value based pricing will become the means of reimbursing health care providers and institutions.   So long, fee-for-service, a system that rewarded the medical profession for excessive and unnecessary care.  Payers will reward physicians and health care systems that deliver favorable outcomes that are cost-effective.   Not surprisingly, when physicians and hospitals have a financial stake in how they practice, the practice style arc bends.   It’s a law of economics that folks spend other people’s money faster than they would their own.   Do you order differently off the menu when someone else is picking up the tab?

I think I'll order the steak tonight.

Changing the reimbursement policies will make sausage making seem appealing.  Remember, every example of excessive medical care is someone else’s income.  It is unlikely that those who will lose out will champion an effort that might cost them money. 

No system is perfect.  Every reform proposal poses conflicts that need to be exposed and addressed.  We all want high quality medicine that is delivered efficiently.  If, however, there is too much zeal in achieving cost savings, then this could adversely affect quality.   We need to ensure that we remain true to our primary mission which is to protect the health of those whom we serve.   The current system desperately needs to be reformed.  But, we want what emerges to be a step forward on a journey that may take a decade or longer to reach the destination.  If we simply exchange one set of problems for another, then we have traded quicksand for falling off a cliff. 

So, let’s look for the pharmaceutical companies, physicians, hospitals, insurance companies, the government, medical device companies, extended care facilities and the public to join hands as they sway in a Kumbayesque moment all pledged to serve the greater good. 

Sunday, September 22, 2019

Do I Have Diverticulitis?

I have been treating diverticulitis for 30 years the same way.  When I suspect that a patient has this diagnosis, I prescribe antibiotics.  This has been the standard treatment for this disorder for decades.
I have found that diverticulitis is a slippery entity that has two trap doors waiting for physicians to fall through.

 It is an easy task to miss the diagnosis.  Every physician has done this.

The diagnosis can be erroneously assigned to a patient.  Every physician has done this.

Recognize that the phrase ‘every physician has done this’ includes me.
The diagnosis can be elusive as there is no diagnostic test that secures the diagnosis.  The technology tsunami has covered the medical landscape, as it has run over so many other spheres in our society.  Doctors and patients increasingly rely upon ‘the numbers’.  Want proof?  Do you think there are many physicians today who can actually plug a stethoscope into their ears and hear, let aloneunderstand all of those clickety-clackety heart sounds?  And, if they do, they order an echocardiogram anyway. 

Hey, what's this new fangled contraption?

The medical community and those we serve are hyperfocused on objective data - stuff that can be measured.  Here are 3 examples of seemingly reasonable questions that I believe often miss the mark.  

What did the CAT scan show?  
Did the tumor marker decrease?   
Is my carotid arteries screening test normal?  

A more relevant question, such as, how is the patient doing?, is ignored or relegated to a lower priority status.  Who cares if the tumor marker goes down if the patient doesn’t feel any better? 

So, when diverticulitis is a consideration, a physician actually has to act like a doctor.  Sure, a CAT scan can be consistent with diverticulitis, but many other conditions can precisely mimic this CAT scan appearance.  So, the physician has to make a ‘clinical diagnosis’ of diverticulitis.  This means that the doctor must analyze all of the data – your symptoms, the labs, radiology results – and then make a judgment.  A common error is when the diagnosis is prematurely made based primarily on the CAT scan, without weighing other factors.  A clinical diagnosis of diverticulitis can also be made without a CAT scan or laboratory data.  Yes, the doctor can actually perform old fashion doctoring, which has become rather quaint these days.

In my practice, many patients who come to me complaining that they are experiencing a ‘flare’ of their diverticulitis are mistaken.  There is some other explanation for their stomach pain.  Or, the patient may state that the pain is identical to a prior episode of diverticulitis, but often the original diagnosis of diverticulitis was incorrect or uncertain.  Yes, I admit again there is always the chance the patient is right and I am wrong, but hopefully my decades of training and experience are worth something. 

My points above are certainly not restricted to diverticulitis.  They cross into every medical specialty.   Technology and objective data too often are wag the dog.  Who do you want evaluating your medical symptoms, a physician or Alexa?

Sunday, September 15, 2019

Should High Blood Pressure be Treated?

In last week's post, I promised an explanation why many screening and medical treatments offer so little benefit to individual patients.   If you invest the time to digest last week's post and the post before you now, then you will be equipped with new understanding that will enable you to make much better medical decisions.  In accordance with this blog's mission, this is truly a 'peek behind the curtain'.  I grant you that these 2 posts are a little wonky, but try to stay focused.  

Here is the main reason that ordinary people – and even some medical personnel – become confused on this issue.  Studies that assess screening tests and medical treatments are often performed on very large groups of patients.  The reason for this is that smaller studies, for reasons I cannot fully explain here, are simply not felt to be sufficiently reliable.   This is why the Food and Drug Administration would never grant approval of a new medicine based on favorable results from small studies.   If a benefit or a failure is shown in a high quality study with hundreds or thousands of participants, the results will be highly credible.   It was large studies, for example that demonstrated that blood pressure control prevented serious complications. 

Here is the key point.  When a medical benefit is established in a large study, this benefit applies to a large population of people.   When this medical test or treatment is later applied to an individual patient in a doctor’s office, the benefit that this person receives may be miniscule.   This reality is not appreciated by nearly all patients I have treated in nearly 3 decades.  If a patient reads about a study that concludes that losing excess weight will cut the risk of stroke by 30%, the patient is likely to make 2 false assumptions:

He overestimates his risk of stroke.

He overestimates the true risk reduction of losing 10 lbs.

If his risk of stroke is already very low, then reducing it by 30% offers almost no benefit.  Follow the next example.

Will Lowering My BP Save My Life?

Assume a study of 5000 patients with high blood pressure demonstrates that lowering blood pressure 10%, can halve the risk of developing a heart attack.  This sounds like a game changer, but not to an individual patient, such as any person reading this.  The benefit is derived from studying a large population.   Assume that without treatment that 100 patients of the 5000, or 2%, would suffer a heart attack in 10 years.  With blood pressure treatment, only 50 patients would suffer this outcome, a 50% decrease in the adverse event.   Wouldn’t it be true that an individual patient would also have a 50% risk of developing a heart attack?  Yes, but let’s play this out.

A patient comes to the doctor with modest high blood pressure and no other cardiac risks. The patient has read about the landmark study that concludes that treatment would halve his heart attack rate.  Let’s assume, that this person’s risk of developing a heart attack in 10 years is 3%.  That means that this individual already has a 97% chance of staying well without any treatment.  Treating this patient would lower his risk of a heart attack from 3% to 1.5%, representing the 50% benefit we have been discussing.  So, with treatment, he now has a 98.5% probability of avoiding a heart attack.  Would someone enthusiastically take lifelong blood pressure medicine for an additional 1.5% protection when he already was 97% in the clear?   Would most of us welcome this return on investment?  I am not even considering the costs of many of these treatments and the potential side effects.   

When large studies’ benefits are applied to individuals, the benefits calculate out very differently. However, treating hundreds of thousands, or millions of people with elevated blood pressure would save many of them simply because we are dealing with large numbers of people.  A percentage point or two of a million people is a respectable number.  That’s why it makes sense to treat many diseases from a public policy standpoint.  The point is that each individual only enjoys a very modest benefit. 

I hope that readers have found this post – and the blog overall – to offer a very high return on investment.   Your comments are always welcome. 

Sunday, September 8, 2019

Does Mammography Save Lives?

I find that the public often exaggerates the benefits of many preventive health measures.  I don’t blame the public for this.  There are several forces conspiring to deceive the average patient into accepting exaggerated claims of various medical tests and strategies.   Of course, the Medical Industrial Complex is a gluttonous beast that must be fed massive quantities of medical testing and treatment if it is to survive.

Most of the public thinks that medical interventions, including mammography, lowering cholesterol levels, blood pressure reduction and even colonoscopy are downright lifesaving.

Recognize that I am in favor of all of these measures, but that the actual benefit to the individual is much smaller than most folks believe.  In the case of mammography, there is uncertainty as to whether it saves lives at all, a view readers can easily find with a rudimentary internet search.  Mammography experts all agree that any benefit of this screening test to the individual patient is very modest.  This is not my opinion; it is a fact.  And yet, most women, including the women in my life, believe that this test offers them solid protection.

Mammography - True Lifesaver?

If I am correct that the individual enjoys only very modest benefit from these routine medical interventions, then how did they gain a permanent foothold in the medical landscape?

Why would physicians zealously recommend tests that were of such limited value?

Why would insurance companies and the government pay for such testing?

Why would patients submit to tests or lifelong medications that offered a very limited benefit?

Why are so many of us unaware of this issue?

As I do not want this post to be double my usual word count, I will provide you next week with a detailed response on this issue.  I strongly urge you to check back here next Sunday for an opportunity to inform and empower yourselves.   I’m not against screening tests or established medical treatments.  I’m for the truth. 

Sunday, September 1, 2019

Labor Day 2019

All work is honorable.

Honor everyone's work.

Work with honor.  

The Whistleblower wishes all of you a meaningful Labor Day.

Sunday, August 25, 2019

Do Patients Like Weekend and After Hours Medical Care?

I have previously expressed how physicianss feel about treating patients that they do not know in a prior post, which readers are invited to review.  This post is the other side of the story.   

Nowadays, patients are used to seeing physicians who are not their doctors.  Often, patients may be seeing a nurse practitioner, a highly trained professional for their medical care, instead of a physician.  A generation ago, patients nearly always saw their own physician, including if a patient was hospitalized. Imagine that, your own primary care doctor sees you in the hospital, an event that occurred when dinosaurs roamed freely.

The medical universe has changed.  Hospitalists care for most hospitalized patients, which in my view, has vastly improved the quality of hospital medical care.  It is commonplace for patients who need to be seen right away in the office, to see a doctor who is available, who may not be the physician of record.  Pregnant women today often see many obstetricians in the group since it is unlikely that the patient’s designated obstetrician will be on-call on D-day.  One of Cleveland’s corporate medical giants boasts that they offer ‘same day appointments’, which is true if a patient is willing to see a medical professional several zip codes away, not the patient's actual doctor.

In the olden days, one doctor did it all.

Understandably, if you call your physician after hours or on the weekend, you will most likely connect with one of your doctor’s partners.  This is why it is not advisable to call the emergency on-call physician 9 pm for a conversation about your chronic arthritis.

Patients are now used to seeing strangers prescribing their medications and ordering their diagnostic tests.  Hospitalized patients may be treated by several physicians they do not know. They have adjusted as best they can, but there are obstacles and drawbacks to this medical care paradigm.
  • It is unsettling for patients to be confronting several medical professionals for their care.  Similarly, if you are reading 4 or 5 books at once, are you really able to keep the separate stories straight in your mind?
  • There is unavoidable loss of continuity when there are multiple physicians at the table.  Hospitalists do a great job.  But, do we really think that all of the nuanced knowledge and objective data can be seamlessly transmitted to your primary care physician whom you will see after you are discharged?
  • What if different primary care physicians who are seeing the same patient have different opinions?  Who does the patient believe?
  • Even in the computerized era, it’s astonishing how often new physicians do not have easy access other physician’s medical records.  Does the weekend physician consultant who is seeing you in the hospital know that another doctor already ordered an ultrasound of the gallbladder a few months ago across town?
  • When there are too many physicians involved in a single patient’s care, medical testing and costs tend to increase, which does not increase medical quality.  In my experience, a new doctor is more inclined to order a medical tes, than to advise watchful waiting, a strategy that the doctor who knows the patient well would more likely rely on.  For example, if I see a patient I know for years with the same stomach pain, I may react differently than another gastroenterologist seeing him for the first time. 
Oftentimes, patients and physicians meet as strangers.  This reality creates many challenges.  Both sides need to be understanding.

Sunday, August 18, 2019

Should Doctors Offer a Money Back Guarantee?

It may seem odd that a gastroenterologist patronizes fast food establishments several times each week.  I’m in one right now as I write this.  I eschew the food items –though French fries will forever tempt me – and opt for a large sized beverage.  In truth, I am not primarily there for a thirst quenching experience, but more to ‘rent a table’ so I can bury myself in some reading.  Indeed, many thousands of New York Times issues have been devoured at these tables.  I saw a sign posted on the wall here that I had not seen before.

Sorry, No Refunds

Refunds?  How often can this happen in a place like this?  We all know that food items in these institutions are remarkably consistent, which is one of benefits that customers enjoy.  Your Big Mac or Whopper will taste the same in Pittsburgh as it does in Peoria.  I questioned the server on this new development and she explained that increasingly customers were demanding refunds for contrived reasons in an effort to bilk the restaurant.  At some point, the restaurant decided to put an end to this practice. 

Refund Free Zone!

I wonder how my patients would react to being greeted by such a sign in my office?  Of course, physicians do not offer refunds or a money back guarantee for our services, as other industries boast.  Nearly every infomercial includes the tag, “and if you don’t agree that these _____  are the best you’ve ever used, simply return it for a full refund – no questions asked!”  Not so in the medical profession.   We are paid regardless of the outcome or your satisfaction.  It is true that physician reimbursement policy is evolving away from fee-for-service (FFS) toward a value-based system.  In other words, physicians won’t be paid separately for every medical service we provide you, but for the overall ‘value’ we provide, which is a somewhat amorphous concept.  FFS clearly incentivizes the medical profession to overtreat patients because we are paid more for doing more, even if such care may not be truly necessary.   It remains to be seen if the value-based payment approach will protect patients and be fair to physicians. I have my doubts.

Many professionals are paid regardless of how their clients fare.  It you lose your case in court, your lawyer will still be paid.  If a judge is overruled on appeal, his wages aren’t reduced.  If your investment underperforms, your financial planner doesn’t return his fee to you.  Tradesmen, on the other hand, make a commitment to satisfy us as a condition for getting paid.  If we hire a plumber to unclog a sink, for example, he understands that if he doesn’t deliver, then we won’t either. 

What if all of us were paid on results rather than on time expended?  Would this lead to higher quality goods and services?  Could it really apply to the medical profession?  If a patient comes to see me with abdominal pain, which often defies explanation even after a thorough medical evaluation, is it fair that I wouldn’t be paid if the patient’s pain persists?

None of this applies to Whistleblower readers.  These posts are free so don't ask me for refund.  

Sunday, August 11, 2019

Joining a Clinical Trial Helps Others

From time to time, I am asked by someone about participating in a medical research study.  These situations are usually when an individual, or someone close to them, has unmet medical needs.  Understandably, a patient with a condition who is not improving on standard treatment, would be amenable to participating in a clinical trial to receive experimental treatment.

I find that most folks misunderstand and exaggerate the benefits they may receive as a medical study participant.  Sometimes, I feel their ‘misunderstanding’ is fueled by study investigators who may overtly or unconsciously sanitize their presentation to patients and their families.  There is no malice here.  Investigators have biases and likely believe that their experimental treatment actually works.  Their optimism is likely evident in their communications.

Here’s what an investigator might say to a patient.

I thought you would be interested in a new clinical trial testing a new medicine for your disease.  Preliminary data show promising results. 

If you were a patient, wouldn’t you infer that the drug might help you?

Patients, I have found, are of the mistaken belief that they may directly benefit from the drug being tested.  Of course, this makes sense to them.  Their rheumatoid arthritis drug isn’t working.  They are informed of a clinical trial of a new treatment for patients who do not respond to conventional treatment.  Obviously, they enter this trial with the hope that their condition will improve.  Unfortunately, this is the wrong way to approach a medical study.

Louis Pasteur - Legendary Medical Researcher

Clinical trials are not designed to benefit the participants.  They are performed to generate new knowledge that may help future patients.  This is the key point that so many study participants are not fully aware of, and they should be.  The investigators do not know important data about safety, efficacy and dosing.  These are among the fundamental data that the study – and future studies – will determine.  If medical investigators knew that the drug actually worked, then there would be no need for a clinical trial.  There’s a reason behind the term experimental treatment.

If you want to enter a clinical trial, know that you are doing so to help others who will come after you.  This is a selfless and praiseworthy event.   Indeed, we have all benefited from the sacrifice and altruism of prior patients who agreed to create new knowledge to help us.   If we enter a study we may not personally receive a return on investment for our efforts, but we are paying it forward to others.

Sunday, August 4, 2019

Transparency in Health Care Costs - New White House Proposal

Opaque:  adjective, not able to be seen through; not transparent

Medical pricing is beyond opaque.  It’s a riddle wrapped in a mystery inside an enigma.  Many readers will recognize that this clever phrase is not my own.

Throughout my career, I have been unable to provide an accurate answer to the perennial inquiry, how much does a colonoscopy cost?  Patients, of course, find this to be baffling.  This ignorance is certainly not restricted to my specialty of gastroenterology.  Does it make sense, for example, that the same medication may have wildly different pricing at different pharmacies or in different cities?   In contrast, we would expect to find a similar price for a gallon of milk among supermarkets. 

My strong suspicion is that seemingly irrational, inflated and complex medical pricing is all by design to serve those on the billing end – hospitals, pharmaceutical companies and pharmacy benefit managers.  Before you accuse me leaving physicians off of this list of Greed & Shame, may I remind you that we physicians do not set our own prices; they are all dictated by the payors.  When we send you a crazy bill, it is all according to your insurance company requirements and policies - not us.  Same for the copays patients fork over when they come to see us.  While we are the target of griping and sniping, these cash extractions are mandated by your insurance companies.

The medical arena is unique.  It does not allow consumers to utilize price comparison as they do when purchasing appliances, vacations, private schools,  apartment rentals or an apple.  It is unlikely that one would sign an apartment lease without being told what the monthly rent charge would be.   But, we will proceed to a CAT scan examination without knowing the cost or if a nearby competitor can provide the same service for less.

Fairly Easy to Determine the Cost Before the First Bite

Recently the White House launched an initiative to require physicians and hospitals and insurance companies to inform patients of the costs of medical care in advance.   Of course, this concept should be welcomed and applauded.  Push back against it was locked and loaded before the new policy was announced.   Who’s against price transparency?  Hospitals and insurance companies and drug companies are united in their opposition.  They claim, among other things, that they would be forced to surrender proprietary information,  that medical prices would actually increase and that the public would not be well served.   I am not an economist, but I surmise that exposing the buried secrets of medical pricing will empower the rest of us in making better choices.  Real and open competition will bring prices down, as is true in all other spheres of commerce.

Some economists are warning that this issue is extremely complex and that the outcomes may be paradoxical.  I'm willing to take a chance.

My goal before I retire years from now is to be able to tell a patient how much their colonoscopy will cost.  

Transparent: adjective, allowing light to pass through so that objects behind can be distinctly seen.

Sunday, July 28, 2019

Value Based Pricing in Medicine - A 'Stinging' Issue!

Some professionals and businesses get paid regardless of their outcome.  They are paid for their time and expertise.  For example, if you hire an attorney, unless you have a contingency fee arrangement, you will be billed regardless of the outcome.   If you sue a business because you allege a product you purchased is defective, but the business counters that you damaged it by using the wrong tools to assemble it, there is no guarantee that you will enjoy a legal victory.  However, if your lawyer has invested 20 hours of labor as your advocate, he or she will certainly enjoy a financial victory if an hourly rate is in place. 

Similarly, if your financial advisor, who is paid on commission, advises that you invest in a certain product, and the investment declines 10%, only one of you will take a major hit.  Guess who?
If you treat yourself to expensive theater tickets, but you find that the performance was dull and uninspiring, do you expect to be given vouchers for another show as you exit?

See my point?  In these instances, and so many others, we pay regardless of the outcome.  The concept of paying for results, which is much more attractive to the consumer, has yet to gain a solid footing in the commercial world.

But, that may change.  It certainly has in medicine.  The fee-for-service era, when every service is reimbursed – regardless of the outcome – will be entirely phased out.  Physicians, hospitals, nursing homes, rehabilitation centers will be paid if they meet designated quality benchmarks.  If these standards are exceeded, then a bonus payment may be forthcoming.  If the standard is not reached, then the provider may be coughing up a penalty. 

Beware the Hornet's Nest!

The concept is attractive in medicine and in commerce overall.  Consider these two hypothetical examples under the fee-for-service model.

A patient sees a gastroenterologist.  Although a colonoscopy is not medically necessary, the physician advises it and performs it.  There is a complication and the patient is hospitalized for 5 days.  Emergency surgery was needed to repair the complication.  All physicians, hospital consultants, the hospital and a few days of post-discharge rehab are all reimbursed.

A patient sees a gastroenterologist.  A colonoscopy is not medically necessary and is not ordered.  The patient is advised to continue Metamucil and to return in 6 months.  The physician is compensated at a mid-range level office visit level.

The absurdity in the above example is apparent.  The wrong incentives are in place.

Here’s the challenge in rewarding outcomes. 
  • What are the quality outcomes that will merit compensation?
  • Is there a fair and reproducible manner to measure the outcome?  (How would you precisely measure improvement in fatigue, depression and abdominal pain?)
  • Would physicians and hospitals be penalized if patients did not follow medical advice and had poorer outcomes?
  • Should specialty physicians who have trained longer than primary care physicians expect higher reimbursement levels?
  • How do you reward a physician who does not order unnecessary tests, consultations or prescriptions? How could you reliably measure this?
  • If a hospital receives a ‘lump sum’ fee for a patient’s care, how is this fairly divided among the hospital and the various physicians?
Let’s be truthful.  Some forces advocating for value based pricing - pay for outcome - are pursuing this strategy to save money as much or more than to enhance medical quality.  The potential conflicts of interest are self evident. 

And, there’s the risk of going too far.  If I see a patient with abdominal pain and after appropriate testing determine that diverticulitis is the culprit, I will likely prescribe medication. If the patient doesn’t respond to the proper treatment, should I have to forfeit my reimbursement?  Would this be fair?  An unwelcome outcome is not evidence of deficient medical care. 

Value Based Pricing, like many slogans, is attractive.  But, there may be a hornet’s nest lurking below.

Sunday, July 21, 2019

Walk a Mile in their Shoes - Lessons from a Backyard Rodent

“He ate my dahlia!” exclaimed the lady of the house. 

Our backyard is a menagerie.  We are often perched at the window gazing at birds hovering over our feeders, raccoons climbing tall trees, ground hogs, possum, wild turkey, deer, a red tail hawk, a seemingly misplaced spring peeper, stray cats and scampering squirrels and chipmunks.

And, the lady was correct.  A chipmunk, who seems to know our property as well as a trained surveyor, hopped into the newly created dahlia flower pot and enjoyed a colorful repast.  As of this writing, there is one remaining, lone dahlia, which might be on his menu later for dinner or a midnight snack.

Where Have All the Flowers Gone?

I will take issue, ever so gently, that the resourceful rodent ate ‘our’ dahlia.  I suspect that readers have uttered or heard similar phrases, such as 'the deer ate our flowers!'  Let’s consider the issue from the animal's points of view.  
  • The land that we claim title to is their home.  So, for starters, there is a property dispute.
  • They and their descendants were there long before we were.  Perhaps, they have a home invasion argument?
  • They are seeking food and shelter in accordance with their needs and instincts on their home turf. How would we react if a higher power summarily banned us from all supermarkets and restaurants?
  • They have to contend with human interlopers placing various repellents, barriers and obstacles impeding safe passage to their food supply. 
So, is the hungry little chipmunk a perpetrator or a victim?   Now, don’t get your acorns all riled up over this.  I’m trying to make a point.  It’s a matter of perspective.  Issues, arguments and positions can appear radically different if considered from another viewpoint.   Being mindful of this, I think, allows for a much more fruitful dialogue.  Which of the following examples do you think is more likely to lead to a constructive outcome.

“I’m right and you’re wrong.  You’re just like your mother!”

“Wow, I never really thought of it that way before...”

Issues of perspective affect all of us, in our professions and occupations and in our lives.  Here’s a few hypothetical but plausible scenarios in the medical world where there might be another legitimate point of view to be considered than the one expressed.  
  • A doctor mentions to his staff, “…that last patient was demanding.”
  • A patient develops a wound infection after surgery and complains that ‘something messed up’. 
  • A patient states that the staff was rude when she was told she would need to reschedule after arriving 30 minutes late for a routine office visit.
  • A patient’s family claim that a physician years ago missed a diagnosis.
  • A doctor complains that a hospital nurse took too long to call him back.
  • A patient files a complaint with hospital administration because the Emergency Department physician would not refill his pain medicines and he left in severe pain. 
  • The doctors are pressuring us to ‘pull the plug’. 
So, whose side are you on, the lady’s or the chipmunk’s?

Sunday, July 14, 2019

Do Patients Like Electronic Medical Record Systems?

I have penned several posts on the pitfalls of the electronic medical record (EMR) system that we physicians must use.  Indeed, I challenge you to find a doctor who extols the EMR platform without qualification.  Sure, there are tremendous advantages, and the ease of use has improved substantially since it first came onto the scene.  But, keep in mind that these systems were not devised and implemented because physicians demanded them.  To the contrary, they were designed to simplify and automate billing and coding.  While this made their tasks considerably easier, it was at physicians' expense.  Features that helped billers and insurance companies didn’t help us take care of living and breathing human beings.   It made us focus on silly documentation requirements in order to be fairly reimbursed.  And, it offered very clumsy mechanisms to record a patient’s history – the story of your symptoms – which is our most valuable piece of medical data.  You simply can't click your way through a patient's narrative. 

Admittedly, the process is much better now than it was a decade ago.  But, it cannot replicate the experience of pen & paper when physicians could use eye contact, facial expression and nodding of the head during office visits.  Indeed, this is how I practiced for the majority of my career. 
A recent job change has given me the pleasure of learning a brand new EMR system.   Learning a new system has been like a undergoing colonoscopy – uncomfortable but necessary.  I wonder how many hundreds of clicks I perform each week as I navigate through a system that seems to have no boundaries.  While some of my colleagues use voice to text technology, or have a scribe shadowing them, I rely upon my 10 digits tapping across the keyboard to get the job done.  And, since I worked as a typist prior to becoming a gastroenterologist, I can look my patients in the eye while typing.  (Interesting that a typist and a gastroenterologist both need to be digitally skilled.  Perhaps, in my retirement I will study piano?)

Pre-EMR Technology

I wonder how the EMR arena has been for patients.  Please share your experiences here especially if you are old (ancient) enough to be able to compare current click medicine to pen & paper documentation.  How has your office visits changed?  Do you think EMR has changed the doctor-patient relationship?  Share your frustrations.  Let me prompt you with Frustration #1.  Why don't all the EMR systems communicate with each other?  Why is this promise still unfulfilled?

Using the ubiquitous rating system, how many stars would you award the EMR experience?

Sunday, July 7, 2019

Is E Pluribus Unum 'Fake News'?

The colonists were not united in the mission to achieve independence from Great Britain. Indeed, there was tension between the Loyalists, who wanted to remain British, and the Patriots, who demanded separation.  Ultimately, the nation came together as the the great experiment in American democracy commenced.  This is embodied in the nation's original motto e pluribus unum, translated from Latin as 'out of many, one.  Have we remained true to this principle?

Challenges and Choices Before Us in 2019

Divide or heal

A cudgel or an olive branch

Dialogue or lecture

Accusation or apology

Breaking or bending

Sneering or smiling

Entitlement or generosity

Shouting or singing

A polemic or poetry

A fist or a handshake

Saying no or saying yes

'You are wrong' or 'I am wrong

In your view, dear readers, how are we doing?  Should we adopt a new motto, to unum de multis, out of one, many?

Sunday, June 30, 2019

Why I Left Private Practice

After 20 years, I have left private practice and joined with the Cleveland Clinic.  To those who know me and this blog, this development may seem surprising, if not shocking.  On many levels, I’m shocked at this unexpected denouement of my career.   Let me explain.

First, these past two decades in private practice have been fabulous.  Our amazing staff and my partner worked hard every day to provide concierge level care to our patients.  We survived only because we provided a level of service that the surrounding competitors simply could not rival.  We provided customized and personal attention.  Our patients were happy and satisfied.  And, so were we.  So, why did we make a change?

Over the past few years, my partner and I had become uneasy about our practice’s ongoing viability.  The economics of a 2-person private practice are increasingly challenging.  Consider the math.  There is ongoing downward pressure on reimbursement with inexorable upward movement on expenses.  We cut every expense that we could – including the physicians’ salaries.  The only expense that remained sacred was our staff’s compensation.  We knew that if we didn’t retain our outstanding medical and administrative staff- the crown jewels of the practice - that the enterprise would decay.  

The math was against us.

Additionally, my partner and I were on-call for hospital work and emergencies every other weekend and every other holiday.  And, this schedule became more burdensome when one of us was on vacation.  This was our situation for years and we were unable to solve it.

And finally, we worried that if our still independent community hospitals were acquired by a larger entity – which we think will happen – that this could herald the abrupt demise of our practice. 
So, this was our mindset when the Cleveland Clinic approached us and expressed interest in our practice.  Twenty meetings or so later, here we are.  My new office is just down the street from my prior practice and I am honored that my former patients are following me.  Of course, it’s a transition from being president of my practice to becoming an employee of a large medical enterprise, but my partner and I correctly judged that this was the right decision at a most propitious moment in the life cycle of our practice.   Frankly, we got lucky.  We saved our practice and much of our staff have joined us.

Our staff and us had some sad goodbye moments.  But, there were some joyful goodbyes as well.  Imagine my mirth and euphoria in saying goodbye to working on weekends, nights and holidays!  Yes, I deserve a lighter load after nearly 3 decades of hard core specialty care; but life isn’t fair and we don’t always get the fair shake we merit.   Conversely, sometimes we catch a break that we didn’t earn.

If the Clinic and I remain happy with each other – and so far we are – then this will be my final gig. I’ll keep you posted, from time to time.

Sunday, June 23, 2019

Is My Doctor Any Good?

When I meet patients in the office, our conversations do not focus exclusively on the medical issue at hand.  Of course, if you come to see me with a stomach ache, at some point I will direct the dialogue toward your abdomen.  Often, our conversations are far removed from livers and pancreases, and deal with more personal vignettes and anecdotes.   Why does this happen?  First, I enjoy it; and secondly, it helps me to understand the patient better as a human being.  I won’t give this up, despite the many forces – Electronic Medical Records in particular – that conspire to dehumanize the medical experience. 

I am a trained typist and had several secretarial jobs in my younger days.   The tool of the trade then was a contraption unknown to the generation whom are now soldered to their smart phones.  It was called a typewriter.  For those curious, you might actually be able to palpate one of these dust covered devices in your grandmother’s attic.  My favorite was the IBM Selectric, which had a sphere covered with raised letters and characters which rotated with each key stroke before striking the paper.  Oh, the simple world devoid of Google, cut & paste, Instagram and Wikipedia.  Kids today would never give up their technology, and they have no clue what they have given up in exchange for 

The IBM Selectric Typeball

When a new patient arrives, I always ask how they came to see me in particular.  Sometimes, I am gratified to learn that a satisfied family member referred them.  On other occasions, they have selected me at random, a seemingly chancy method of selecting a physician.  These folks likely would do more due diligence in purchasing a washing machine. 

If they have a primary care physician (PCP), I always ask if they are satisfied with the care there.  These have been extremely valuable inquiries and are unique opportunities for me to learn of patients’ views on their PCPs.   Of course, their review may not be the full story.  And, I would not allow one bad review to change my impression of a doctor.  But over time, I accumulate more data on individual physicians.  For example, if nearly every patient cared for by a Dr. Kildare offers a glowing tribute, this will weigh heavily when I form an opinion.  Similarly, when we read reviews on line for various products and services, they carry more weight if there are a large number of reviews, rather than one or two, leaving aside for a moment the pitfalls of relying upon on-line product and service 'reviews'. 

The truth is that doctors have little clue about what actually goes on in our colleagues’ offices. Physicians and their offices may treat medical colleagues differently than they do their patients.  I’m amazed how often a patient’s experience differs from my impression of a physician who may be quite cordial with me in the elevator.  And, it goes both ways.  I’ve met doctors who seem to me to deficient in social skills and yet, patients love them.

If primary care physicians are smart and seasoned, they will ask their patients about us - the specialists.  Are we as nice to their patients as we are to them?

So, when you come to see me in the office to discuss your heartburn and your hemorrhoids, don't worry.  We''ll get around to it.  First, we may reminisce about milk bottles, fountain pens, paper road maps, Encyclopedia Britannica and my beloved IBM Selectric.

Sunday, June 16, 2019

Medical Risks and Benefits - Shades of Gray

Readers know how strongly I feel that my profession is suffering from the twin chronic diseases of Overdiagnosis and Overtreatment.  Here's a primer on how physicians make medical recommendations to our patients.

Take a look at this grid I prepared, which is worth a full year of medical school.

                                    Low Benefit                   High Benefit

Low Risk                                                           Medical Sweet Spot!


High Risk                DANGER ZONE!

When we physicians are contemplating a treatment, or are weighing one treatment against another, we are aiming for the Medical  Sweet Spot highlighted in blue above.  We want low risk and high reward for our patients.   Would we ever consider a treatment within the DANGER ZONE?  We would if the patient’s medical circumstance were dire and there were no superior options.  For example, if a patient was under a serious threat of a severe outcome, we might consider a treatment with considerable risk that had limited evidence of efficacy.  Of course, it may be that an informed patient might decline the treatment. 

There are times when the Danger Zone is reasonable.

Obviously, medicine is a murky discipline and most treatments do not fall neatly into one of the 4 quadrants of this grid.  Moreover, medical experts often disagree to the extent that a treatment is safe or effective.  In other words, different physicians may place the same treatment in different regions of the grid.  This is one reason why pursuing a second opinion can become more bewildering than clarifying.   Just because a second opinion is different from the original, doesn’t make it right.  To further confuse you, two differing medical opinions can both be right!

How does an average patient make sense out of this morass?  By asking the right questions.
  • What are my reasonable treatment options?
  • What is the scientific evidence supporting each of these options?
  • What is the scientific evidence of the risks?
  • Does my personal medical situation favor one option over another?  (For example, if a medical option’s risk is to suppress the immune system, and you already have a diminished immune system, then this option may not be suitable for you.)
  • How will I be monitored for adverse drug reactions? 
  • Is no treatment an option?  Where would this choice fall on 'grid'?
In my view, the 'no treatment' option should be considered much more often.  Why do so many patients and physicians move this option ‘off the grid’?

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