Sunday, May 24, 2020

Memorial Day 2020 - A Plea to Remember.

Tomorrow will be a Memorial Day worth remembering.  Of course, its core meaning – to remember and honor those we have lost in the service of this nation – remains paramount.  I have thought over the years that the day’s essence has become blurred as the day has become one of family picnics and barbecues.  I confess that I have not sufficiently paused and meditated on the day's meaning in year's past as I think I should have.  I placed a small American flag on our front lawn today, the smallest of gestures to honor a very solemn remembrance.   

But this Memorial Day is different.  To those of us like me who have never served, this may feel as close to a war atmosphere that we will hopefully ever know.  Lockdown.  Shelter in place.  Commerce shuttered.  Empty streets and concert halls.  Fear.  Desperation. Hope.  Propaganda.  Supply chain disruption. Heroes.  Victims.  Agony and death.  

We are battling an invisible and cunning enemy who knows no borders.  Thusfar, he is bulletproof.  Yes, we are winning, but it has a been a tortured grind leaving a staggering wake of destruction.  We are not even sure what winning will look like.  We will get to the other side, holding a collective fantasy that life as we knew it will await us. But that destination is yet unseen and unknown.

Let’s remember those we have lost in the current war, and the loved ones who still grieve, and the ordinary folks who became extraordinary heroes as they ran straight into the fire.

Sunday, May 17, 2020

A Primer on the N95 Mask

A few months ago, most of us had never heard of an N95 respirator or mask.  I had never heard of it. It is an essential element of Personal Protective Equipment, or PPE, which we have all heard so much about.

The N refers to ‘non-oil’, meaning that the mask should not be used in the presence of oil-based substances.  The 95 means that 95% of airborne particles are screened out if the mask is worn properly.  Keep in mind that 95% is less than perfect.  It means that the mask will fail 5% of the time.  And, if the mask is not worn with a tight seal, the efficiency percentage will drop further.  And, the mask wearer is instructed not to adjust the mask during use which will break the seal.  So, the 95% standard is likely under idealized circumstances. 

As of this writing, I have only worn the N95 mask on two occasions.  My initial experience donning the mask was for a fit testing by an occupational health specialist to verify my proper mask size.  The objective, I learned later, was not comfort, but to obtain a tight seal.  The fitting took less than 5 minutes.

After weeks of performing telemedicine from home, I was called into the workplace for the first time this past week to perform a day long marathon of procedures.  I hadn’t touched a scope in over a month, the longest I had been separated from my flexible friends since they first let me loose 3 decades ago.  Hopefully, performing colonoscopy is like riding a bicycle.  Along with my amazing team of medical professionals, I performed 17 procedures without incident.

PPE in place

Scope doctors like me are prone to various aches and pains.  We can be standing for hours which can be tiring.  Our necks can become stiff.  And, we do all sorts of repetitive twisting maneuvers with  both hands which can give rise to various ailments.  There is an actual condition called colonoscopist’s thumb.

But, during this scope jamboree, I became very sorely acquainted with a new malady.  My nose was crying out for relief.  A great contest of Man vs Mask commenced, and it was not a fair fight.  I now know that the N, which I had thought mean ‘non-oil’ really stood for Nasal torture. The N95 mask was burrowing into the bridge of my nose hour after hour.  For those who have not donned the N95, here is some guided imagery to assist you.  

Imagine you are seated cross legged in a pastoral meadow. The sounds and aromas of spring abound.  A sunbeam pierces the clouds as a gentle breeze laps against you. Now imagine that your head is encircled tightly with sharp barbed wire that crosses your nasal bridge.  Now, imagine that every few minutes that the circle tightens...

By the end of the day, my proboscis looked like I either needed plastic surgery or I had just had it performed.  I queried my colleagues and learned that my experience was not unique.  We’ve all seen the photographs of medical personnel whose faces at the end of their shifts are marked with deep grooves and crevices.  

I realize, of course, that my nasal assault is but an inconvenience compared to the suffering of front-line medical professionals and afflicted patients.  But, I was not prepared for the slow grind of a nasal buzz saw.  I have 2 other endoscopy session this month.   I think I know who will prevail in the N95 vs Nose competition.  

Sunday, May 10, 2020

Do Masks Protect Us?

Prior to the pandemic, patients who entered my office building were greeted by 2 staff professionals who would assist patients in checking in and performing the usual logistical tasks that occur prior to a medical appointment.  Shortly after the pandemic commenced, I would arrive to work to witness these 2 ladies in rather different garb. They were now fully gowned, masked, gloved and goggled.  Each carried a bottle of hand sanitizer.  If not for their voices, I would not have recognized either of them.  Patients and medical personnel passing by would extend one an open palm to receive a squirt of the precious cleansing elixir. 

While I acknowledge the necessity for staff interfacing with the public to don protection, it was an eerie site for me to witness, even as a medical professional. It is simply a scene that is foreign to most Americans.

I recall when I traveled to Israel for the first time, I was struck at the site of uniformed and armed soldiers ambling everywhere.  Of course, Israelis paid them no mind, similar to how we might react to police or security guards on patrol in our cities.  But, as a first time tourist, it felt as if I were on a movie set.  

I also recall when I was traveling in Asia years ago, that it was very common to see ordinary folks wearing surgical masks everywhere.  Was I in the midst of an epidemic?   Was the mask to protect the mask wearer or the community from disease?  Or, might it be an effort to filter out impurities in the air?  Might there be a different cultural basis for shielding the mouth and nose?

Folks wear masks for many reasons.

In the coming days and weeks, we will see more masks in public.  In Ohio, our governor announced that he will set an example by wearing a cloth mask when in public, and has urged Ohioans to do the same.  

Experts have advised us that these masks are not to protect us, but are to protect others from us in the event that we are silently infected.   Nevertheless, I suspect that many will be masking up with the belief that the cloth will prevent coronavirus from reaching them.

Masks will soon take on a normal appearance if they are widely used over the coming months.  Most of what we now take for granted appeared odd and novel when we first encountered it.  What was our reaction the first time we saw a cigarette smoker, sushi or a tattoo?

Sunday, May 3, 2020

COVID-19 and Chloroquine and Hydroxychloroquine: First, Do No Harm

In a recent post, I presented why I believe that the fragmentary and anecdotal medical evidence supporting the use of chloroquine and hydroxychloroquine for COVID-19 does not justify its use. Certainly, if I become infected with the coronavirus, I would be reluctant to accept a recommendation to take either of these 2 medications, based on what is currently known.

Ordinary people, especially when they or loved ones are afflicted with a disease, will readily accept unproven remedies, especially when conventional medicine has no effective treatment.  We all understand this.  But the lack of a treatment, in my view, does not justify abandoning our usual standards that physicians rely upon when we make treatment recommendations.  
Shouldn't Physicians Weigh the Risks and Benefits?

Here are some reasons why I object to coronavirus patients taking chloroquine and hydroxychloroquine for COVID-19.   The principles outlined below certainly extend beyond the coronavirus issue.
  • The medical profession should not be prescribing treatments that have no reasonable evidence of efficacy.  Patients should have confidence that our therapeutic recommendations are based on sound science, professional experience and sound judgment.
  • Chloroquine and hydroxychloroquine efficacy against COVID-19, like any treatment, should be tested in well-designed clinical trials.
  • Clinical trials may have difficulty recruiting a sufficient number of patients if coronavirus patients are opting instead to take the medicines being tested on their own outside of a trial.  A clinical trial’s conclusions are more reliable when it contains more patients.
  • It may be true that chloroquine and hydroxychloroquine worsen the condition of COVID-19 patients.  Medicines do not always behave predictably.   Should we be condoning the use of medicines when we have no proof of either benefit or harm?   The safety record of the 2 medicines being discussed here with regard to their established medical indications may not be true for coronavirus patients, particularly when higher dosing is being advised. This is why scientific study of medicines is absolutely necessary. 
  • Prescribing medicines irresponsibly consumes resources that should have been devoted to more worthy endeavors. 
Consider who is publicly promoting chloroquine and hydroxychloroquine use for COVID-19.  Are they our public health experts or politicians and administrative officials?   Whom would you trust more for medical advice? 

Sunday, April 26, 2020

Coronvirus - Test Your Knowledge!

Folks love quizzes and puzzles, especially now when most of us are spending most of our time hunkered down at home.  I had attempted to send one my kids a jigsaw puzzle that I ordered on line, only to discover a few weeks later that the item was out of stock.  Apparently, like hand sanitizer and foster dogs, jigsaw puzzles are in very high demand.

Scarcer than toilet paper.

In an earlier phase of my life, I prepared ‘quizzes’ that were passed around on holidays and family dinners when guests competed for valuable prizes such as stickers, packs of gum and other treasures that are sold at dollar stores.   Not only were these experiences ‘fun for the whole family’, but they were effective educational tools.   Ask a Kirsch kid even today whose portrait is on the $50 bill or how many neck bones are inside a giraffe’s neck, and he or she (I hope) will nail it.

So today, I will offer readers a lighter fare.  Here’s a coronavirus quiz based on recent news reports.  Rely upon your knowledge and judgment.  To relieve your performance anxiety, I have made this a True-False examination.   I could have constructed a multiple choice and even included an essay question, but my generous nature prevailed.  Good luck!
  • Coronavirus takes its name from Corona beer as the virus was first isolated in brewer’s yeast.
  • Coronavirus is named after Rosie, the Queen of Corona, who refused to practice social distancing and contracted the virus.  Julio, who wore a mask, escaped infection.
  • Gargling with Lysol. and followed by a Mr. Clean chaser. kills the coronavirus and also rids the body of various harmful germs and toxins.
  • Anthony Fauci takes a dose of valium before and after the daily Coronavirus Task Force press conferences.
  • Vice-president Mike Pence has shown America that he has a spine of steel.  He is his own man.   
  • Deborah Birx’s scarves are impregnated with a potent antiviral agent, which is the main ingredient in Ty-D- Bol toilet bowl cleaner.
  • President Trump’s scientific knowledge has been credited for the sudden spike in applications to college engineering programs.
  • Masks are for sissies.
  • 4 out of five dermatologists surveyed no longer recommend any sunscreen.  UV light wipes out coronavirus even better than Chlorox.
  • It has been inspiring to witness the seamless and harmonious cooperation between the state and federal governments.  

So, how did you do?  Scores of 80% or higher are prize worthy.  Of course, since we are in the midst of pandemic, you will have to settle for virtual trophy. 

Sunday, April 19, 2020

When Should We Open the Economy after Coronavirus?

In the weeks ahead, there will be growing tension between forces wanting to open up the economy and those who demand that we hold the line.  And no one can tell us now when it will be okay to pull the trigger.  It is so much easier to endure a challenge if there is a firm end date to focus on.   In this case, not only is there no clear trigger-date, but there will never be agreement on when it will be acceptable to pull back.  I’m no expert, but here’s a brief list outlining the complexities of this conundrum.
  • Public health experts will disagree on the economic relaxation date.
  • Corporate leaders will likely favor a sooner and broader opening of the economy.
  • Governors will have diverging views from national leaders about what actions their state should take.
  • Businesses who are not permitted to open may howl and protest as competitors are given a pass.
  • Can schools, for example, be reopened while we are still urged to maintain social distancing?
  • Will the nation accept being told that we are opening up the country when in reality only scattered pockets are being permitted a gradual loosening of restrictions?
  • What happens when COVID-19 rates rise as the economy is revived?   Will we have the tools and the will to do what is necessary?
  • As difficult as it has been to shut down the economy, it will be a much harder and longer process to bring it back to life. 
  • Will we be told, and will we accept, that we will not be able to return to the status quo ante?
The decision of when and how to open the economy will always involve risk.  Doctors and medical professionals understand this reality.   We may advise a patient that there is a choice of surgery or continued medical treatment, and both options have risks.  If we open up the country too soon, we risk a resurgence of the virus and a squandering of what we have accomplished.  If we wait too long until the last remnant of the virus has been vanquished, then we may have no economy left to resurrect.

A Cure for Termites?

If a house has termites, we can cure the infestation by burning the house to the ground, but would the homeowner celebrate this victory?

We will have to balance serious risks in an evolving situation with endless moving parts with no playbook to refer to and disagreements on how to proceed among experts.  Would you like to be making the decision? 

Sunday, April 12, 2020

Chloroquine and Hydroxychloroquine for COVID-19?

Kindly refer to the article linked below explaining my great concern over the massive hype over these 2 medicines that many are perpetuating.    MK

Sunday, April 5, 2020

CDC Advises Cloth Masks for Everyone. Why Now?

I haven’t seen so many masks since I was a Trick or Treater.  Even as a physician, I have worn surgical masks very rarely as it was uncommon for me to be in an operating room, where masks and gowns are part of the dress code.  Until I embarked upon a transition to telemedicine recently, many of the patients coming to see me in the office were masked.

The official dogma on wearing masks during the pandemic is evolving. Experts at the Center for Disease Control and Prevention (CDC) the World Health Organization (WHO), the Surgeon General as well as many prominent public health officials had advised just recently that masks were not an effective barrier against coronavirus.  This is why asymptomatic individuals were not advised to mask up.  In contrast, we were told that these masks should be worn by symptomatic individuals who were coughing or sneezing as masks may reduce the risk that others will become infected.

Just days ago, there was a sudden change in policy.  Now the CDC and many of the president's advisors and others are recommending widespread cloth mask use to keep those who are silently infected from transmitting the germ to others. The WHO has not signed on to these revised recommendations. While it is still true that cloth face coverings are not likely to protect a healthy individual from infection, the hope is that such a barrier may prevent a asymptomatic infected individual from spreading the virus.  It's not clear to me why the revision was issued now as we have known for months that asymptomatic individuals can spread the infection.  The explanation for the policy change has been murky  

Could there be a downside?

It is confusing when an important safety recommendation undergoes dramatic and abrupt revision, particularly when there is already endemic anxiety.  The public needs consistent messaging.  It is unsettling when organizations, experts and government officials have different opinions on what precautions we should take.

Here are some of my concerns about widespread use of cloth face coverings:
  • Frequent adjusting of the cloth covering by new users will increase hand to face contact, which is a sure method of coronavirus infection
  • Individuals, despite CDC advice, may use medical grade masks which should be reserved for medical professionals
  • False sense of security of masked folks who may relax their social distancing practices, which every expert maintains is our paramount strategy to flatten the curve and save lives
  • Symptomatic individuals who should be at home might feel that a mask will allow them to enter out into the community risking transmission as they may believe that they are less infectious
  • Will mask wears know how to carefully remove the mask when they return home, clean it after every use and wash hands well when placing and removing the mask?
Don't misunderstand me.  I'm not qualified to opine on the wisdom of the policy.  I do think that the abrupt policy change and mixed messaging is confusing.   And, I don't think it's quite as simple as slap on a mask and all will be well.  I offered above a listing of some of my concerns that I do not think have been sufficiently considered or publicized.  .  
I worry that the expanded attention and use of masks may distract us from two measures that every expert unwavering insists upon.   Keep your distance consistently  And wash your hands often and thoroughly as if you have just touched the virus. 

Sunday, March 29, 2020

Do Doctors Wash Their Hands Properly?

There is no person unaffected by the coronavirus pandemic.  It does seem that the public and the government are responding belatedly in a manner commensurate with the threat.  I write this knowing that less than a week ago from the time I am composing this, Florida beaches were teeming with vacationers.  A memorable quote from one of these selfless and enlightened partiers was:

“If I get corona, I get corona. At the end of the day, I’m not gonna let it stop me from partying.”

This individual, from my own state of Ohio, did apologize for his remarks.  I would suggest that his mouth be mandated to take a 14 day quarantine from all speech. 

Look, we’ve all said dumb stuff.  I know I have.  My advice?  If you sense some dumb words about to erupt, and there are cameras rolling, sprint in the opposite direction as if the coronavirus is on your tail and gaining ground.

Right now, Ohio and many other states are in a ‘shelter-in-place’ status, in an effort to enforce social distancing.   I’m trying to do my part.  I’ve learned about curbside grocery pick up.  I haven’t shaken hands in weeks.  I try to keep my distance from others as best as I can. And, I am practicing telemedecine.  I watched a video that demonstrated ideal hand washing technique.  I’m in a profession that should be model hand scrubbers.  I’ve washed my hands probably hundreds of thousands of times and I’ve seen many colleagues lather up.  But I’ve never seen hand washing as depicted in the training video. This was no mere soap & water exercise.  It was a performance, a veritable choreography of cleanliness.   In other words, I think my own profession could use a hand hygiene refresher course, as could the rest of us.

Scrub Vigorously
(You Don't Have to Get This Deep.)

Interestingly, when the president and his medical minions are giving their frequent news conferences, they all seem huddled together, much closer than 6 feet apart. 

But, at most I’ve been inconvenienced during the pandemic.  For so many, this pandemic has been devastating medically and economically.  The job losses and company closures are horrifying.  I am more sanguine about prevailing over the virus than I am over recovering our economy.   And, there is tension between public health experts and many in the business world about when to permit economic activity to resume.  

As I write this, the U.S. Senate has still not agreed on the zillion dollar recovery package, which I anticipate will occur shortly.   If there was a legislative bill that was against cancer, would it be able to pass the House and Senate easily? I wonder.

We will get to the other side.  And, we will recover eventually.  But we will not be the same. We and the world will have learned about the ferocity and tenacity of an invading microbe and the strategy and tactics necessary to defeat a wily and stealth enemy.   And, we will surely need these battle skills again and again. 

Sunday, March 22, 2020

Coronavirus or Coronoverse?

A worker was told of corona.
Who's boss said, "You're on your own-a."
"Leave the arena"
"Begone! Quarantina!"
"You mean I'm gonna be all alone-a?"

Coronavirus - An Invisible Foe

We will get to the other side.   Clearly, the path to a safe and secure future has not been a straight shot.  Both the government and the public have fallen short. The initial coronavirus testing launched here was a debacle, in contrast to other countries that knew how to aim straight.  We have seen price gouging for hand sanitizer and face masks.  As recently as this past Thursday, Florida beaches were teaming with folks who brazenly and selfishly risked contracting the virus and transmitting it to others.

But, most of us have fallen into line.  And, so have our leaders.

I feel more sanguine that we will prevail in the medical arena than we will on the economic front.

Epidemics and pandemics will join the array of natural disasters that have become commonplace events in our lives.  And, we will learn to combat them more skillfully.

It's scary.  It's surreal.  A microscopic entity with no brain and no motive can bring the world to its knees.  The world will surely stand up again, but we may need to hold on to each other.

Sunday, March 15, 2020

Doctor-Patient Relationship Needs John Adams

In 1770, in Boston, British soldiers fired into a crowd of colonists who were taunting the soldiers.  Several colonists died and several soldiers were arrested and charged with murder.  This event known as the Boston Massacre was a seminal historical episode that contributed to the colonists’ growing desire to separate from the British Crown.

Boston was a cauldron of the independence movement.   Hatred against the British was prevalent.  Who would be willing to defend the accused soldiers at trial risking opprobrium or worse?  John Adams, our future second president, defended the soldiers believing that every accused deserves adequate representation.  To this day, America distinguishes itself with our belief and practice that an accused man is presumed innocent and is entitled to a competent legal defense.  As we all know, lawyers are often assigned or volunteer to defend unsavory individuals to protect their clients’ constitutional rights, ensure that the legal process is being respected and to prevent a rush to judgement from taking hold.  Understandably, many lawyers would not rush to defend accused child molesters, terrorists, white supremacists, kidnappers or abusers of the elderly or other vulnerable people, and yet these accused people fully deserve and are entitled to representation. 

John Adams Sets Example for Doctors

But, John Adams accepted defendants who were reviled and thereby burnished his own reputation as a principled statesman performing the noble mission of the legal profession.  Six of the soldiers were acquitted and two were convicted of manslaughter.

Both lawyers and physicians don’t choose their customers.  They come to us.  While many who come to physicians for assistance are pleasant and cooperative, others have less sanguine traits.  I have seen patients who are argumentative, demanding, rude, dishonest, hostile and overtly racist.  A few days before writing this, one of our secretaries became rattled when a patient cursed her. Of course, patients who are worried or sick are entitled to great latitude, which doctors and our staffs extend to them.  But, aside from this, there are disagreeable patients whom I just don’t like.  But, these folks are entitled to the best medical advice I can provide, and I do my best to meet this obligation.  Everyone has a right to competent medical care.  But, as doctors and nurses would testify, it is easier to do our jobs when patients and their families are pleasant and cooperative.

First, let me admit that not every physician is a clone of Marcus Welby, MD, and patients may legitimately complain that some of their doctors are wanting in their bedside manners and attitude.  If readers wish to speak on this issue, leave a comment.

There is no application process to become a doctor’s patient.  Universities and employers can reject applicants, but physicians, for the most part, see everyone.   While I like and enjoy the majority of my patients, there are some whom I serve despite harboring some negative feelings.  And, of course, even those whom I enjoy being with may have a variety of private views and opinions that differ from mine.  Part of my job is to make sure that any personal feelings I have do not interfere with my ability to serve the patient well. 

I’d like to think that I could serve any patient, but I recognize that this idealistic statement is not realistic.  Humans cannot be expected to exhibit superhuman behavior.  If the doctor-patient relationship is strained beyond the point where the doctor can give sound and sober medical advice, then the physician may need to step aside. 

John Adams has set a stratospheric example for lawyers, physicians and, indeed, for all of us.

Sunday, March 8, 2020

Has Coronavirus Infected our Politics?

Have you heard enough about Coronavirus yet?   If not, feel free to tune in to the Coronavirus News Network, also known as CNN.

I have zero medical experience in virology and public health, so read no further if you are looking for a Whistleblower travel advisory or if it’s safe to pet Scruffy if he develops a fever.

I’m also not here to gripe about our nation’s response to this incipient pandemic.   Although we have a first class team in place now, even they admit that they stumbled initially.  I'm more interested in making progress than in racking up debate points.

My observation is that there is no issue or event that is immune to politicization, a reality that depresses me.  We all agree that prior to the virus’s emergence from China, we were already rabidly hyper-polarized and hyper-partisan in the zero sum game that now defines our political landscape.  I won’t add to this sentence so as not to waste readers’ time in reading what we all know and agree on. 

On many issues we should expect differing views from our two main political parties that are philosophically distinct.  For example, changing income tax rates, border issues, health care policy, funding our defense department, trade policy are examples that will give rise to spirited policy debates. This is as it should be.  During normal times, meaning decades ago, these differences would be debated and a solution forged by resorting to the diabolical technique called compromise. 
But, or so I had thought, some issues should hover above this chaos in the rarefied region of the stratosphere where reasonableness prevails.   

Illustration of Coronovirus
Is it Democrat or Republican?

To offer an absurd hypothetical, if a lawmaker offers a bill declaring cancer to be evil, would this pass unanimously?  It seems non-controversial, but who knows?  Perhaps, the opposing party might be suspicious of the motive, or fear that this is the entry point to the slippery slope that will lead to Medicare for All.   Or, the opposition will agree to vote for the bill only in exchange for votes on some unrelated issue.  We all know how this works.

I have hear many pundits and partisans in recent days who can’t resist taking political shots at their adversaries when they are questioned about Coronavirus issues.  These crass responses give this gastroenterologist heartburn.   Let them save their partisan venom for an appropriate issue.  Coronavirus is a potential global health crisis and, as a medical professional, I assure you that it is non-partisan.  It will infect anyone.  So, when a salivating political hack is asked about it, he should be telling us how he intends to help rather than angling for a cheap political dividend.

I wonder how my patients might react if I queried them about their political leanings as they were about to be sedated before undergoing a procedure.  

Sunday, March 1, 2020

Can Sherlock Holmes Teach Today's Doctors?

To Sherlock Holmes, she is always the woman.   Thus begins Conan Doyle’s, A Scandal in Bohemia published in 1891.   In this gripping tale, Holmes is bested by a woman who proves to be the detective’s equal in intelligence and deception.  

For reasons I cannot explain, I restrict my exposure to Holmes and Dr. Watson to podcast listening when I am airborne.  Years ago, I did love watching the classic movies starring Basil Rathbone and Nigel Bruce who defined the roles for me. 

Conan Doyle, a physician, was a superb story teller, who wove his tales with texture, plot and humanity.  I think he wields words with surgical precision.   I admire his skill.

I wonder to what extent Conan Doyle’s medical training influenced his writing?  Certainly, the stories often discuss arcane medical conditions that provide the detective with important clues.  In The Adventure of the Blanched Soldier, Holmes suspects that the protagonist is suffering from leprosy, a diagnosis that is revised after Holmes arranges for a consulting dermatologist to examine the soldier. 

Holmes would have been master diagnostician.

Beyond these medical intricacies that the author includes, I suggest that Conan Doyle has a more direct connection to the world’s most famous sleuth.  Physicians operate as detectives.  We gather facts and evidence in real time.  We have suspicions which may be strengthened or refuted as additional data emerges.  There may be competing theories that torture us.   At times, we are forced to make judgments and recommendations when our knowledge base in incomplete.   And some of our patients’ dilemmas remain unsolved, similar to crime solvers’ cold cases. 

In The Sign of the Four, Holmes remarks to Watson, How often have I said to you that when you have eliminated the impossible, whatever remains, however improbable, must be the truth.  Holmes would have been a superb physician.  

Sunday, February 23, 2020

Can Doctors Help You Lose Weight?

As a gastroenterologist -a trained specialist in digestive issues - I should have expertise in obesity, nutrition and weight loss strategies.  I really don’t.  While I have knowledge on these issues that likely exceeds that of most of my patients, I received inadequate formal training on these subjects during my gastroenterology training.   It is inarguable that digestive doctors – and indeed all physicians – should bring a high level of expertise on these medical issues into their exam rooms.  The impact of obesity reaches nearly every medical specialty.   Obesity is linked to heart disease, stroke, cancer, arthritis, diabetes, sleep apnea, high blood pressure and many other illnesses. 

Most of my overweight patients tend to remain so.  Many of them are simply resigned to a shape and size that they feel they cannot alter.   Some are not motivated to engage in the hard work and long journey that can lead to a leaner dimension.  Some do not recognize that successful weight loss requires a steely and sustained mental commitment to the task.  Others have food addiction issues and need an appropriate strategy to break through.   Some are convinced that they are plagued with a lethargic metabolism that retains pounds despite minimal food intake.  Many eat, not because they are hungry, but because of anxiety and stresses in their lives which have not been adequately addressed. 

Of course, medical professionals need more knowledge and skill in addressing nutritional issues.  How relevant are these skills to medical practice?   According to the CDC, over a third of American adults are obese.   And, more of us will be classified as obese if the definition of obesity is broadened.  This is analogous to what has happened with diagnosing folks with elevated cholesterol levels.  The medical profession, with a huge assist from the pharmaceutical industry, has lowered the ‘normal’ level of blood cholesterol over the years.  The result is that previously healthy people now have a cholesterol condition.   We saw a similar result last year when ‘normal’ blood pressure levels were made lower which instantly created millions of new hypertensive individuals.  Now, many of them may be subjected to the risks, expense and psychological effects of being told that they are diseased.   The argument, of course, is that this more aggressive approach saves lives.   Let’s see over the next decade or two if this hypothesis will be supported or refuted by medical evidence.   Keep in mind that many medical ‘breakthroughs’ announced with fanfare and optimism have been proven wrong. 

So, if you are among the millions who are struggling to shed some pounds, there are pathways available.   It can be a challenging road.  After all, if it were easy, then we'd all be think.  But, it can be done.  The first step on the journey takes place in your mind.  Are you all in?  

Sunday, February 16, 2020

The White Coat Wall of Silence

We’ve all heard about the blue wall of silence that describes a belief that law enforcement personnel will refrain from reporting misconduct of their colleagues to the proper authorities.  Physicians had similarly been accused of hiding behind a white coat wall of silence, as I have on this blog.   This describes the belief that physicians do not reliably turn in colleagues who are incompetent and impaired.  Personally, I have never knowingly participated in the care of a patient with an impaired colleague.   Competency is a murkier issue and is, of course, variable in the medical profession.  In addition, it’s not easy to define or to measure.  It is this very fact that has made me so hostile to the Pay-for-Performance schemes that claims to be a quality metric, but is truly used as a cost cutting tool.

'I Know Nothing'

I am aware of physicians in my community who do not have a strong reputation of medical skill.  Yet, many of these physicians are beloved by their patients.  Clearly, they are delivering something of great value that may not be included in our traditional definition of medical competence.  In addition, if physicians of lower medical skill levels, consult specialists more liberally to assist in the care of their patients, then the patients receive good medical care, albeit at higher cost.

What obligations to physicians have to come clean to patients about other doctors and health care facilities? Weigh in on the following.
  • A patient asks you if her primary care doctor is any good.  The primary care physician is a strong referrer to the practice, but is not highly regarded among colleagues.  How would you respond if you were the doctor?
  • A private practice surgeon operates at only one hospital.  His patient asks if another hospital would be a better choice.  The doctor is aware that the post-operative infection rate in his hospital is 5% higher than in area hospitals.  How would you respond if you were the surgeon?
  • A hospitalized patient is medically ready to be sent home.  Every additional day in the hospital consumes time and resources.  More importantly, it exposes the patient to risks of hospital life including infections and other complications.  The admitting doctor intends to discharge the patient home at the end of the week.  If you are a physician consultant on the case, what would you do?

Of course, I know what the correct answers should be.  But, my profession, and probably yours, are not as pure as we would like them to be.   While integrity may be absolute and impeccable, alas, we are not.

Sunday, February 9, 2020

Do You Need a Patient Advocate?

I wish I could write that medical care today is an optimal, cost-effective and efficient system that consistently provides appropriate and sterling medical care.  I wish I could write that pharmaceutical companies, hospitals and extended care facilities all view patient care as their primary and overriding mission.  I wish I could write that physicians all share the highest ethos of patient advocacy.

It is not possible to achieve these idealistic goals as the individual professionals, corporate entities and the government that comprise the medical profession are imperfect and face numerous conflicts of interests.  Indeed, this blog as devoted considerable space to highlighting these issues.

Here’s a representative vignette from my world. 

I was asked to see a hospitalized patient for an opinion on her low blood count, or anemia.  This is a common request for gastroenterologists as internal bleeding is a frequent explanation for anemia.  This is when we gastroenterologists get a truly ‘insider’s view’ of your intestine with our colonoscopes and other gadgets.  Not every anemic patient, however, needs to be subjected to our probing.  If we judge, for example, that the anemia is not caused by blood loss, then we will hold our fire and request that an appropriate medical consultant be recruited.   Another reason we might keep our scopes securely holstered with a patient who has had true blood loss is if we have safety concerns about proceeding with procedures. 

The patient I saw was ailing and elderly.  She had many chronic medical conditions.  There was no evidence of blood loss explaining her anemia.  Therefore, I advised against proceeding with any scope intrusions.  The attending physician was dissatisfied with my advice and requested that another gastroenterologist, presumably a more compliant practitioner, see the patient.  The doctor reached over me instead of reaching out to me.  

I am not asking readers to support my medical advice.  Perhaps, I was entirely wrong and the attending physician correctly recognized that internal bleeding was the culprit.  Perhaps, she was aware of certain medical facts that I did not know.  Maybe I am a mediocre specialist.  The point is that the next step in the process should have been for the two of us to engage in a conversation so when we could have a dialogue and arrive at a decision that we both felt served the patient’s interest. 

I would have settled for a message by carrier pigeon. 

Of course, conversations between physicians are commonplace.  But, patients would be surprised how seldom conversations between medical colleagues occur.  For example, there are certain physicians who don’t send reports to me when they see one of my patients.

For these reasons and others, there is increasing space in the medical marketplace available for an emerging medical professional – the patient advocate.   These folks can be hired by patients to make sure the medical evaluation is proceeding smoothly and that everyone on the case is fully informed. Isn’t this what we doctors are supposed to do?

Sunday, February 2, 2020

10 Mistakes Democrats Made on Impeachment

I am not going to offer an opinion if the Senate’s anticipated acquittal of the president in the impeachment proceeding will be correctly decided.   I have nothing to add to the millions of words that have already been said, written and dreamt on this issue.  And, even if I had divine inspiration to contribute a new thought, would it change anyone’s mind?

Leaving aside the merits of the case, I do think the Democrats have committed a series of errors that contributed to the GOP’s victory and made it more palatable for senators to support the president.

Flag of the U.S. Senate

  • House members and others have been clamoring for the president’s impeachment since his inauguration.  Indeed, a resolution for impeachment was submitted to the Republican controlled House in December 2017.  This feeds the narrative that the Democrats were fixated on the impeachment outcome long before the Ukraine imbroglio developed.
  • Democrats and others in print and the airwaves were warning us incessantly over Trump’s collusion with Russia.  They presented collusion as if it were an incontrovertible fact.  When Mueller announced there was no collusion, not a single Democrat admitted error.  They simply moved on to obstruction.  This pivot supported the theory that their plan was simply to find or concoct a pathway to achieve their pre-determined goal.
  • If the charges of bribery, extortion and violating the Emoluments Clause of the Constitution were so serious and secure, then why weren’t they included in the articles of impeachment?
  • Why didn’t the House Democrats test the President’s claims of privilege in court for witnesses?  If they judged that this effort would be too inconvenient or lengthy, then why would they expect that this same process would proceed smoothly in the Senate?
  • Why did the House Democrats withdraw the subpoena for Charles Kuperman, who was willing to testify if so ordered by a court, before the court issued a ruling?  What changed their minds?
  • Why did Speaker Pelosi give out pens used to sign the impeachment articles as souvenirs, serving to cheapen such a serious and rare undertaking?
  • If impeaching the president needed to occur with great dispatch, informing us that our democracy was at risk, then why did the House tarry for 33 days before forwarding the articles to the Senate?
  • Why did Speaker Pelosi make futile demands to impact on the Senate trial when the Constitution plainly states that the “Senate shall have the sole power to try all impeachments”?  Did Majority Leader McConnell try to tell the House how to conduct their hearing?  Would they have allowed him to?
  • Should House Managers have declared that the “Senate is on trial” or that if senators voted to acquit that they would be participating in a cover up?
  • Should the House Democrats have emphasized to exhaustion that their submitted case was ‘overwhelming’?  (It was overwhelming to hear the word overwhelming used so often!)  If the case were truly overwhelming, then why would witnesses even be necessary?  Shouldn't the case have been able to stand on its own?

Yes, of course, I could have written a similar post highlighting Republican partisanship, gamesmanship and hypocrisy.  And, I hope readers will comment accordingly.  But my narrower point is that the Democrats’ feeding of their base alienated others and made crossing over less likely for those whose view on the issue was not yet fixed.  So, while they decry the outcome and claim that the trial sans witnesses was illegitimate, they bear some responsibility for this.

Sunday, January 26, 2020

Personalized Medicine - The Future of Medicine

Future doctors will celebrate that they no longer prescribe the same drug at the same dosage for hypertension or pneumonia or arthritis or cancer or many other conditions.  Who knows even if drugs will be the mainstay of medical treatment.  Tomorrow’s treatments will be tailored to one’s age, gender, weight, race, overall medical condition, severity of the medical threat and genetic profile, among other variables.  We don't all wear the same sizes of socks and shoes, but yet medicine today has a one-size-fits-all treatment utility.  A new era, however, is upon us.

What will be the fate of my beloved colonoscopies or heart catheterizations or blood draws or biopsies of tissues?   Fear not.  They will all be available to you, just as Van Gogh paintings or fossils of T-Rex are -  in museums.  The first exhibit will be a diorama of the physician’s office from yesteryear, adorned with some antique artifacts such as a stethoscope, an EKG machine and a reflex hammer. 

Museum Quality

Without question, health care will smash through one barrier after another.  But, the humanity of the profession will be subsumed and sacrificed as the medical technological tsunami bursts forth.  Our health will improve but the health care experience will be unrecognizable.  Indeed, all aspects of our lives will be technologically driven.  Today, Alexa can turn off the lights.  Tomorrow, Dr. Alexa might be cleaning out our arteries. 

And while technology will permit portions of the exam to be transmitted, such as vital signs, heart and lung sounds, skin lesions, etc., I don’t see how a patient’s abdomen can be palpated, at least not yet.

Performing robotic surgery remotely is already a reality and such surgeries and medical procedures from afar may become commonplace.  Individuals may place their smart phones on various parts of their body and transmit information to their physicians.  Patients may be able to use their phones or some other device to do a CAT scan (or whatever technology will replace it) on their own bodies.  And, reminiscent of the once futuristic novel Fantastic Voyage, patients may swallow a trackable pill that can course throughout the body transmitting data about the health of various tissues and organ systems.  Similarly, medications will be customized to each individual that can be directed to the target location.  For example, a medicine for Alzheimer’s disease will be personalized for a specific patient with the drug remaining only in the brain.  These developments will boost drugs' efficacy and reduce adverse drug reactions.   When drugs are free to roam throughout the entire body, obviously there will be unintended and unfavorable consequences.

The routine physical examination may be replaced by spitting into a tube or submitting a cheek scraping for a comprehensive medical analysis.

We can hope and pray that the upcoming technological take over will be guided and restrained when necessary by just and ethical principles.  The revolution is coming and no force can derail it.

Sunday, January 19, 2020

Electronic Medical Records - Broken Promises

I have written, or more accurately ranted, about electronic medical records (EMR) systems throughout this blog.  While the systems have clearly improved since their mandatory introduction into the medical universe, they have still not delivered on many of their promises.

Of course, EMR has brought tremendous advantages to the medical profession and we are all grateful for the technology.  But this progress has exacted a cost.  Many of them are clumsy to utilize.  When the technology breaks down or freezes, the office become paralyzed.  The systems are vulnerable to hackers who can exploit personal medical data or demand ransomware.  Many of the computerized notes  are so filled with pre-populated fluff carried over from prior visits, that it can be challenging to identify new medical information.  I often scroll through several pages in search of the physician’s thoughts and plans.  And a physician who is staring at a computer screen during an office visit will create a very different genre of a doctor-patient relationship. 

But here’s an EMR frustration that I am astonished is still torturing us.  In our digital era, different EMR systems cannot communicate with each other.  Indeed, one of the seductive promises of the EMR prophets was that physicians would have access to all of a patient’s medical data.  Imagine, for example, how useful this would be to an emergency room (ER) physician who is treating a sick patient who has been treated for the same condition elsewhere?

The Medical Records are in there somewhere!  

Every day in my office practice, I see patients with active conditions who have been treated by other physicians and at other hospital systems.  The patient before me with abdominal pain may have been seen for this in an ER a few weeks ago, and then seen by his own primary care physician days afterwards.  Shouldn’t I be able to have real time access to all of this data?  Wouldn’t this help me to make a more accurate diagnosis?  Might this prevent me from ordering an unnecessary medical test?  Is this vexing issue simply insurmountable?  ‘Is there no app for this’?

Patients are as frustrated over this as we are.   “Alexa, please get my this patient’s CAT scan report!”

Sunday, January 12, 2020

There is Too Much Technology in Medicine

As promised, here is the continuation of last week's post where I discussed the loss of physicians' diagnostic skills which have been largely replaced by technology.

Of course, the medical community celebrates the miracles that technology has brought us.  Innovation has improved our lives and will continue to do.  On this issue, there is no debate. But, as with many advances, there is a cost.  Here's my take on the downsides of the technologization of the practice of medicine.  

Could a CAT Scan Do Damage?
Readers, Scan Below!

  • Overreliance on technology has cost zillions of dollars.
  • Much of the overdiagnosis and overtreatment in our health care system – which I have decried on this blog – is caused by medical technology.
  • Technology has strained the doctor-patient relationship.  It is often easier to order a scan than to have a deeper conversation with patient who needs advice and counsel, particularly when physicians’ schedules are jammed.
  • CAT scans and their ilk regularly find unrelated ‘abnormalities’ that would remain dormant for life, but now assume a life of their own as doctors must pursue them. 
  • Technology is not perfect, even though we all tend to regard it as the Holy Grail.  A negative test result may blind us to the truth if we are not vigilant.  A patient with stomach pain and a normal CAT scan can still be in deep trouble. 
  • Patients have taken heed of our technology obsession.  They regularly ask their doctors for testing that they may not need.  Every doctor has had a patient facing him insisting that a CAT scan be done.  The public understandably believes that more testing is better medicine.  Of course, this is false premise but try convincing a patient and their family of this.  I know from my own family; they don’t get it and the medical profession and our payment system is responsible for it. (Patients are more enthusiastic for testing that the insurance companies will pay for)
  • There are financial conflicts of interests that drive the overuse of technology.  Yes, medicine is a business and we would should expect that the normal forces of profit seeking are operative.
  • Technology has not only eroded physicians’ physical exam talents but has also diminished doctors’ skill and enthusiasm in obtaining patients’ medical history, the important narrative that the patient communicates to the physician.   
I often hear and read presentations of patients' medical history where the 3rd sentence is “…and the CAT scan showed…”   This premature intrusion of a technology result - a physician spoiler - immediately prejudices the doctor who should have been given time just to hear the patient’s own story.  If you are told in advance of an important future development in a mystery story, will you still read the book as carefully as you would have otherswise?  The danger for doctors who are given a sneak preview of events is that we become less attentive and vigilant which can lure us into false passages.

Sunday, January 5, 2020

Can Doctors Still Examine Patients?

Does your doctor really know how to use a stethoscope or palpate your abdomen?

Today’s physicians do not have the physical exam skills that our predecessors did.  We can argue if this truth has diminished medical quality – I’m not sure that it has.  But it has completely changed how medicine today is practiced.  The reason for declining physician exam skills is that technology has largely supplanted physicians’ hands, eyes and ears.  In the olden days, the stethoscope was the diagnostic tool for examining hearts.  I spent a month as a medical student with a legendary cardiologist who could make all kinds of cardiac diagnoses right at the bedside using 2 advanced medical instruments known as ears.  Surgeons and gastroenterologists in years past had to make  diagnoses of acute appendicitis and other abdominal emergencies based on feel and their ‘gut’.  Neurologists made accurate diagnoses of stroke just using their clinical skills.

An Advanced Medical Instrument

These days, there is really no need to be sleuth with a stethoscope since any murmur or extra click will be followed by an echocardiogram.  I can’t recall a case of appendicitis in my career that didn’t involve a CAT scan to confirm a surgeon’s suspicion.   And, if a stroke is suspected, a head CAT scan will be arranged.

Since, medical technology has in many cases taken over the physical examination, doctors’ hands-on skills have decayed.  There is much less pressure for our exam skills to be superb since we know that some rescue scan or diagnostic test that does it better will follow.  Conversely, if a physician were seeing a patient with stomach pain, and there was no technology available, I surmise that this doctor would do a more careful exam than he otherwise would.  Get my point?

Are patients better served with more accurate technology to make and exclude diagnoses?  Some have and many haven’t.  We all celebrate how technology in medicine has revolutionized the profession and has saved and improved lives.  I rely upon this every day in my practice.  But we must acknowledge that this progress has exacted many costs.

What’s the harm with ordering a CAT scan?  After all, it’s non-invasive.  Next week, I will address this issue in detail giving you a true ‘peek behind the curtain’, the raison d’etre of this blog.  Feel free to offer your own thoughts on this issue on this post in advance of next week’s full disclosure.

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