MD Whistleblower

Drug Marketing and Data Mining: Free Speech or Free Ride?

2012-01-29T06:00:00.001-05:00

Pharm Tractor Mining Physician Data

Drug reps come to our office fairly regularly, but not as often as they used to. Some of them look like regular folks, but many still look a lot like Barbie and Ken. These guys have a tough job. It’s hard to cultivate relationships when you can’t pay off physicians with free trips or offers of remuneration for serving as a ‘consultant’. Remember ‘dine and dash’?

Despite these prior excesses, I do not disparage pharm reps, many of whom are ethical professionals who have developed vertical knowledge on a narrow niche of medicine. I have learned from them, but I remember that they are salesmen. Caveat emptor.

Drug reps face other challenges beyond the ban on ballgame and theater tickets. We physicians are often constrained by insurance company formularies that dictate what we can prescribe. The insurance companies would balk at that statement and would offer a lawyerly response that, of course, we physicians can prescribe any drug that we believe best serves the patient’s medical interest, but that this selection may not be a covered benefit. Get the idea?

One tool that pharmaceutical companies have relied on for years is to purchase individual physician’s prescription data from pharmacies. This data mining gives pharmaceutical companies lists of physicians by name and the drugs prescribed by each doctor. In other words, the Nexium rep can learn how much or how little of the drug I prescribe compared to its competitors. (No patient identifying data is included.) Drug reps can be given sales goals based on this data.

Memo to Barbie and Ken

Kirsch is prescribing too much Prevacid, which is giving the corporate folks heartburn. More aggressive sales techniques required. Launch OperationBURYPREV ASAP.

Physicians have always hated this open secret in the pharmaceutical industry. It’s open because we all know it is practiced and it’s secret because drug folks won’t talk about it. Doctors, test this the next time a drug rep wanders into your office. Use the following ice breaker as a guide.

“Yo Rep, can I see my individual prescribing data that your company has mined on me?”

At that moment, you will be amazed at the stillness of the lips and larynx that are facing you. An orifice that is usually a portal for endless chatter becomes a hollow cavern. It’s almost a miracle.

The Supreme Court ruled in a 6-3 vote at the end of their term last year that data mining by pharmaceutical companies is constitutional. Vermont had previously passed a law restricting this practice, which the Court has struck down.

I respect the decision because the Supreme Court’s responsibility is to determine if an action is legal, not to make policy. The court did so to protect free speech. Drug reps, however, won’t be speaking freely on this to physicians. Wonder how they and their bosses would feel if we mined their data. Would they agree that free speech goes both ways?

Concierge Medicine and Boutique Medical Practices: Cure or Disease?

2012-01-22T06:00:00.000-05:00

Some time ago, I rented a car during a visit to another city. I chose among the various categories of vehicles which are listed from the last expensive to the most costly. Here were my choices.

• Economy

• Compact

• Intermediate

• Standard

• Full Size

• Premium

• Luxury

As I have pointed out on this blog with regard to medical care, people spend other people’s money much more easily than they spend their own. This is why I have argued that patients need to have some ‘skin in the game’ to serve as a brake on profligate medical spending. There may be other effective brakes to consider, but diagnostic and therapeutic restraint demanded by patients is a potent and reasonable option.

In the rental car case, I was not on someone else’s expense account, but was handing over Kirsch cash. I chose a standard sized vehicle. Of course, I could have saved $$$ by driving off in an economy vehicle, but rental cars are priced like movie popcorn. For a few dollars more per day, you can drive a bigger car. It is a brilliant pricing strategy that encourages the consumer to upgrade.

Here’s the point. I ordered and paid for a standard sized car. I cannot expect that I will be presented with a luxury automobile when I arrive at the rental car lot. Of course, I can upgrade to a higher category, but I will have to pay more. Isn’t this fair? If you are paying for a Chevy, don’t expect to drive away in a Cadillac.

This concept relates to the practice of concierge medicine, also known by the even more derogatory description of boutique medicine. In these practices, patients pay a premium to the physician in return for higher level medical services. These physicians can earn the same income, or more, while caring for much fewer patients.

Why Do Insured Patients Pay More For Concierge Care?

• Same day appointments

• On time office visits that last as long as needed

• Direct access to the physician’s cell phone

• Physicians accompanying patients to specialists’ offices

• Comprehensive annual physical examinations and health review

• Emphasis on preventive medicine, nutrition and wellness

• Posh waiting rooms with New Age soothing music

Concierge Medicine Criticisms

• It’s not fair

• Insured patients should be getting these services anyway

• It’s elitist

• It siphons primary care physicians away from those who can’t afford concierge care

Concierge medicine didn’t emerge in a vacuum. It was not concocted by greedy physicians who were seeking to provide Cadillac care so they could continue to drive Cadillacs.

1903 Cadillac

Boutique medical practices have become popular because private practice primary care physicians faced three mounting challenges.

• Financial pressure with declining reimbursements and rising overhead

• Declining quality of care from seeing higher volume of patients

• Burnout

Concierge medicine is a response to this reality. Concierge practices are financially solvent and provide premier quality medical care to a smaller group of patients. This is not exclusively a benefit for the wealthy. Many average income folks have decided that spending $100 each month for superior medical services is worth it for them and their families. How much do you spend each month on your cell phone? Is concierge medical care more important to you than an iPad, a smart phone or joining a pricey gym? We all make choices in how we spend our money.

For those who want this higher level service for their families, they may need to cut back on other expenses. What kind of car are your driving now? Full size? Luxury? Sports Car? Hybrid? Perhaps, it is worth downsizing your wheels and upgrading your medical care.

I realize that many folks don’t have this option right now, particularly under current economic conditions. We all wish that they, and everyone, could receive concierge level medical care, but this is not how our society works.

Concierge medicine isn’t the avaricious aggressor here. It’s self-defense.

Does Revised American College of Physicians Ethics Manual Need Revision?

2012-01-15T06:00:00.001-05:00

I regard myself as a spirited patient advocate. (What doctor doesn’t?) When facing a patient, I try to focus entirely on the patient’s interest. My advice is hopefully not tainted by the patient’s insurance status or external influences. A patient without medical insurance should receive the same medical advice as a corporate CEO, although the former may reject the medical advice for financial reasons.

As Whistleblower readers know, I am a conservative practitioner of the art and science of gastroenterology. I first developed this medical world view as an intern and resident, and remained a parsimonious practitioner even after completing a gastroenterology fellowship at an institution where patients were routinely subjected to a tsunami of testing.

I don’t pull the colonoscopy trigger easily or order many imaging studies. I prefer to prescribe a tincture of time instead of a test. Most patients appreciate this measured approach, although some prefer the tsunami.

I don’t practice conservatively because it is cost-effective. I do so because I think it’s best for patients. I think it is inarguable that our patients are over imaged, over treated and over tested. I am convinced that there is more than enough wasted money in the health care system to rescue it. Reminiscent of Eisenhower’s warning of a military industrial complex, we are now trying to chip away at a medical industrial complex that is an expanding hydra that takes no prisoners. This is not to suggest that I support Obamacare as a remedy,. I don't. For a fuller airing of my Obamacare opposition, I invite you to wander through the Health Care Reform Quality category on this blog. But, our health care system surely needs better health. It has inadequate access for millions of patients, conflicts of interests, misaligned incentives and quality lapses that must be addressed. I think that Obamacare aims to restrain excesses and remedy deficiencies by settling for mediocrity. I’d rather strive for excellence.

Physicians are strongly advised to practice cost-effective medicine, a practice that is often resisted by patients who interpret this as an effort to save money at their expense. Of course, the term cost-effective communicates that the mission is to save dollars and not save lives. Perhaps, the medical linguists who have concocted phrases including pay-for-performance and medical provider and pharmacy benefit manager can create a more appealing label. Here are some suggestions.

No Frills Medicine
Cheapo Medicine
Medicine on Five Dollars a Day

Seriously, even the hackneyed evidenced base medicine (EBM) phrase would be a step forward. However, EBM is limited since so many clinical issues that doctors face must be addressed without any available medical evidence to guide us. Perhaps, readers have a suggestion of a better phrase than cost-effective.

Recently, the American College of Physicians issued revised guidelines in its newly published ethics manual that instructs physicians that our responsibility extends beyond the patient before us. Here’s an excerpt.

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.

This is an ethical game changer. According to the updated ethics manual, physicians should consider preserving health care resources for the population at large, which may conflict with our patient’s interest. Now, we are told that we are ethically obligated not only to advocate for our own patient, but also for hundreds of millions of other patients. If this becomes standard operating procedure, how will it impact the doctor-patient relationship? Will patients, who are increasingly skeptical of the medical profession, trust us? Will they suspect that we are restraining their care to serve the greater good?

I think that the merits of cost-effective medicine can be persuasively made to individual patients without having to consider society’s needs. Of course, preserving medical resources and health care reform are legitimate issues. But, do they belong in the exam room?

How would patients respond to the following question?

When seeing your doctor in the office, do you expect that he is focused on

(a) your medical interests exclusively?

(b) your medical interests exclusively on Mondays and Wednesdays?

(c) your medical interests exclusively if you are a concierge medical patient?

(d) your medical interests and society’s need to save money?

Physicians are trained advocates. Remind me, who are we advocating for?

As always, your comments are most welcome.

Cigarette Warning Labels May Go Up in Smoke

2012-01-08T06:00:00.001-05:00

We live in a free society. One of our most treasured freedoms is our right to free speech. This means that we are free to advertise goods and services to potential customers, although commercial speech does not enjoy the same constitutional protection as does noncommercial speech. Some advertised products are good for us and others aren’t. In many cases, the worth and value of the product are in dispute. Nevertheless, if a product is legal, the manufacturer is entitled to advertise and to lure customers.

While an advertisement may not be false, it may not be the complete truth either. We expect that these pitches will be buffed and sanitized to present the product in a favorable light. That’s why they’re called advertisements, and not testimony.

It would be absurd for a company to include negative material about its products in its promotional materials, barring a legal requirement to do so. While issuing product warnings and legal disclaimers may be a laudable public interest maneuver, it’s not a way to run a company.

Imagine the following scenarios.

Join Our Tanning Salon. Get skin cancer!

Join Our Gym. Have a stroke on our treadmills!

Dine at our Family Restaurant. We don't wash hands!

Computer Protective Services Our PCs have viruses!

Expert Car Repair. We're Crooks!

The tobacco companies, the mother of all villains, had been required by the Food and Drug Administration (FDA) to include graphic and dire death and illness warnings prominently on their packages. One of the warnings depicts a corpse with the traditional autopsy incision visible. I don’t dispute the accuracy of the health claims. Indeed, I’ve often issued them personally as a doctor in my office. But is it fair, reasonable and necessary to compel cigarette companies to scare folks from purchasing their legal products? It would be more rational and intellectually honest for the FDA and the federal government to declare tobacco to be illegal. How can they permit a product so dangerous to be freely sold to the public? The reasons that restrain them from doing so are self-evident. Readers are free to offer their own views on the government’s paradoxical (in)action.

A federal judge recently issued a preliminary injunction against the FDA’s edict arguing that the cigarette companies were likely to prevail in a First Amendment challenge. The judge recognized that graphic and macabre material likely exceeded a reasonable government requirement to inform smokers of health risks on cigarette packaging. Their purpose was quite transparently to shock, not inform. Not surprising, my beloved liberal New York Times has editorialized that the judge’s injunction was wrong. This judge, in my view, was spot on. I predict that his ruling will be upheld on appeal.

As an aside, are there folks out there who are not aware that smoking cigarettes is not a salubrious activity?

Our medical office needs new promotional material. Since I’m a taxpayer, perhaps the FDA can assist me. Here's my draft.

Michael Kirsch, MD

Specialist in Screening Colonoscopy

WARNING!

He Has Perforated Many Colons.

You Might End Up Here!

Can Spiral CT Scans Detect Curable Lung Cancer? But Wait, There's More!

2012-01-01T06:00:00.002-05:00

A hundred bucks doesn’t buy much these days. A crisp Ben Franklin can be exchanged for

50 Big Macs
A Broadway show ticket
A night in a New York City hotel (just joking)
A college textbook (paperback)
Your life

Your life? Yes, 5 crumpled Andy Jacksons can save your life, as was reported earlier this year in a front page article in The Plain Dealer, Cleveland’s only daily newspaper. University Hospitals is now offering a $99 spiral computed tomography (CT scans) of the chest in individuals who are at increased risk of developing lung cancer. The rationale is that if cancers can be detected early, then the cure rate for surgical removal is very high.

Gary Schwitzer, medical blogger and press watchdog, tries to bring some balance to the distorted media coverage of CT lung cancer reportage.

The test is not covered by insurance, so consumers will have to hand over 10 Al Hamiltons to get in the door.

I’m a deep skeptic of this effort, and predict that with some more time, the promised benefits will prove to have been exaggerated and the drawbacks will become clear. Although one national study suggested that spiral CT scanning was effective, one study shouldn’t change the course of medical practice. If you’ve been reading medical journals for a while, as I have, you realize that today’s breakthrough may break apart tomorrow. Let’s see what future studies on screening for lung cancer with spiral CT scans conclude. I predict growing medical dissent on this issue.

Although I am uncertain about the early promise of saving lives, I am quite certain that the scans will uncover zillions of 'abnormalities'. Undoubtedly, folks will be discovered with benign, insignificant lung lesions, which physicians call incidentalomas. This term refers to abnormalities found by radiologic tests that have no medical significance, but inexorably generate a cascade of medical testing. Every physician can attest to this phenomenon.

Most lesions that spiral CT scans discover will be incidentalomas. Of course, unless there exists a prior CT scan that would prove that the lesion was present years ago and is unchanged, then the incidentaloma will be described as suspicious. So, although most of the abnormalities are benign, they will have a malignant effect on patients and their families. Here is what these folks have to look forward to.

Anxiety that cancer is present
Diminishment of quality of life
Referral to a pulmonary specialist for more fun and games
Prospect of periodic CT scans for 2 years to verify the lesion is stable
Consideration of a biopsy of the lesion (Ouch!)
Consideration of surgery to remove the lesion (Mega-ouch!)
Medical complications from biopsy or surgery
Waste of health care dollars

Although The Plain Dealer’s piece was gushing, there is another side to the story. Is University Hospital pursuing this for medical or for marketing reasons? Will other area hospitals start hawking their own screening CT scans so as not to be left out? Will a bidding war begin driving prices down. This sounds like it could become a 2 a.m. TV telemarketing pitch.

“You won’t pay $250, or even $200. No, you won’t pay $150. For just 5 easy payments of $19.99, you get a state-of-the-art spiral CT scan. And, if you order in the next 10 minutes, we will include a set of Japanese steak knives guaranteed for life. These knives alone are a $200 value. But wait, there’s more. If you promise to tell a friend about this special TV offer, we will include a cigarette lighter that opens up to form an ashtray. No smoker should be without one. And, if for any reason, you are not completely satisfied with your scan, we will return the full purchase price, minus a shipping and handling charge, no questions asked. Return the knives, but keep the lighter/ashtray as our gift.”

My view? I recommend that smokers find a better use for 20 Abe Lincolns than a spiral CT scan. My suggestion? See a Broadway show.

Happy New Year to All!

Whistleblower Holiday Cheer 2011!

2011-12-25T06:00:00.004-05:00

Jingle Bells, jingle bells,

Romney cracks a smile,

Oh what fun it is to watch

The Gingrich pompous style.

Bachman bleats, Cain retreats,

Huntsman tries to please.

Oh what fun it is to watch,

When Perry’s brain goes freeze!

Ron Paul’s weird, Very weird,

Santorum has no chance,

Oh what fun it is to watch

His Tea Party romance.

Who will win? Who will Spin?

Who won Debatorama?

The winner dancing in the streets

Is Barack Obama!

Wishing you Joy & Peace

Colt McCoy's Concussion Fumbled by Team Physicians

2011-12-18T06:00:00.001-05:00

The Cleveland Browns have been in the news this week, and not because of newfound success on the gridiron. While sports is not among my highest priorities, I have developed increasing interest over the years since professional sports is religion to so many here in Cleveland and in Ohio. Cleveland sports teams all enjoy great success, provided that success is not defined by victories. It’s not if you win or lose but how…

I watched the Cleveland Browns compete against the Pittsburgh Steelers two Thursdays ago. I cringed as I witnessed our young quarterback, Colt McCoy, take a blow to the head that could have landed the perpetrator a 10 year prison sentence had this act occurred on the street. I wasn’t worried that McCoy would have to miss the rest of the game. I feared that he might have to miss the rest of his life. Violence sells tickets.

If an activity requires a participant to don a helmet and a coat of armor, then clearly it is an unwise activity for a human to engage in.

McCoy was taken off the field and reentered the arena 2 plays later, after an exhaustive evaluation that was completed in about 100 seconds. Since everything in sports and medicine is now measured, we know that McCoy was sidelined for a total of 3 minutes and 50 seconds before his soggy head reentered the arena. Perhaps, emergency room physicians should consult the Browns’ medical staff to learn how they can expedite their medical evaluations in their emergency rooms. With a little training, a heart attack patient, for example, can be treated in 3 minutes or less.

McCoy’s father went public chastising the Browns for the decision and the process that led to his son Colt returning to the field. While the NFL is now investigating, the Browns maintain that proper procedures were followed.

As more facts dribble out, we learn that McCoy did not receive the standard medical evaluation that is required after a suspected concussion known as the SCAT2 (Standard Concussion Assessment Tool , version 2). Apparently, Browns’ medical personnel were attending to others and did not witness the helmet-to-helmet collision. Are these folks aware of the futuristic technology commonly known as instant replay?

If the only medical training you ever had was how to swallow aspirin or apply Band-Aids, it is likely you would know that a 4 minute time out is not a sufficient assessment period after a cannon ball blow to the skull. Initially, the Browns were vague on the extent of neurologic testing that was performed on the concussed quarterback. We now know that there was no evaluation.

As a physician who has been sued, I am sensitive to applying blame retroactively. I can understand based on the available facts why McCoy was sent back in. But this event shows that either the process is flawed or that proper procedures were not followed. This episode warrants investigation for the right reasons, not simply to apply the broad brush of blame to make some folks feel good.

Nevertheless, this is a particularly galling vignette for physicians like since we are trained and dedicated to practice high levels of patient advocacy. We advise our patients on what we believe to be in their best interests. Sometimes, we take heat for this. We may, for example, advise an individual that they should surrender their driver’s license. We may counsel a patient not to travel even though a family trip was planned months ago. We may warn a patient that his job is threatening his health.

Our advice should not be contaminated by external considerations. We would not, for example, clear a patient to return to work prematurely because this would serve the employer’s interest.

In professional sports, team physicians advocate for the team. Obviously, there is an enormous conflict between serving the team and serving the player. If McCoy’s primary care physician were consulted after the head thrashing incident, do you think he might have offered a second opinion? Let’s hope so.

Colonic Hydrotherapy and Colon Cleansing; Time to Bend Over?

2011-12-11T06:00:00.002-05:00

Garden Hoses in Assorted Colors

A few times each month, a patient asks me for my opinion on colonics. They ask me because I am a gastroenterologist, and I am supposed to know this stuff. After 2 decades of performing colonic intrusions, I should be well qualified to respond to these alimentary inquiries.

To those who are unfamiliar with the concept of colonic detoxification, I offer a brief rationale of the procedure. Those who have been lured into the Fraternal Association of Rare Toxins (acronym not provided) have been persuaded that stagnant stool within the colon is a source of toxins that seep into the body causing disease. According to the anti-toxin crowd, when stool overstays its colonic welcome, it can lead to chronic fatigue, lassitude, restlessness, irritability, mood disorders, skin rashes, arthritis, cardiac rhythm disturbances, seizures, allergies, dementia and the murky diagnosis of candidiasis, or yeast infection. This symptom list could apply to half of my medical practice. So far, I've never prescribed a colonic to any of these sufferers. Have I been medically negligent to withhold this treatment from them? Could a plaintiff attorney accuse me for failure to cleanse?

This is a scary symptom list, which is only a partial listing of the maladies attributed to a slothful colon. Patients reading through these symptoms, might be inclined to use a garden hose for an unintended purpose. Amateurs, however, are strongly advised not to do try this at home. Leave it to the professionals, who are trained to separate you from your stool and you from your money. They succeed on both counts.

To assist you in your research efforts, be aware that there are various names for colonics.

Colonic cleansing
Colonic hydrotherapy
Colonic irrigation
High colonics
Wallet cleansing

Then names may change, but the mission doesn’t. The objective is to get the colon toxins out. The motto of the Society of Hydrotherapists Investigating Toxins (acronym not provided) is, Don’t just die, detoxify!

If any readers at this point are tremulous over your toxins, let me reassure you. There is no science that supports colonic cleansing and no responsible medical doctor will prescribe them. Indeed, if a health professional does recommend that your colon gets hosed down, I'd look for a second opinion. Obviously, stool is waste matter. That's why your intestinal system reliably and regularly eliminates it from your body. There is no persuasive scientific evidence that dangerous 'toxins' in your stool leech into your body and cause disease in normal folks. Hydrocolonic power washing can't compete against millions of years of human evolution.

But, colonic hydrotherapy is big business, and I'm aiming to get a piece of the action.When health care reform gets underway in a few years, and doctors are on salary working supervised by government bureaucrats, I’ll need a side job to make a living. The colon can again be my pathway to success, particularly as colonscopy becomes obsolete. I’ll need a niche as the colonics competition will be fierce, from out-of-work gastroenterologists who will be on the street corner with a sign that reads, Will Do Colonic for Food. However, it won’t be enough to offer routine colonics to gain a foothold in the marketplace. I will need to provide a Bionic Colonic, or perhaps a Supersonic Colonic to turn a profit. Of course, there will be family discounts and volume pricing. Kids under 12 will be half-price. Tuesdays will be Ladies Night. Pets? Endless possibilities.

A year ago, I was worried that health care reform legislation, if it became law, would erode my livelihood. More wiser now, I realize health care reform will be a fountain of opportunities for resourceful physicians. For this gastroenterologist, there’s light at the end of the tunnel.

Pay-for-Performance Attacks Hospitals - Shake Down or Fair Play

2011-12-04T06:00:00.001-05:00

This blog has tried to support the virtue of personal responsibility. If you smoke, don’t blame Joe Camel. If you surrender to Big Mac attacks, don’t go after Ronald McDonald. If you love donuts, and your girth is steadily expanding, is it really Krispy Kreme’s fault? And, if you suffer an adverse medical outcome, then…

Medicare aims to zoom in on hospitals, suffocating them with a variation of the absurd pay-for-performance charade that will soon torture practicing physicians. Of course, a little torture is okay, as our government contends, but pay-for-performance won’t increase medical quality, at least as it currently exists. It can be defended as a job creator as several new layers in the medical bureaucracy will be needed to collect and track medical data of questionable value.

Medical quality simply cannot be easily and reliably measured as one can do with a diamond, an athlete or a wine. Most professions resist being graded or claim that the grading scheme is a scheme. Teachers, for example, refute that testing kids is a fair means to measure their teaching performance. Conversely, any individual or profession who scores well on any quality review program will applaud the system’s worth and fairness. Shocking.

Under the government’s new program, hospitals could be financially responsible for the cost of medical care that a patient requires for up to 90 days after discharge. One can imagine why this provokes angst with hospital administrators. It’s easier to defend the government’s concept if a heart attack patient is discharged prematurely and is readmitted two days later with congestive heart failure. The case is harder to argue is a stroke patient falls at a rehab facility 2 months after discharge and needs to be hospitalized. There will be spirited arguments as to whether the post-discharge events were preventable by higher quality and better coordinated out-patient care. Paradoxically, it might influence hospitals to prolong discharges, which increases costs and the risks of various hospital adventures, including infections and C. difficile colitis.

Government lexicographers have concocted a new phrase, ‘Medicare spending per beneficiary’, which will be used to compare costs among hospitals caring for the same types of patients.

How much responsibility can fairly be assigned to hospitals for bad stuff that happens once patients are released? If a medical event occurs at the nursing home, for example, would this be the hospital’s fault or the nursing home’s? It will be fun to watch the two institutions, who both champion patient care, duke at out. Cash breeds competition.

One item is beyond dispute. It’s a lot easier to measure cost than medical quality. I fear that many of these quality initiatives are veiled attempts to save money, but are camouflaged as medical quality incentive programs.

The ironic flaw in all of this is the absence of any quality control over pay-for performance and its cousins who claim they can raise the medical quality bar. I wish there was a way that we could pay these guys depending upon their performance. The government would resist this as it would be a job killer when all of these newly hired bean-counting bureaucrats would lose their jobs.

Fecal DNA for Colon Cancer Screening and Cleaner Sidewalks: Which Matters More?

2011-11-27T06:00:00.002-05:00

It’s Saturday morning, and I’m in an undisclosed location drinking a fabulous cup of coffee while turning the pages of The New York Times, knowing that ink and newsprint will be vanishing too soon. Yes, I do have an iPad now, but I haven’t figured out how to blog on it. Any suggestions?

Buried in the first section of the paper is an article on stool, which in my view as a gastro specialist, should have merited front page placement. Yes, we all know the adage, ‘one’s man’s trash is another man’s treasure’, but stool - as in excrement - should be prized by everyone. Perhaps, as a gastroenterologist, I have a jaundiced view on this issue, which explains my dyspeptic reaction.

All Whistleblower posts have an accompanying image, and I wonder what visual would be appropriate here. I opted against my first choice, and chose instead a photo of our beloved Labrador Retriever, Shoshie, of blessed memory.

The Times reported a new program to trace canine unscooped poop back to Spot’s owner. Several apartment complexes around the country are now participating. All dogs residing there will submit a DNA sample that will be forwarded to data base. Hopefully, the mailing containers will be secure. It is not clear if a fecal sample can be acquired without obtaining canine informed consent, documented with a paw print, but until the courts rule on this issue, doggie cheek swabbing will continue.

Here’s how it works. If a pedestrian steps in the wrong place, as in ‘glitch’, then a sample from the bottom of the soiled shoe can be mailed to the Turd Squad to determine if there is a DNA match in the data base. If a connection is made, then the pet’s owner will be properly shamed and sanctioned.

Of course, howls of protest will erupt from barking pet owners who will challenge the company’s scientific credentials, or will claim that they were set up by landlords who were seeking back rent. Hey, Dick Wolf, is there a new version of Law and Order Here? How ‘bout, Law and Order: Excremental Intent?

I love seeing gastroenterology making an important difference in people’s lives.

Fecal DNA, I anticipate, will be doing much more for us than keeping our sidewalks a little cleaner. This technology may be the force that transforms colonoscopy from its position as the premier instrument to investigate the colon and to prevent colon cancer into a museum piece. I suspect that that this transformation will occur sooner than we all think.

While the FDA (Food and Drug Administration) has not approved fecal DNA testing for colon cancer screening, professional societies including The American Cancer Society, the U.S. Multi-Society Task Force on Colon Cancer and The American College of Radiology all endorse stool DNA testing as a screening alternative.

In the coming years, there will be a parking lot rumble among competitors who will argue that their colon cancer screening is best. I think screening colonoscopy has some good years left, but this is not the future. Fecal DNA promises to be one mean screening machine.

Lawyers and Medical Malpractice Reform: Tort Reform Allies for Doctors?

2011-11-20T06:00:00.002-05:00

When lawyers talk, I listen. Two attorneys penned a piece on medical malpractice reform in the April 21st issue of The New England Journal of Medicine, the most prestigious medical journal on the planet. Here is an excerpt from their article, New Directions in Medical Liability Reform.

The best estimates are that only 2 to 3% of patients injured by negligence file claims, only about half of claimants recover money, and litigation is resolved discordantly with the merit of the claim (i.e., money is awarded in nonmeritorious cases or no money is awarded in meritorious cases) about a quarter of the time.

This is not self-serving drivel spewed forth by greedy, bitter doctors, but a view offered by attorneys, esteemed officers of the court. Apply the statistics in their quote to your profession. Would you be satisfied if your efforts were benefiting 2-3% of your customers or clients? Would this performance level give me bragging rights as a gastroenterologist? Perhaps, I should attach a new slogan to my business card.

Michael Kirsch, MD

Gastroenterologist

Correct Diagnosis and Treatment in 2-3% of Cases

We would have to build a second waiting room to accommodate the crowds of new patients who would be jamming in to see me.

The current medical malpractice is beyond broken, and it is absurd to debate this. When even lawyers write under their own bylines that medical malpractice reform is needed, then it must be even worse than I thought. I assume that their bylines are true, but perhaps they used pseudonyms for their own protection.

In fairness, the authors did not find persuasive evidence that various medical malpractice reform proposals, some of which I have advocated on this blog, would accomplish the desired objectives of improving care and controlling costs. They examined various reforms including damage caps, pre-trial screening panels, certificate-of-merit requirements, joint-and-several-liability reform and statutes of limitation limits. They advocate continued study and experimentation to achieve meaningful medical malpractice reform.

As a physician, I understand the value of evidence. We should not adopt a medical malpractice reform measure that is shown be ineffective, even if doctors like me favor it. This assumes, of course, that the reform measure has been fairly tested. Debating tort reform proposals is a legitimate discussion and lawyers should be included in the conversations.

Defending the current system, however, is not legitimate. Even lawyers admit that the current system targets but a tiny fraction of patients who have been harmed by medical negligence. What relief do the other 97% of patients receive? In addition, the system targets too many innocent physicians, ultimately releasing most of them after dragging many of us on an agonizing journey. In my office, and probably in your doctor’s office also, litigation fear promotes defensive medicine, which harms patients and costs money.

I will now turn away from tort reform and turn to my morning pleasure, The New York Times. I read a hard copy with ink and newsprint, but I am sure that this anachronism will soon be extinct. I have a new suggestion for their motto, which appears in the top left corner on page 1 of every issue.

“2-3% of the News

That’s Fit to Print”

Joe Paterno Fired: Proper Punishment or Political Correctness?

2011-11-13T06:00:00.003-05:00

As a gastroenterologist, I know a few things about scoping. Indeed, every working today I am tunneling through either end of the alimentary canal. These exercises are literally and figuratively enlightening as I seek new information that will make patients’ lives better or keep them well.

Endoscopy is an example of prospective scoping, meaning the result of the scope is not yet known because the diagnostic study had not yet been done. This contrasts with the concept of retroscopy, which describes the concept of looking backwards at events that have already transpired and then making judgments on these events. In the vernacular, retroscopy is known as ‘Monday morning quarterbacking’.

While I am not officially credentialed in retroscopy, and received no training in this procedure during my gastroenterology training program, I am quite familiar with the technique. Retroscopy is one of the main tools wielded by medical malpractice plaintiff attorneys who sue physicians for alleged medical negligence. It is in easy task in medicine, and in life, to look backwards after a tragedy has occurred and to assign fault by demonstrating how the event could have been averted. Those of us who must operate in real time, however, do not have power of clairvoyance which would enable us to choose the path that leads to a blissful outcome. We have all read about police officers who are vilified after using excessive or even deadly force against an individual. While there are times that law enforcement have clearly erred, on other occasions I’m not so sure. I’m grateful that I don’t have to make a split second decision with a gun in my hand as I face someone whom I believe poses an immediate danger to me or to others. What if the officer were to hold his fire and the suspect would then shoot some innocent bystanders? During the inquiry that properly follows deadly force by law enforcement, a team of investigators may take weeks combing through every angle and aspect of the episode to determine if the officer was trigger happy. The officer may have had but a moment to make his decision.

We physicians face the same unfair process when years after an unfortunate medical outcome we are chastised for failing to prevent the disaster when we - through the retroscope - had ample opportunity to do so.

“Why didn’t you recommend surgery, doctor, which clearly would have saved the patient?”

Because at the time the medical and surgical team believed that the patient would not have survived surgery and that continued intensive medical treatment was appropriate.

“Why didn’t you prescribe the antibiotic that was appropriate for the infection?”

Because, the rare germ that was infecting the patient wasn’t identified until autopsy.

“Why did you discharge the patient 12 hours before he returned to the hospital with a massive heart attack?”

The patient was discharged after a routine hernia repair. He had no symptoms at discharge and was properly sent home.

I think that Joe Paterno has been victimized by the retroscopers. He was fired this past week for failure to have done more after he was notified in 2002 of an illegal and indecent act that was perpetrated by a former defense coordinator. He didn’t bury the information, but promptly informed the athletic director and a Penn State vice president of what he was told. True, he did not follow-up on the issue afterwards or notify law enforcement of what he knew.

Interestingly, the two Penn State individuals who have been charged with crimes will have their legal bills paid by the University, while Paterno, a cooperating witness, was fired. Sure this might be a contractual requirement, but does it sound fair?

As more facts emerge, we will learn that many had knowledge or suspicions of sexual abuse, but remained silent. What standard will be applied to them?

Should Paterno have done more? Yes, and Coach Paterno deeply regrets his inaction, as he has stated publicly. However, is firing him the proper and proportionate response in the context of a lustrous career that spanned decades? He has spent 62 years at Penn State including 46 seasons as the Nittany Lions’ head coach. He has been a role model for thousands and thousands of young athletes and students on his campus and throughout the country. He has a legendary reputation. By any measure, this man has done much good over a long and brilliant career.

He committed no crime and did not engage in a cover up. He made a mistake. In my view, his abrupt and ignominious ouster was wrong. This affair could have been handled much more gracefully, preserving the coach’s dignity, while still demonstrating disapproval of Paterno’s stopping short 9 years ago.

I know that my view here is not popular, but I hope that readers will give it fair-minded consideration.

Is this the best that Penn State could have done? I don’t need to pull out the retroscope here. I’m watching the game in real time. Penn State fumbled.

Medical Malpractice Reform Losing Physician Support

2011-11-06T06:00:00.001-05:00

With regard to physicians’ support for medical malpractice reform, the times they are a changin'. These iconic words of Bob Dylan, who has now reached the 8th decade of life, apply to the medical liability crisis that traditionally has been a unifying issue for physicians.

The New York Times reported that physicians in Maine are going soft on this issue, but I suspect this conversion is not limited to the Pine Tree State. Heretofore, it was assumed that physicians as a group loathed the medical malpractice system and demanded tort reform. The system, we argued, was unfair, arbitrary, and expensive. It missed most cases of true medical negligence. It lit the fuse that exploded the practice of defensive medicine. Rising premiums drove good doctors out of town or out of practice.

What happened? The medical malpractice system is as unfair as ever. Tort reform proposals are still regarded as experimental by the reigning Democrats in congress and in the White House. The reason that this issue has slipped in priority for physicians is because our jobs have changed. Private practice is drying up across the country for the same reasons that family owned hardware and appliance stores are vanishing. Look what has happened to independent bookstores? If you want to find one in your neighborhood, you may need to hire a private investigator. Private physician offices are being squeezed out by surrounding medical institutions that, using Ross Perot’s famous phrase uttered in the 1992 presidential campaign, have created a ‘giant sucking sound’ as it vacuums up patients from private doctors’ waiting rooms.

This is only half of the story. Sure, the medical behemoths that employ doctors have cut deeply into private physicians’ patient bases. But, increasingly, physicians are joining these enterprises willingly becoming employees of hospitals and large multispecialty clinics. Understandably, these physicians who are entering their careers do not want the lifestyles of their predecessors. They want time off and a decent family life. They want hospitalists to admit their office patients who need in-patient care. They don’t want to spend hours of uncompensated time each week on paperwork that doesn’t help patients or improve their medical skills. They don’t want the stress of making payroll, hustling for patients or engaging in the fun pastime of trying to convince insurance companies to pay them what they are owed. You get the idea here. They are shifting to a shift work culture, and I certainly understand why.

Can these doctors still get sued? They can, and they will. But, they are not paying their own medical malpractice premiums. Some of the larger medical institutions that employ them are self-insured. Since these physicians are not paying the bill – or any bills – they don’t have the same stake in the game that we private practitioners do. Medical malpractice reform is still on their radar screen, but the blips occur at a higher orbit. They are focused on other issues.

What this means that one of tort reform’s most unified and vocal constituencies will lose interest in the medical liability issue. The crop of physicians entering the profession in the next decade just won’t view medical malpractice reform as a religion. Of course, they will reel when they are unfairly sued, as we do, but it won’t be an issue that commands much of their attention in between lawsuits.

Folk music is prophetic. Where have all the doctors gone? Long time past seen. Will medical malpractice reform ever really happen or will it continue to be just blowin’ in the wind?

Medical Device Approval vs F.D.A. Whose Side Are You On?

2011-10-30T06:00:00.002-04:00

Last week, I attended a 2 day medical conference in Cleveland on obesity. It was a heavy seminar, which I would rate 8 on a (bathroom) scale of 1-10. Interestingly, the majority of the speakers appeared to have BMIs (body mass indices) within the normal range. Coincidence? I suspect discrimination against rotund academicians. I’m sure that if any attorneys were in attendance, that a proper legal response would have been promptly initiated. They would take the matter on a contingency fee basis, or in a more novel approach, fees could be linked to excess body weight so that each pound that was unfairly discriminated against would be fully and fairly compensated. I’ve been told that I think like a lawyer. Is this a compliment I should graciously accept or a slur that warrants a lawsuit for defamation?

The conference was excellent and I hope to incorporate what I have learned into my practice. My community gastroenterology practice is ever expanding, and I don’t mean my patient volume.

There were lectures on exercise, nutrition, commercial diets, bariatric surgery, medications and medical devices. There was a fascinating lecture given at the conference’s conclusion by a banker who works with venture capitalists. He lamented that the F.D.A. was a major impediment against product innovation and delivering products to market. Investors and companies pour millions of dollars into start-ups or toward medical device research and are frustrated by what they believe are unreasonable governmental obstacles or migrating goal posts. He stated that this was not simply his personal view, but was a widespread view across the industry. Some of the consequences of this policy include:

Suffocation of of many small device companies and entrepreneurs
Diminishing competition to foreign device companies
Loss of investor confidence resulting in scarcer funds to fuel research and development
Encourages corporations to pursue ‘safe’ projects where F.D.A. approval is achievable but medical benefit is marginal
Harms the public by preventing or delaying new medical treatments from reaching them

A senior Cleveland Clinic physician offered a spirited rebuttal of the banker’s view stating that the system, while imperfect, is fundamentally sound. He pointed out various examples where recent medical devices were found to be seriously flawed which have cost millions of dollars and patients’ lives. Failing metal on metal hip appliances is the most recent example of the risk of under regulation. Indeed, it sounds horrendous for patients to have to undergo repeat hip surgeries because their new metal hips will soon be out of joint.

Earlier this year the Institute of Medicine (IOM) advised the F.D.A. that the system for approving medical devices should be scrapped, as it was too lax. The F.D.A., who commissioned the study, didn’t accept the IOM’s recommendations. Perhaps, they believe the agency can reform itself from within, always a dicey prospect.

Of course, a proper balance needs to be established between protecting the public and stimulating vigorous innovation. It seems to me that we are out of balance. We must recognize that no system will be perfect and please all players in the game. While we all strive to protect the public, if we tolerate no risk, then there will be no new products, devices or medications coming to us. How much risk is reasonable? There is no single answer here as most of us would tolerate more risk depending upon the circumstances. We accept more risk as the stakes increase.

While industry and the government have different interests and agendas, ultimately they both hope to serve the public good. Failed devices harm patients and harm industry by eroding the public trust.

All of us accept risk in our daily lives. Should the federal highway speed limit be lowered to 35 miles per hour? Why not? Wouldn’t this save lives? Wouldn’t this be worth some added travel time for all of us?

The political aspects of the medical device approval controversy were discussed in a New York Times article earlier this week which is worth a perusal.

Do you want more civil liberty protections or do you favor more power for intelligence gathering? Do save wildlife and forests or promote development and job creation? Do you want more public safety or do you want more medical innovation? It’s vexing to navigate through these tortuous conflicts.

We are being presented with a version of Trick or Treat. Each side claims to offer the treat and disparages the other as a trickster. It’s not quite that simple, is it?

Whose side are you on?

Could Herman Cain Have Survived Obamacare? 9-9-9 Man With A Plan Speaks Out

2011-10-23T06:00:00.002-04:00

Photo Credit

Herman Cain gleefully shouts to adoring crowds that he now has a target on his back. Amazingly, this non-pol has vaulted to the front of the back, leapfrogging over career politicians who have been running for president and other political offices for years. Can Cain go the distance? Does he have the right stuff? With a 'wink' toward Genesis, is Cain ‘able’?

He is derided over his 9-9-9 plan by folks who are scared that his bold and innovative reform proposal is attracting voters. They are more frightened that his plan may actually work. Critics point out or invent flaws in his proposal, trying to chip away at the edifice. Carping is a lot easier than constructing.

I’m not an economist and I have no idea if the 9-9-9 plan should be championed or stuffed into a pizza box and recycled. Increasingly, the public believes that whatever flaws and inadequacies 9-9-9 may have are preferable to the deficiencies and abuses of the current tax system.

Reform threatens the status quo whose agents will push back hard for all the wrong reasons.

A Whistleblower reader could use the above statement to challenge my numerous posted arguments against Obamacare, claiming that I am the hypocritical whiner who is clinging to the status quo and attacking medical reform.

This argument would have some merit if I accepted that Obamacare was truly reform, which I do not. Simply (mis)labeling the law as the Patient Protection and Affordable Care Act, doesn’t make it so. Over the years, I have been amused by the labels that legislators assign to the laws they sponsor. These names are often sanitized sheep’s wool covering up rotting carcasses.

Here are some other labels for Obama’s health care reform law that just missed the cut.

Phase 1 Government Takeover of Health Care Act
Medical Malpractice Attorneys Protection Act
Medical Private Practice Unaffordable Act
Medicaid Expansion Act
Pandering to Medicare Beneficiaries Act
Government Rationing of Health Care Act
Hassle Doctors Out of the Profession Act
The Democratic Party Protection Act

Of course, nothing is all good or all bad. There are elements of Obamacare that I do support. I do not think folks should be discriminated against for pre-existing medical conditions. I agree that everyone should have access to medical insurance coverage. I zealously support comparative effectiveness research, which I don’t think has a prayer to succeed against the medical industrial establishment. I support the objective of improving medical quality, but reject the pay-for-performance and related charades that will diminish quality and demoralize and punish doctors.

Herman Cain, like his GOP rivals, all promise to bury Obamacare if elected. Cain, a Stage IV colon cancer survivor believe that had Obamacare been the law of the land when he was ill, that he might have ascended prematurely to heaven.

If I had been under Obamacare, and a bureaucrat had been trying to tell me when I could get that CT scan, that would have delayed my treatment. I was able to get the treatment as fast as I could based upon my timetable, and not the government's timetable. That's what saved my life.

While Cain’s pronouncement may be hyperbole, patients should be concerned about the intended destination of today’s medical ‘reformers’. While the law is called the Patient Protection and Affordable Care Act, I think the law will strive for affordability at the expense of patient protection.

The government wants to shrink the pie and yet promises that we will all be satisfied. Which candidate today understands pies best?

This post is not a political endorsement. Herman Cain has not yet earned my support, but I’m glad he’s at the table. The ferocity of attacks against him convinces me that he has a valuable voice in the conversation. At the very least, it has forced the other candidates to defend their policies and positions. Competition breeds excellence. Let the games begin.

Ten Questions to Ask Your Doctor?

2011-10-16T06:00:00.001-04:00

The blog, Shots, posted a question primer to prepare patients for medical office visits with their doctors. A reaction to this appeared on Glass Hospital, where John Schumann offered his own wry version of the question list. My less wryer, and more drier response appears below.

While I agree with Shots that education is power, a closer look at the question list demonstrates that the intent to educate may obfuscate instead.

First, the post is entitled, Ten Questions to Ask Your Doctor, suggesting that patients arrive at their physician’s office armed with 10 inquiries spanning a spectrum of medical knowledge and philosophy including medical treatment strategy, physician qualifications, risks of treatment, medical treatment alternatives, choice of hospitals and even how to spell the names of their medications. (I guess Shots believes that spelling counts!)

Some of the questions sound reasonable, but could patients make sense out of the answers? For example, Shots suggests asking which hospital is best for my needs? Patients often are focused on the choice of hospital, when they should be more interested in which physicians will be caring for them. While the hospital matters, it’s much more important who will be performing your surgery, then where it will take place. Are patients equipped to evaluate hospital quality anyway? Is a good reputation or a shiny exterior a true surrogate for medical quality? Patients often have a negative view of a hospital based on an isolated anecdote, which they may not have even experienced first-hand.

Another suggested question is how many times have you done this procedure? Will this provide useful information for patients? I agree that for many medical procedures, a higher case volume means a lower risk of complications. But, will it enlighten a patient to know that the gastroenterologist has performed 2000 colonoscopies or 5000 or 10,000? Better questions, which can’t be quantitatively answered, would be how many times have you done this procedure well, or, how many of your procedures were truly medically necessary? I object to Shots’ version of the ‘how many’ question which simplistically reduces medically quality measurement to a check-off form, paying homage to the deities who gave life to the pay-for-performance beast. What really counts can’t be counted. Paradoxically, what can be counted, will count.

In addition, if you bring your doctor the 10 question list, be prepared for some frustration when your office visit ends and you’ve only covered the first 3 items on the list. There may not be time left for you to discuss the issue that brought you t see your doctor in the first place. It may take a few visits and a fair amount of dialogue for you to understand your physician’s philosophy and style of medical practice. This important information can’t be acquired by taking a multiple choice test or answering a series of questions.

The question list on the blog Shots is a guide that needs to be prioritized. You simply can’t cover them all in a single visit, and you shouldn’t have to. Experienced physicians know that patients often want to cover every last medical concern and we will often begin a visit with a question from our own ‘top ten list’. What are the 1 or 2 issues that we need to cover today?

Any questions?

Health and Wellness Programs: Medicine or Marketing?

2011-10-09T06:00:00.001-04:00

Shark Cartilage: Cancer Cure?

There’s a new term that has entered the medical lexicon. The word is wellness. Hospitals and medical offices are incorporating this term into their mission statements, corporate names, business cards, medical conferences and other marketing materials. The Cleveland Clinic Foundation has appointed a Chief Wellness Officer, an intriguing fluffy title that does not clearly denote this individual’s role and function. This is deliberate, as the word wellness is designed to communicate a ‘feel good’ emotion, not a specific medical service.

Just a click or two on Google will lead you into the wellness universe. Here’s a sampling.

Institute of Sleep and Wellness
Wellness Institute of America
Naturopathic Wellness
National Wellness Institute
Physicians Health and Wellness Center
Physicians Wellness Group

There’s even a sponsored ad on Google where one can search for physicians, presumably trained in the medical specialty of wellness. I was dismayed that my name didn’t appear in a wellness search of the Cleveland, Ohio region. Does this mean that I don’t offer my patients health and wellness?

Where is all of this wellness coming from?

It’s coming from marketing departments who understand the public mood. While conventional physicians view complimentary medicine warily, the public can’t swallow it fast enough. Patients want a softening of the medical profession and are willing to accept new genres of care based on promises, testimonials and faith. I admit that much of what my colleagues and I prescribe and recommend is based on scant medical evidence. I don’t have satisfying treatments for irritable bowel syndrome or chronic abdominal pain. I understand why such patients look beyond me and my colleagues for healing and relief. They are spending billions of dollars on herbs, colonic hydrotherapy, Reiki, massotherapy, holistic medicine, naturopathy, aromatherapy, biomagnetism, guided imagery, medication and homeopathy.

Hospital and medical marketers may not know how to cure disease, but they sure can count. The vast majority of Americans have pursued alternative medicine for one reason or another. The medical establishment has expanded its healing mission to gain access to this huge and growing market. Conventional hospitals, where cardiac catheterizations and colonoscopies are performed, now offer a variety of wellness programming to extend their branding into the surrounding communities.

I think that we are risking a wellness overdose, and there is no antidote. My concern is that it confuses the public between ways to improve their lifestyles and state of mind and actual medical care and treatment. I concede that many alternative medical treatments make folks feel better, but I’m not sure they cure disease. There’s a danger in medicine when faith overtakes reason. An extreme example is when cancer patients were spending precious time and resources for shark cartilage or other high cost alternatives that have no scientific basis. These opportunities exploit desperate people who have no way out. They shouldn’t have to spend money to pray for a miracle. They can do that for free, and they should.

I know there is spirited belief and support for unconventional medicine to complement traditional medicine’s failings. If they want to turn skeptics like me into believers, then they’ll have to pursue a more conventional approach. Test your treatments in high quality clinical trials. If scientific studies determine that these treatments, or any therapies, offer no benefit, then abandon them rather than assail them as flawed and biased studies.

I’m in favor of any intervention that makes people feel good, provided it is safe and doesn’t exploit folks. Just because the word medicine is in the label, doesn’t make it so.

Secret Shoppers in Doctors' Offices: Placebo Medicine for Physicians

2011-10-02T06:00:00.006-04:00

Physicians are still debating whether prescribing placebos is ethical. Dissenters argue that this is dishonest and would erode trust between patients and their physicians. If the practice were to gain acceptance, then physicians’ credibility would be diminished. Patients would wonder whether the medicines their doctors are recommending are evidenced-based or fraudulent.

Patients can now push their own snake oil right back onto their physicians. I learned that the ‘secret shopper’ mechanism for quality assessment has been introduced into the medical profession. I first read about this in the March/April 2010 issue of the Journal of Medical Practice Management, a periodical that I suspect is not widely read by physicians.

Folks are hired as pretend patients and are dispatched to doctors’ offices and hospitals to document their findings. Their mission is to assess office staff, appointment issues and the waiting room experience. I wonder if soon they will add encore performances and will subject themselves to Pap smears and rectal examinations to assess doctors’ clinic skills and techniques directly.

Surprisingly, the American Medical Association’s Council on Ethical and Judicial Affairs endorsed the practice, although many physicians objected.

I agree that these pseudopatients could improve office quality by highlighting flaws that have not been recognized or remedied. Yet, I cannot support the stealth tactics of this quality control method. On its face, it is dishonest. It also costs medical practices and institutions time and money attending to people who are masquerading as actual patients. If the secret shopper strategy did gain traction in medical quality assessment, could it be used as an investigative tool by malpractice attorneys? Finally, the concept is wholly unprofessional using a technique that is generally used in large big box retail establishments and restaurants. It is demeaning that physicians are already being evaluated on Angie’s List and the Zagat survey, as if we are automobiles or toaster ovens.

The federal government has now indicated that it will initiate its own secret shopper program to gauge how difficult it is for patients to gain access into primary care physicians' offices. Big Goverment becomes Big Brother. Hours after this stealth plan was boldy announced, it was rescinded in a Big Retreat.

Let's make a deal. Don’t make an appointment to see me unless you truly are seeking medical care. In return, I’ll never prescribe you a sugar pill. This will strengthen the trust between us, the foundation of a successful doctor-patient relationship.

Better Bedside Manners? What's It's Worth To You?

2011-09-25T06:00:00.001-04:00

How much are good bedside manners worth? Would you double your copay if you could be guaranteed an extra measure of TLC from your physician? Can we put price on a physician’s warm smile, an understanding nod or a reassuring hand on your shoulder? Do patients have to contract with a concierge medical practice to receive this treatment?

I agree that our bedside manners with patients need some rejuvenation. It’s not fair, however, to isolate this issue out of context. Physicians today are facing crunching pressures from various sources that we cannot always compartmentalize when we are facing our patients – even though we should. Most folks believe that the bedside manners of the prior generation of physicians were superior to ours. Were our predecessors simply more compassionate and caring human beings than we are? I don’t think so. I think the medical profession was a different beast then. I hypothesize that if these wizened physicians entered the profession today, that they would behave differently.

Context is so critical when examining any issue. Many physicians find today’s patients to be demanding and entitled. Again, before pronouncing a verdict here, there are reasons and explanations behind this that need to be aired. Patients and physicians are both different today because the culture and nature of the profession has changed. How would Marcus Welby behave if he weren’t making house calls with a black bag 40 years ago, but were now an employed physician in a large clinic who was sued every few years and whose medical ‘quality’ was monitored by bureaucrats who determined his reimbursement?

Again, I’m not excusing deficient bedside manners, but the issue has nuance and complexity.

A Chicago couple, Matthew and Carolyn Bucksbaum, believe that bedside manners are worth a lot. These philanthropists are donating $42 million to the University of Chicago which will create an institute under their names which will be devoted to teaching medical students good bedside manners. The hope is to ingrain values of compassion and empathy deeply enough into medical students that they will not be contaminated when they enter the medical arena later. The training would function like a suit of armor to protect young physicians from bedside manner decay and attack.

This is a fantastic initiative and I hope that other donors and medical institutions emulate the Chicago program. While medical schools do teach bedside manners and the importance of the doctor-patient relationship, it was undervalued, at least in my day. Younger physician readers can comment if times have changed.

Can you really teach compassion or do you have to be born with it? A Chicago couple has wagered in a big way that it’s nurture, not nature.

Minute Clinics Threaten Doctors: Who Wins?

2011-09-18T06:00:00.002-04:00

All of us have been to fast food establishments. We go there because we are in a hurry and it’s cheap. We love the convenience. We expect that the quality of the cuisine will be several rungs lower than fine dining.

We now have a fast medicine option available to us. Across the country, there are over 1000 ‘minute-clinics’ that are being set up in pharmacies, supermarkets and other retail store chains. These clinics are staffed by nurse practitioners who have prescribing authority, under the loose oversight of a physician who is likely off sight. These nurses will see patients with simple medical issues and will adhere to strict guidelines so they will not treat beyond their medical knowledge. For example, if a man comes in clutching his chest and gasping, the nurse will know not to just give him some Rolaids and wish him well. At least, that’s the plan.

Primary care physicians are concerned over the metastases of ‘minute-clinics’ nationwide. Of course, they argue from a patient safety standpoint, but there are powerful parochial issues worrying physicians. They are losing business. They have a point that patients should be rightly concerned about medical errors and missed diagnoses at these medical care drive-ins. These nurses, even with their advanced training, are not doctors. It is also true serious or even life threatening conditions can masquerade as innocent medical complaints and might not be recognized by a nurse who treats colds and ankle sprains.

The Annals of Internal Medicine, a prestigious medical journal, reported on the quality of these retail clinics and concluded that the quality of care for ear infections, sore throats and urinary tract infections in fast-medicine outlets was similar to that in physicians’ offices, but at lower cost. While this is ammo for fast-med aficionados, it doesn’t address a more important point. I’ll concede that if I take my kid with an ear infection to a Wal-Mart clinic or the pediatrician, then the outcome will be similar. (Many experienced Moms would also know what to do.) The tricky part is when the symptom is murky and the range of medical possibilities is broad. If my kid were having stomach pain, for example, I want a physician to decide if this is simple constipation, intestinal gas or acute appendicitis that needs urgent surgery.

These clinics are proliferating because the market demands them. The fundamental cause is the inadequate number of primary care physicians in this country. This shortage will become more acute when Obamacare extends coverage to tens of millions of uninsured. Massachusetts discovered this a few years ago when they provided coverage to the uninsured, but didn’t have enough primary care physicians to care for them. These clinics are also providing a service that physicians have been unable or unwilling to match. They offer evening and weekend hours at low prices. Patients come at their convenience and are seen without waiting.

Pharmacies and big box stores benefit from minute clinics. They bring shoppers into the store who are likely to purchase other items after their scraped knee is bandaged. And if a prescription is needed, guess where it gets filled? From a patient’s point of view, this experience sure beats an emergency room adventure.

Are these clinics a good idea? It doesn’t matter because they’re coming and they can’t be stopped. They fill a legitimate need that the medical profession cannot address and the public demands. Market forces created the opportunity and will monitor its success.

Will they survive? Remind me, how long have McDonalds, Burger King and all the rest been around?

We Remember

2011-09-11T22:12:00.001-04:00

Overtreatment Alert! Antibiotics Fuel Medical Overutilization

2011-09-04T06:00:00.002-04:00

A good friend of mine and Whistleblower reader contracted the sniffles and received a prescription for antibiotics at a local urgent care center. Nothing newsworthy here. So far this quotidian event sounds like a 'dog bites man' story. Had antibiotics been denied, this would have been 'man bites dog', as this denial would be a radical departure of standard medical practice, particularly in the urgent care universe.

No doubt, my friend was not assigned the dismissive diagnosis of 'the sniffles', but was likely given a more ominous diagnosis of 'acute upper respiratory infection', a term that sounds so serious that he might have feared that a 911 call had already been made.

Why are antibiotics prescribed so casually and so frequently? Choose from the following answers. There may be more than one correct response.

Antibiotics are the appropriate 'shock & awe' response to sniffle syndromes.
Patients demand antibiotics and offer evidence of necessity that their prior physician always prescribed them for the exact same symptoms.
Prescribing antibiotics is a sure method for increasing patient satisfaction.
Antibiotics are extremely safe and only rarely cause adverse reactions.
Patients fear that a delay in antibiotics could bring them to the brink of an infectious calamity.
Drug reps and direct-to-consumer advertising create a climate to prescribe medications including antibiotics.
It takes a physician 10 seconds to zap an antibiotic prescription to the pharmacy, but could take 10 or 15 minutes to explain why they're not indicated.
Antibiotic drug samples in physicians' offices encourage written prescriptions for patients.
Since physicians can't reliably distinguish viral infections from bacterial attacks, it's safer to prescribe antibiotics just to be sure that a bacterial infection isn't left untreated.

I'm sure that readers could add many other reasons that contribute to the antibiotic avalanche that is burying us, and I hope you will comment below. Infectious disease specialists and primary care physicians know that the majority of infections seen in outpatient visits are viruses - common colds - which do not respond to antibiotics; yet they are often prescribed for these illnesses. Changing this practice won't be easy and will take time. Look how long the public resisted buckling up in the car and using bicycle helmets, which are now universally accepted practices.

Antibiotic overutilization has real consequences.

It costs money.
It fosters a climate of medical overutilization.
Antibiotics can cause severe side-effects including C, difficile (C. diff) infections, which can be fatal.
It leads to the proliferation of resistant bacteria - superbugs - which won't respond to any available antibiotic. Care to be infected with one of these germs?

The Chief Complaint in medicine refers to the patient's summary statement explaining the reason for the medical visit. Typical Chief Complaints include:

Fever and cough
Chest pain
Abdominal Pain
Trouble breathing

These days, many patients have created their own version of the Chief Complaint (CC). Instead of describing their symptoms, they are now directing the treatment. See below.

Traditional CC: "I have a sore throat and a cough."

New & Improved CC: "I need an antibiotic."

Medical overutilization is my Chief Complaint.

Should Patients Join the Pay-for-Performance Circus?

2011-08-28T06:00:00.001-04:00

There was an extremely popular game show where several times each episode the emcee would shout out, "Survey Said!". Of course, this was just a game, not real life. Now, several times each week I am asked to respond to surveys. They pop up uninvited on the internet and are often veiled advertisements for products and services. They are on the back of receipts from coffee houses and doughnut shops. Is it worth 10 minutes of my time clicking through the doughnut survey for either a free chocolate frosted doughnut or the chance to be entered into the grand prize drawing months later? Hotels I stay at routinely follow-up with e-mail surveys for my feedback. I suspect most folks delete these instantly, which skews the customer base to those who do respond. (Remember, disatisfied folks are often more motivated to give feedback than the rest of us are.) How often do we call a restaurant, a retail store, a bank or even a doctor's office to offer hosannas about great service?

Medicare recently released fascinating patient-survey data that raises interesting issues. In over 120 hospitals, patients rated the hospitals very highly, despite high death rates for heart disease and pneumonia. So, who do we believe here, the patients or the death rates? I wonder if the patients' survey results were more optimistic since only the live ones were available to complete them.

Surveys are now serious bu$ine$$. Reimbursement for hospitals and physicians will be influenced in either direction by patient satisfaction results. But, are patients equipped to measure medical quality? The discrepancy between the Medicare patient survey results and actual medical outcomes suggest that they are not the right tools for this task. How can we expect ordinary folks to understand and rate medical quality when experts are confounded by the same mission?

Surely, there are important aspects of the medical experience that patients can evaluate.

On-time performance
Cleanliness of the facilities
Courtesy of the staff
Compassion and bedside manners
Responsiveness to billing issues
Ease of making appointments
Timely communications
Ease of reaching a living, breathing human being for a question or concern

But, while the above items are significant, are they true measurements of medical quality in the conventional sense? Is the definition of medical quality being broadened simply to encompass measurable events?

Patients are being recruited under the Big Top, aka as the Pay-for-Performance Circus. But, should patient surveys really count? Or, do they count simply because their results are so easy to count? Despite the dissenting arguments against P4P advanced on the Whistleblower, a must-read blog for health care thought leaders across the country, patient surveys will be folded into the expanding hydra of P4P programs. These programs won't measure true medical quality, at least in their current forms. But, what a performance they will be. The curtain will rise as the Secretary of Health and Human Services approaches the podium and shouts out, Survey Said! What a Family Feud this will be.

Tort Reform for Medical Malpractice System Another Study Needed?

2011-08-21T06:00:00.002-04:00

Medical malpractice reform is in the news again. Of course, for the medical profession, the medical malpractice system is the wound that simply will not heal. For the plaintiffs bar, in contrast, the medical liability system is the gift that keeps on giving. I have argued that the current system fails on four important fronts.

Efficiency
Cost
Fairness
Quality Improvement

I admit readily that my profession has not been as diligent as it should be in holding ourselves accountable. We have not been forthright in admitting our medical errors, although can you blame us under the current medical liability construct? There is merit to the argument that tort reform is championed by medical malpractice insurance companies who have an economic agenda in this issue.

I recognize that certain malpractice reform measures, such as caps on non-economic damages, means that some individuals who have suffered severe injuries as a result of medical negligence, would not be adequately compensated. Nevertheless, I support caps because I am convinced it would serve the greater good, even though I would feel differently if I were one of the plaintiffs whose deserved compensation would be curtailed.

Despite the above admissions, the current system is a dysfunctional mess that fails in its mission to provide justice and fairness to the participants. More than physicians' arguments for reform, plaintiffs lawyers' pleass for maintaining the current system is permeated with economic self-interest. In my view, theirs is a weak brief that is transparent with regard to its true motives.

Here are some inarguable weaknesses of the current system.

The vast majority of patients harmed by medical negligence are not captured in the current system.
Non-partisan analyses confirm what we physicians know instinctively: litigation fear costs billions of dollars in defensive medicine, medical tests ordered to protect us, not our patients.
The majority of physicians targeted are ultimately released at some point in the process.
By stimulating defensive medicine, the current medical liability system diminishes medical quality, and does not serve as a deterrent against negligent care. Paradoxically, arguing that defensive medicine is negligent could be a potent niche for plaintiff attorneys.

The New England Journal of Medicine (NEJM) recently released a study after analyzing data from a medical malpractice insurance company involving over 40.000 physicians. Here are some highlights.

Every surgeon will face a medical malpractice lawsuit at some point in their careers. Is this a good lure to recruit talent into the surgical specialty?
About 7.5% of physicians face a medical malpractice lawsuit every year. 'Hey, I haven’t been hit for a few years. Is my number coming up soon?'
About 80% of claims against physicians are dropped. Would physicians be satisfied if a medical treatment were effective in 20% of patients?
Nearly 20% of neurosurgeons and cardiac surgeons are sued every year. Would you perform well at your job under a 20% yearly threat of being sued?

So, the NEJM has sprinkled some more data on a mountain of evidence that the current medical liability system is broken. Did we really need another study? Let's study if patients who are suffering heart attacks or severe pneumonias fare better if they are hospitalized rather than left at home. Who can divine the outcome of this hypothesis? After all, since this issue has never been published, who could predict the outcome? Yes, of course, I am being deliberately absurd.

Some issues are self-evident and don't require a study to determine the obvious conclusion. Yet, when it comes to medical malpractice reform, the current administration and Democratic legislators reassure us that they are serious about tort reform and want to 'study the issue' further. We hear the euphemism 'pilot program', which means quicksand. Tort reform is moribund and has been assigned a DNR (Do Not Rescuscitate) status. Defensive medicine, in contrast, is alive and well.

Greedy Insurance Company Backs Down: The Little Guy Wins!

2011-08-14T05:00:00.011-04:00

A few months back, while we were on vacation in Washington, D.C., my 17-year-old son Noah sustained an injury at 1:00 a.m. I was asleep, but this is usually a few hours earlier than he typically retires. In our hotel room’s bathroom, he dropped a glass and then managed to step in the wrong place. A sharp shard sliced through the soft skin between his great and second toes. Blood was spurting wildly and he woke me up with a shout. He was spooked.

We gastroenterologists are experienced at stanching bleeding, although I was uncertain how to do so without some kind of scope in my hand. I reflected on my ACLS training, which is a comprehensive 2 hour course that my partners and I take every 2 years. In between those sessions, I neither think about nor practice any advanced life saving procedures. It doesn’t seem rational that a community gastroenterologist should be schooled in temporary pacemakers, when most of us haven’t interpreted an EKG in decades.

I still remember the fundamentals of life support, the famed A, B, Cs, standing for airway, breathing and circulation. I decided to apply this to the hemorrhage at hand.

Airway: the windpipe was open and functioning

Breathing: the kid was breathing

Circulation: BINGO!

After going through this brief but critical checklist, I now knew where to focus. No need to intubate him. No need to call the front desk to rush a defibrillator to the room. No need for chest compressions, at least not yet. I considered tightening a tourniquet around his waist to clamp the aorta, but opted instead to apply direct pressure to the wound. Luckily, this high class hotel was equipped with just the medical apparatus I needed - a wash cloth. Once the bleeding slowed and I was able to visualize the wound, I realized that this was no Scotch tape fix. It was time for a field trip to the ER.

The hotel front desk advised me where to take him and 20 minutes later we were in Sibley Memorial Hospital. The care was excellent and the sutures were applied expertly by Gregory Cope, M.D. Two hours after our arrival, we were back in the hotel room. I decided not to rouse the kids at 9 a.m. for our intended trip to Ford’s theater, a site that has been deferred for a future trip.

Nothing is certain but death, taxes and emergency medical care bills. I reviewed the explanation of benefits form I received, which are never easy for me to unravel, even though I am somewhat of an insider of the medical profession. One of the 2 charges that I am responsible amounts to $391.50. I phoned my insurance company, always an opportunity for stress management, and reached a living breathing human being. Of course, I was first greeted by a mechanical voice who assured me that my call was important to them. Melanie, the insurance company customer service representative (Any reader agree with me that the phrase customer service is a euphemism?) explained that I had selected an out-of-service facility and was charged accordingly. After some research, she determined that there were in-network hospitals in the Washington, D.C. region. See what I mean about stress management?

“Melanie, let’s forget for a moment that I am a doctor and that you are an insurance company tool. It’s two o’clock in the morning. I am 500 miles away from home. My son’s foot is spewing blood. While you might regard me as irresponsible, I never contemplated whether the hospital was on the formulary. Should I have researched this issue then? How would I have done this at that hour? It’s challenging enough to reach a living insurance company soul during ordinary business hours. I wonder what my son would have thought if I told him we had to wait for authorization before we could leave the hotel. I’m sure this would have elevated his opinion of me as a doctor and a father.”

Melanie checked with a superior who agreed that under these circumstances they would reprocess the bill as an in-network charge. Victory! How much will I save? Probably, only a few bucks, but some victories are not measured in dollars. I ‘stuck it to the man’.

I have learned an important lesson from this experience. The next time I’m traveling with kids, I’m bringing paper cups.

Is Cost-Effective Medicine on Life Support?

2011-08-07T06:08:00.000-04:00

The concept of cost-effectiveness in medicine is elastic. One’s view on this issue depends upon who is paying the cost. Of course, this is true in all spheres of life. When you’re in a fine restaurant, you order differently when the meal will be charged to someone else. Under these circumstances, the foie gras appetizer and the jumbo shrimp cocktail are no longer luxuries, but are considered as essential amino acids that are necessary to maintain life.

In the marketplace, except in the medical universe, goods and services are priced according to what the market will bear. If an item is priced too high, then the seller will have fewer sales and a bloated inventory. Consumers will not pay absurd prices for common items, regardless of supernatural claims of quality.

Would you pay $100 for an ice cream sundae that boasted it was the best in the world?
Would you pay $1000 for a tennis racket that promised performance beyond your ability?
Would you pay $500 for a box of paper clips that never lose their tension?

Of course, you wouldn’t because none of this stuff is worth it, even if the quality claims are true. If any readers disagree, then send me a private email so I can enter into a business arrangement with you.

We lose sight of this obvious truth in medicine. It is not enough for a treatment to be effective. The benefit must be worth the cost. I realize that a cost-benefit analysis is interpreted differently by sick people and their families. I am sure this would be true for me and my own family. If my child needed a bone marrow transplant, I would devote my entire being to making this happen, regardless of long odds against success and a six figure price tag. In this hypothetical, I am no longer a smug blogger, but I am a terrified parent.

There will always be arguments about where to draw the line. Some treatments, such as routine vaccinations and proven preventive medical screening tests should be under the line. Other therapies that have minimal clinical benefit and astronomical costs should remain in high orbit and out of reach. All the stuff in between will be the grist for comparative effectiveness research, if it ever gets airborne.

A few months back, The New York Times reported on 2 new drugs, approved by the FDA for cancer treatment. Provenge, a new drug for prostate cancer extends life by 4 months at a cost of $93,000. Impressed? Wait, there’s more. Yervoy, a treatment for melanoma also extends life by 4 months at a cost of $120,000.

Are these two treatments under the line or over the line? In my view, as a spectator and not a sufferer of either disease, I think they should both be directly in the line of fire.

What’s your view?

Will Wireless Capusle Endoscopy Replace Colonoscopy?

2011-07-31T05:55:00.008-04:00

Most of born several decades ago, recall the futuristic book Fantastic Voyage by Isaac Asimov, where a miniaturized crew traveled through a human body to cure a scientist who has a blot clot lodged in his brain. Ironically, miniaturized medical care is now upon us while books are at risk of becoming obsolete.

I hope that gastroenterologists won’t become obsolete, at least until my last kid graduates from college.

I perform an amazing diagnostic procedure called wireless capsule endoscopy (WCE), when patients swallow a camera. Once swallowed, this miniaturized camera takes its own fantastic voyage through the alimentary canal. The test is used primarily to identify sources of internal bleeding within the 20 feet of small intestine, which are beyond the reach of gastroenterologists’ conventional scopes. I have performed over 200 of these examinations, and I am still awestruck when I watch a ‘movie’ of someone’s guts. While most examinations do not reveal significant findings, I have seen dramatic lesions that were bleeding before my eyes. WCE can crack a cold medical case wide open.

Here’s a typical view of the small bowel as seen by the cruising camera.

Up to now, cameras are used only diagnostically, but this will change. In other words, at present, the camera can only visualize. Prototypes are being developed that can equip cameras to take biopsies of lesions and to stop bleeding that is encountered on their journey. Physicians will be able to guide cameras in real time to perform diagnostic and therapeutic tasks. Once perfected, a physician on the west coast could be directing a camera that is voyaging inside a Manhattanite. (Aren't most movie directors on the west coast?) Amazing stuff. Of course, this technology may also be used by other medical specialties to search out and destroy diseases in their organs of interest. It will certainly have applications beyond the medical arena.

The capsule endoscopy folks have been trying to use their technology as an alternative to colonoscopy. This is a tough sell to patients who must endure a camera prep that is more vigorous than the routine torture that we gastroenterologists require prior to a colonoscopy. In addition, since the camera is only diagnostic, if a polyp is encountered, the patient would then enjoy the delight of a future colonoscopy to remove it. The latest advance in this area is a self-propelled camera that is inserted into the rectum and then guided by remote control by a physician.

When I read about the self-propelled capsule, I realized that I have committed a grievous parental miscalculation. I have tried to restrict and discourage our kids from playing video games, which I was certain wasted time and destroyed neurons. How wrong I was. These were the precise skills that would have permitted them to become medical pioneers. I have closed off many professional options for them from my misguided zeal to encourage them to pursue silly activities, such as reading.

How will gastroenterologists react if a ‘camera colonoscopy’ becomes ready for prime time? Perhaps, a future generation of colon cameras will be able to remove or destroy polyps and other lesions? Will we willingly surrender our colonoscopes to serve the greater good? We might do what many of us do in our bedrooms and our living rooms. We may fight with other medical specialists, or even technicians, as to who gets to hold the remote control.

Pharmacy Benefit Managers vs Physicians: Let the Games Begin!

2011-07-24T06:00:00.000-04:00

As a gastroenterologist, I treat hundreds of patients with heartburn. You already know the names of the medicines I prescribe, since they are advertised day and night on television and appear regularly in print newspapers. Pharmaceutical representatives for each one of these drugs come to our office each claiming some unique clinical advantage of their products over the competitors. They have a tough job since the medicines are all excellent, are priced similarly and are safe. On some days we will have 2 or 3 reps visiting us, each one proffering a medical study or two that supports their product. They show us graphs where their drug is superior to the others regarding an event of questionable clinical import. Their goal is to show that the graph line of their drug is going up, while those of their competitors are going down.

Physicians, like me, who do give these folks some time, have mastered the art of the slow head nod as the drug’s virtues are being related. In the past, the relationships they cultivated with us translated directly into prescriptions being written. Not so today, when our prescribing pens are controlled by insurance company formulary requirements. Those drugs that are not on the coveted list not just swimming upstream, they’re trying to scale a waterfall.

Drug companies know a lot more about us than we know about them. They have detailed prescriber information about what we are prescribing to our patients. Though I assume they don’t have specific patient identities, they purchase date enabling them to know how much Nexium, for example, I am prescribing. This information is used by the companies to motivate their reps. “Kirsch is prescribing Nexium to only 20% of his reflux patients. We need him at 30% by the end of the year.” Drugs reps, who are hired for their extroverted personalities and communication skills, become tongue twisted or even mute if this issue is raised with them.

One of physicians’ most exasperating waste of time is handling calls from pharmacies that the heartburn drug we prescribed isn’t the ‘preferred medicine’. There is no way that a busy medical practice can keep track of the drug coverage preferences for every insurance, company, particularly since these lists change regularly. When the pharmacy calls us, we have to review the record and then change to the new drug, if this is medically acceptable. This takes an enormous amount of time, clogs up our phone lines and doesn’t seem to improve any patient’s health. The real fun starts when we try to convince a pharmacy benefit manager (PBM) to authorize a medicine that is not on their magic list. The phone calls and paperwork are designed to discourage all but the most dogged doctors from pursuing the request. Doctors who enter this arena must relish the thrill of combat if they are to have any chance to prevail. Of course, the PBMs have the leverage, but skilled and seasoned medical professional can pierce their armor to achieve a Pyrrhic victory.

On those occasions when I triumph over the PBMs, I bask in the glow of victory. But, no victory is total. At the end of these setbacks and skirmishes, guess who needs the Nexium most?

An iPhone App for Medical Checklists?

2011-07-17T06:00:00.000-04:00

Not quite, but my iPhone inadvertently made a strong case for medical checklists.

This past weekend, I was once again in Denver. Colorado is a great destination for those who love natural beauty and outdoor adventure. My own personal adventure involved a fierce competition between me and water. Which machismo activity was I engaged in?

Level 5 white water rafting
Slalom water skiing
Cliff diving
Hang gliding with water landing
Sitting poolside with my iPad

If you are agonizing over the above choices, then you don’t know me.

I put the iPad down and crept into the pool slowly. Why do folks in the pool always beckon others in claiming the water temperature approaches hot tub levels, when it’s freezing? I’ve never been one to dive right in. I enter at a glacial pace. I dipped my toe in and in 10 short minutes, the water and I became as one. Then, the shock struck me with cold fury. Had Zeus pierced me with a lightning bolt, it would have been a mere pinprick in comparison. At that moment, I am standing in the pool with the water level at my navel. The iPad was resting safely on a nearby lounge chair. The iPhone, however, was in my pocket, an electronic submersible being bathed in chlorine.

While it took me 10 minutes to enter the pool, it took me 10 nanoseconds to exit it. The iPhone was dead. There were no breath sounds or pulse. I scanned the area for an AED (automated external defibrillator), not for the fibrillating phone, but for its terrified owner. ‘Get some rice’, my friend exhorted. I had heard of this fantasy where dead phones were resuscitated by lifesaving, hydrophilic rice. I sprinted to the hotel restaurant and received a large container of raw rice. I plunged the iPhone into the abyss and prayed for a miracle.

How could I be so careless? Humans make mistakes and I am a typical Homo sapiens. Who hasn’t locked their car keys inside their car, placed a food item in the fridge that needed to be frozen or left the umbrella in the car at the wrong time? Yes, to err is human, but drowning your iPhone seems downright inhuman. Indeed, if there were an eighth deadly sin…

Could this catastrophe have been avoided? What if I always performed a ritual prior to entering a pool, a lake or an ocean? What if I checked my bathing suit pockets every time before my toe hit the water? Had I done so, I would have discovered the iPhone before it became iDead. In other words, if I had a swimming checklist, my phone would still be alive today. If only I had considered this ‘app’ beforehand.

Medical checklists are red hot these days. These are procedures that doctors and nurses are encouraged or required to follow without exception to prevent human errors. The medical community has belatedly adopted this concept from the airline industry, where pilots proceed through an ordered checklist every time before take-off. Deviating from the ritual invites disaster, even though checklist adherence can become a mechanical process that can lose its meaning. (How closely do we listen to the flight attendants as they yawn through their safety presentations at the beginning of flights?) Checklists are being adopted in operating rooms throughout the country to reduce errors such as wrong sight surgeries and other preventable events.

Just this week, I read of two medical horrors that could have been prevented had checklists been followed.

The prestigious UPMC in Pittsburgh has shut down their living kidney donor transplant program when several folks missed that a donor was positive for hepatitis C. Yes, this tainted kidney was transplanted into an unsuspecting recipient. Whoops!
A Florida veteran is suing for a mere $30 million claiming he contracted hepatitis C from a colonoscopy performed at a VA hospital 2 years ago. It is well known that many cases of hepatitis C and other infections transmitted endoscopically occurred when standard scope cleaning procedures were breached.

My iPhone has been replaced costing me the $169 deductible on my replacement insurance and $16 for the screen protector, which probably costs Apple 3 or 4 cents each.

Santa

My advice? When you’re ready to dive in from the deep end, or you are poised to begin a colonoscopy, think of the sage advice from the Christmas standard, Santa Claus is Coming to Town. Are you making a (check)list and checking it twice?

Health Care Reform and Obamacare: Lessons from the Last Century

2011-07-10T16:05:00.002-04:00

Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity…The poor have more sickness, but they get less medical care. People who live in rural areas do not get the same amount or quality of medical attention as those who live in our cities.

The above quote wasn’t taken from an Obama administration policy proposal. These words are from a 1945 speech by President Harry Truman. It is astonishing that over 60 years later, the health care crisis is not only still with us, but is slowly smothering us. How many years of oxygen do we have left until health care in America is entirely asphyxiated? Each year, the challenges deepen and multiply, which pushes necessary solutions and reform further out of reach. The financial costs of simply maintaining the current system are sailing beyond the stratosphere. The ‘reform’ strategies in my adult lifetime have been to promise, procrastinate and pray, methods which provide politicians with short term gains at our long term expense.

As I write this, Democrats and Republicans are arguing on reforms to preserve and protect Medicare, even though the contours of the solution are well known to all. Politics is a poison pill.

Last year, about 17% of the GDP was devoted to health care, compared with about 15% in 2003. It is projected that 20% of GDP will be spent on health care in 2017. Medical economists agree that the current rising medical costs are unsustainable. The present government will be under enormous pressure to reduce costs of healthcare. Do we believe that costs can be cut while maintaining, or even improving medical quality? Will budget slashers swing their axes so wildly to drive down costs that medical quality will be crippled as collateral damage? Will the country be satisfied with medical mediocrity as a side-effect of cost control?

Operating on the health care system requires major surgery. The fear is that the government will declare that the operation was a success, even though the patient died. President Obama has stated repeatedly that health care reform is one of his highest priorities. While he didn’t create the mess, once his Patient Protection and Affordable Care Act was passed, he now owns it. Although I oppose Obamacare, and have explained my views throughout this blog, I congratulate the president for taking on this radioactive issue. This was a promise kept. Nevertheless, I hope that many of its damaging provisions will be repealed.

Will Obamacare ultimately sink from its own ponderous weight? If it does, or is watered down, the president may be tempted to start spreading blame around. President Truman, who worried about health care in America before President Obama was born, can offer our new president some advice on leadership. Remember his famous homespun maxim the buck stops here? Let’s hope President Obama remembers it also.

Why This Lawyer Won't Sue Me

2011-07-03T06:00:00.021-04:00

I spent the entire last weekend with an attorney, not a desirable circumstance for most physicians. However, I wasn’t being deposed or interrogated on cross examination. This was a rendezvous that we both sought with enthusiasm.

Lewis is my closest friend, a bond that was forged since we were eight years old. We are separated now only by geography, and we meet periodically because we both treasure the friendship. Earlier this year we rolled the dice in Vegas. Last weekend, we sweated in the sweltering heat of the Mile High City. Next stop? Back to Denver with a few youngins'!

Lewis is the managing partner in a prominent west coast law firm that specializes in tax evasion. (Or is it tax avoidance? Am I confusing my terms here, Lew?) He has been redrafted to this position because he has earned the respect of his colleagues. Clearly, both Lewis and I have ascended to the highest strata of our professions. Lewis is in charge of a large law firm that has global reach; he travels all over the world cultivating business and negotiating deals; and he navigates clients through complex and labyrinthine legal conundrums. I, an esteemed community gastroenterologist, perform daily rectal examinations and counsel patients on flatulence.

I am sure that readers will agree that our future professional prestige is already evident in this photo of us taken several decades ago.

Lewis and me a few years ago

Among the many ponderous issues that we discussed, were the current state of each other’s profession. I enlightened Lewis that electronic medical records (EMR) has not yet fulfilled its promise of ease of use and integration with other medical offices and institutions. I shared my disapproval of ‘point & click’ medicine, which is the default mode of many EMR systems. I also opined that EMR has created many viable avenues for medical malpractice attorneys to pursue. For example, is it now the community standard for physicians with EMR to search surrounding medical databases during an office visit to gather results of all prior laboratory and radiology records from area hospitals if it is technically possible to do so? If a patient sees me to discuss the heartbreak of hemorrhoids, am I negligent if I do not perform a wide data search and discover that an ultrasound of the liver done 2 years ago for other reasons showed a small lesion that in 3 months would become a serious clinical issue? Am I now responsbible for every lab and x-ray result that is within cyber reach? Sure EMR can save the doctor, but it can sink him also.

Lewis shared his views on the state of our economy, the current tax structure and the fairness and efficiency of our legal system. His colorful descriptions of these and other issues cannot be reproduced here verbatim as this is a family blog. Using softer language and paraphrasing, he did not exude optimism for America’s future.

He related some of his interesting legal matters, and I shared anecdotes from my gastroenterology practice. This created an interesting philosophical question. Consider the following 2 inquiries.

If a tree falls in the woods, and no one hears it, has noise occurred?

If a doctor mentions a patient and his diagnosis, and no one hears it, has HIPPA been violated?

Luckily, I always travel with my HCH, a HIPPA Compliant Helmet, a device that resembles a CPAP apparatus that sleep apnea patients wear at night. Once fitted with the device, any patient’s name I utter becomes encrypted and emerges from my mouth as a Disney character.

If I Say...                                You Will Hear...

Joe Bellamy                                    Goofy

Susan Sherman                                Dopey

Karen Carmichael                            Dumbo

My HIPPA helmet this past weekend was strapped in tightly, even during sleep in the event I somnambulated and started murmuring privileged patient information. Sure, Lewis is my best friend. But, he is also a lawyer and he might have been wearing a wire. After all, business is business.

We actually discovered common elements in our jobs.

We can’t guarantee the outcome to those we counsel.
We are routinely blamed for adverse outcomes that are not our fault.
Both of our professions are screaming for reform, but politics won’t permit it to happen.

We didn’t solve all of the world’s problems, but many of the intractable issues we did discuss seemed like they could be solved if 10 reasonable folks around a table could hash it out without political interference.

Real friendship matters. A lawyer and a physician are an ideal combination, as odd as this sounds. Sometimes the relationship may need the skills of a negotiator, and other times it may need some healing. If you are really lucky, as we are, the friendship just coasts on naturally, powered by the strength of a bond that in a few years will reach a half century mark.

Lewis and me today

Do Overworked Medical Interns Cause Medical Errors? Let’s Sleep on It.

2011-06-26T05:26:00.002-04:00

As of this writing, 5 air traffic controllers have been found asleep at the switch. By the time this piece is posted, several others may have joined the slumber party. Keep in mind, there’s a lot more snoozing in the towers than we’re aware of. We don’t know the denominator here. Our wise reactive government has recently issued orders that airport control towers must not be manned by only one individual. Somehow, prior to NappingGate, our bloated and inefficient government that is riddled with redundancy thought that one sole guy watching the radar at night was sufficient.
There are some jobs where nodding off poses no risk. Let me test my readers’ acumen on this issue. Which of the following professions would not be at risk if an unscheduled siesta occurred?

A race car driver
A congressman
A circus clown (not to be confused with above listing)
A lawyer (not to be confused with the above listing)
A school bus driver

Let’s face it. Some folks on the job simply can’t safely snore their way through it. We don’t want New York City taxi drivers to fall asleep while they are swerving through midtown. We don’t want a navy pilot who is racing through the sky to catch some ZZZs. And, we don’t want a surgeon to have to be nudged into consciousness while he is performing some task within an abdomen.

We don’t know yet the reasons why folks are sleeping in the air traffic control towers. Maybe it’s the soft music they play. Perhaps, the sounds of incoming aircraft have a hypnotic effect. Or, maybe they’re just tired.

Indeed, the issue of control tower fatigue has been raised, among other potential explanations. It may be that their assigned work schedules are too demanding, and there are not sufficient work breaks. We’ll find out. Most of us who enjoying the luxury and comfort of air travel (turn on guffaw track now) are hoping that the air traffic controller who is guiding our plane to the runway is reasonably alert. However, I shouldn’t assume this. Choose from the following 2 statements.

I prefer that my air traffic controller be alert and well rested.

I prefer that my air traffic controller be in the 36th hour of his shift, with only a few pockets of interrupted sleep. I feel safe knowing that this battle hardened professional is prepared for any adversity. I don’t want some softie managing the radar. I want a tough guy who will do his job regardless of how fatigued and stuporous he is.

I’m afraid that many readers are now stuck, as they are agonizing over the above choice. If after 15 minutes, you still cannot choose an answer, then move on. You will have time later to return to this question.

The issue of fatigue is now recognized to be an important issue in the training of medical interns and residents. I remember when the tragic Libby Zion case in New York City occurred in 1984, which we all hoped would lead to reform in medical education. It is amazing how entrenched the medical education system is, and how difficult it is to modify it. New rules were issued to allow interns and residents more sleep and some mandatory time off, but there were exceptions and loopholes that are still used today. This was not simply an effort to introduce humanity into medical training. Relieving overworked medical interns and residents was designed to reduce medical errors and reduce medical malpractice. Even if I can't prove it, I maintain that a rested medical intern is more likely to avoid medical errors.

Why do so many still want medical interns and residents to work when they are exhausted? Is it for cheap labor for hospitals? Is it to test their mettle for when they become real doctors? Is it really so interns don’t ‘sign off’ at 5 pm and miss the natural history of their patients’ diseases? Are program directors trying to minimize patient ‘hand offs’ by having medical housestaff work extended hours? Or, do some senior physician educators advocate arduous work schedules because they endured it in their time?

All of the above reasons, and others I may have overlooked, can be refuted with sensible reforms, and everybody knows it. Sure, practicing doctors have to be sharp in the middle of the night, and we are. But, most nights we sleep comfortably at home. I don’t think the fatigue and ongoing sleep deprivation I suffered as a medical resident was necessary preparation for the nocturnal care that I am called to render now, from time to time.

I know that many physicians have strong opinions that oppose mine. I hope that they and others will express themselves here. I would like to close this post with the irrefutable evidence that supports my argument, but I feel myself starting to nod off. No worries. When a blogger bugs out for a few minutes, no one gets hurt.

Emergency Room: Revolving Door or Backstop?

2011-06-19T06:00:00.001-04:00

I received a call recently from an emergency room (ER) physician about a patient who presented there with rectal bleeding. Does this sound blogworthy? Hardly. We gastro physicians get this call routinely. Here’s the twist. The emergency room physician presented the case and recommended that the patient be discharged home. He was calling me to verify that our office would provide this patient with an office appointment in the near term, which we would. We had an actual dialogue.

This was a refreshing experience since the typical emergency room conversation of a rectal bleeder ends differently. Here’s what usually occurs. We are contacted and are notified that the patient has been admitted to the hospital and our in-patient consultative services are being requested. In other words, we are not called to discuss whether hospitalization is necessary, but are simply being informed that a decision that has already been made.

There is a tension between emergency room physicians and the rest of us over what constitutes a reasonable threshold to hospitalize a patient. I have found that many ER docs pull the hospitalization trigger a little faster than I do. What’s my explanation for this? Here are some possibilities.

Pressure from hospitals to fill beds
Pressure from admitting physicians who seek to increase their in-patient volumes
Belief that hospitalization markedly reduces medical malpractice risk of ER physicians
Desire to eliminate uncertainty that a benign complaint is masquerading as a serious condition. “It’s probably your heartburn, but let’s observe you overnight just to be sure.”
Pressure from patients and families to be hospitalized
Uncertainly that a patient will follow-up with a physician after ER discharge
ER physicians are making the proper judgment to admit the patient, while we specialists and primary care physicians cavalierly advise discharge.

What’s the harm of hospitalizing a patient for a day or two, ‘just to be sure’, or to expedite a medical evaluation that might take a few weeks to accomplish as an out-patient? Here are a few drawbacks to that option, and I’m sure that patients and physicians can add to the list.

Resource consumption
Risk of hospital acquired misadventures including infections, medication errors and side-effects
Overutilization of medical care. Hospitalized patients are routinely visited by numerous consultants who proceed to attack their organs of interest with zeal and enthusiasm

Every physician can attest to how much hospital illness is caused by hospital life and is unrelated to the original medical issue. We see this every day.

I understand the tension between the ER and the outside medical world. The ER is under a unique set of pressures and concerns, and the rest of us need to be mindful of this. Nevertheless, patients would be better served if there were more discussion and collaboration between medical colleagues to determine whether hospitalization or discharge is the preferred option. A recent study confirms that communication between ER physicians and primary care physicians needs healing.

Many patients and their families mistakenly think that hospitalization is the safer choice. Think again.

Privatizing Social Security and Medicare: Who Can Defuse Political Dynamite?

2011-06-12T06:00:00.002-04:00

In response to my prior post where I averred that cigarette companies were treated as scapegoats, I have had several cyber and actual conversations about personal responsibility. I believe that folks should realize the consequences and the benefits of freely made decisions. While we want American society to be compassionate, we do not want to punish success and reward failure. Our goal is to do all that we can to maximize everyone’s success. We should be ready to assist those who need and deserve our private and governmental assistance, but personal effort and responsibility are necessary elements of these interventions.

When we see patients who are in financial difficulty, my physician partners and staff will do all that we can to help them. While it is not our policy to do colonoscopies for free, we will make whatever adjustments are necessary to make sure that the patient receives colon cancer screening. However, when patients who owe us money hang up on our calls, or express their view of medical entitlement with foul language, then we forward these accounts to a collection agency.

There is also a self-interest angle to helping others. One day, we may need a boost ourselves.

In one of my post-scapegoat posts, I discussed the concept of privatizing social security, a sound proposal that was vilified and snuffed out during George W. Bush’s presidency. Antagonism against this modest proposal was seasoned with a large measure of arrogance, a splash of hubris and a dash of paternalism.

In summary, this proposal argued that if folks could manage a small portion of their social security money, which they earned themselves, that it could be a force that would reinforce and extend the program’s solvency. The political left turned white hot over the notion of the government transferring any responsibility for managing these retirement funds to the citizens who actually earned the money. Isn’t this preposterous? They predicted doomsday when our imbecilic citizenry, who were somehow smart and industrious enough to earn the money in the first place, would squander it all, vaporizing the last remaining safety net that would keep them afloat. Then, the lefties argued, the rest of us would have to rescue them at much greater expense.

Their argument is specious and transparent. Review some pesky facts below.

The plan only permitted individuals to invest 4% of their earnings privately in the first year, with modest increases permitted in subsequent years. So, even if these investment tyros lost it all, which is hard to do in any investment, it wouldn’t be a game changer.

The government was not permitting folks to invest in hedge funds, penny stocks or junk bonds. They were required to select from a list of legitimate investment vehicles.

The program was voluntary. If an individual did not have the skill or desire to make personal investment choices, he did not have to. He could continue to allow the government to manage his money.

The program was so modest and so reasonable, that it seems that it would be difficult to attack it. Why, then, did it provoke such ire and vitriol from the left?

These guys were scared. They weren’t frightened that folks would lose money and be vulnerable during their retirement years. They weren’t spooked that it would jeopardize the social security system’s financial stability. They were terrified that the privatization program would actually work. They couldn’t tolerate any fissure in their edifice that stood for total government control of other people’s money and personal decisions. If this initial privatization effort succeeded, they knew that the public, now empowered, would demand greater control of their own money.

To those who believe that the government knows best how to invest my social security retirement money, then why shouldn’t it control all of my investment income? Should I be trusted to invest money that will one day be used to pay tuition for my kids? Indeed, anti-privatizers could argue that all of our money should be turned over to the government, so they can wisely manage it and then disburse it as it sees fit.

Alice Rivlin, a Democratic economist and Paul Ryan, a Republican congressman, who many hope will become a GOP presidential candidate, advised consideration of privatizing the Medicare program. Of course, this idea is political dynamite, but their proposal from two thoughtful public servants on opposite sides of the aisle shows that this strategy deserves air time and public discussion.

Privatization should not be a private matter. Let’s bring it out into the public square.

The Future of Medicine: Do Pre-med Students Have a Clue?

2011-06-05T06:00:00.001-04:00

At this writing, I am in Atlanta visiting our daughter at Emory University. This may be the only college campus in the nation where you can’t buy Pepsi. Coke is King here. If you don’t know this, do some due diligence before you or someone you love interviews here.

I remember a few decades interviewing at the medical school here. There are only 2 medical school interviews that I recall after all these years. At N.Y.U. School of Medicine, the canny interviewer asked me what the death rate of Americans is. I correctly responded, “100%”. I suppose that untangling enigmatic questions was an N.Y.U. admission requirement, since they did accept me, and I did attend. The other medical school interview I still recall was at Emory, although it’s not the questions I remember. Their unique interview format made the experience memorable. Three medical school applicants were interviewed simultaneously as we faced a bank of questioners. This was reminiscent of the ancient and popular TV show, The Dating Game, where 3 bachelors or bachelorettes heard their competitors’ responses and often had to respond to the same questions.

Emory University still has a strong pre-med focus in their undergraduate community, as do many other colleges. Do these idealistic kids have a clue about what post-med life will be like on the other side of the wall? Have they been reading newspapers (or iPads) about the convulsions the medical profession is experiencing, or have they been immersed in memorizing arcane facts about anatomy and pharmacology? Will they find medicine to be a satisfying career? What are their expectations?

In many ways, it will be easier for these new physicians than it has been for their ossified, older colleagues. You can’t miss what you never had. Their reality will be that they will be controlled by the government and insurance companies, if the latter still exist. They won’t be frustrated over loss of autonomy that they never had. They will regard absurd medical quality programs, such as pay-for-performance, to be necessary and integral components of quality medical care. They will routinely submit patient outcome data to payers who will link these outcomes to their reimbursement. These new doctors, who didn’t witness the evolution of these accountability initiatives, won’t recognize the gaping flaws and hidden agendas in these programs. They will likely be employed, and won’t harbor resentment and regrets of having been forced to leave private practice. There won’t be medical guidelines to consult designed by academics, but there will be medical mandates that will require compliance. Those who dare to deviate will have to submit volumes of documentation to justify thinking outside the mandate.

They will enter a profession very different from the one we did. They will be conscientious practitioners, but they won’t have the unbridled dedication to the profession that defined physicians for generations. They will value their lifestyles and their leisure time with friends and families. They will have more of a shift work mentality, which is natural for employees who don’t feel ownership of the operation. Increasingly, medicine will be practiced remotely from the patient, with telemedicine and robotics.

Of course, many of these changes will offer amazing medical benefits to patients. But, there will be a cost. Many of these advances will change what has been the core element of medical care – the doctor-patient relationship. This new paradigm is a difficult concept for many of us to accept, but it may not translate into inferior care. In many cases, medicine will be practiced without putting a reassuring hand or stethoscope onto the patient. Relationships will become more clinical and less personal, particularly as medical advice is offered from physicians in remote locations, who may not have met the patient. A skin rash in Cleveland may be evaluated by a dermatologist in New York City. An abdominal tumor in Topeka might be removed surgically by remote control by a surgeon in Chicago.

I think that physicians of the next generation can still find great fulfillment and reward in their work. Their satisfaction, however, will have to be linked to their expectations, which are quite different from those of their predecessors. There is another side of the equation that I have bypassed here, but is worthy of comment. The expectations of the public – our patients – will have to change also. The new rules of the game will challenge healers and those who come seeking their assistance. Will patients who have yesterday’s expectations be satisfied with tomorrow’s doctors?

Medical Myths Exposed: Do We Want Truth or Zeus?

2011-05-29T06:02:00.001-04:00

We have had many family conversations about education reform over the years. Whistleblower readers have seen some of this creeping through some prior posts. It’s an issue that affects every American and deserves the efforts of our most talented and innovative thinkers to elevate the system to a higher orbit.

One of the mantras of traditional reformers is that smaller classes for students are optimal. Indeed, local school boards and teachers’ unions often warn of expanding or exploding class sizes if requested levies are not passed. They know that we parents believe that class size varies inversely with the quality of education. Ask parents if they would prefer a class of 20 or a class of 30 students for their youngsters and all will opt for the former.

Are smaller classes really better, or do we just believe they are because our intuition instructs us that it is? Is something true because it seems self-evident to us?

I found recent New York Times article on this issue very enlightening. There are education experts who are not convinced that larger classes compromise educational quality. Are they right? I can’t say, but I’m happy to see that not everyone is drinking the Kool Aide. Assumptions are not data.

The medical profession is permeated by myths that we physicians and the public believe to be true, but may not be, or have not been rigorously tested. Practices and procedures that are done routinely and repeatedly are considered to be standard medical practice. In other words, evidence is not needed.

Consider the following medical procedures and offer a view if they are sound practices or medical myths.

Lowering your cholesterol level will have a significant impact on your risk of developing heart disease or stroke.
Influenza vaccine is a highly effective vaccine and should be administered yearly to all eligible individuals.
It is important for physicians to check patients’ reflexes during physical examinations to determine if subtle neurologic injury is present.
Vitamin supplements are important to maintain good health.
Early detection of disease leads to better outcomes.
Probiotics cure everything and should be mandated for all school children.
Periodic laxative use is advised to cleanse the colon of injurious toxins.
Adults should have their abdomens examined at least every 3 years to discover if any tumors or organ enlargement have occurred.
Yearly eye examinations are necessary to screen for glaucoma and other eye disorders.
Colonoscopies have been proven to prevent colon cancer.
The prostate-specific antigen (PSA) test saves lives and should be measured periodically in men starting at age 50.
If a cardiac catheterization shows a narrowed artery, then a stent should be inserted to prevent a heart attack from developing.
Pelvic examinations in women are important opportunities to detect ovarian cancer at an early stage.
Mammography is proven to save lives.
Fiber supplements benefit patients with irritable bowel syndrome.
Patients with acute back pain benefit from an early MRI to guide medical treatment.
Medical bloggers always tell the truth.

Is our medical advice coming from sound evidence or from the mythological gods on Mount Olympus?

Ronald McDonald Promotes Obesity: Call in the Navy SEALS!

2011-05-22T06:00:00.002-04:00

Fast Food or Front for Evil?

As Whistleblower readers know, I have a 6 day-a-week love affair with The New York Times. I love the paper’s reportage, but not its editorial policy. However, it’s important to seek out other views on the issues of the day. This is an opportunity to defend your beliefs by disarming the opposition’s argument, or to change your mind.

The news these days is very dark. There’s an apocalyptic aura as we read about terror, war and natural disasters occurring all over the globe. And, since we all like reading about villains, the news media readily supplies us with demons to root against and to distract us from more serious challenges that hover over us.

In this past week, there were four prime villains that the national media offered up for us to consume.

Osama bin Laden
Mouammar Khadafi
Mahmoud Ahmadinejad
Ronald McDonald

Don’t let Ronald’s sunny visage fool you. Behind his painted smile and underneath his red hair is an evil mind who is devoting his life to promoting obesity and ruining our kids. To recall a bold pronouncement issued by a prior Republican president who was poised to send troops into danger across the globe, ‘this aggression will not stand!’ Ronald must be stopped.

Full page ads appeared in several major newspapers asking McDonalds to fire Ronald McDonald, whose nefarious purpose is to lure mindless kids to ingest too much fat, too much sugar and too many calories. Even Happy Meal toys were targeted by the organizing group Corporate Accountability. They properly recognized that these ‘toys’ were dangerous mind control devices that subliminally cause cravings for Big Macs with extra cheese.

Where’s the outrage? How has this purveyor of poundage been permitted to operate freely for decades?

Hopefully, the Patriot Act has given law enforcement and the intelligence community enough tools to gather damning evidence against Ronald. I suspect that the Hamburglar is wearing a wire. Legal experts are already debating whether a future trial should take place in a civilian court or a military tribunal. I lean towards the latter, not wanting Ronald to have a public platform to spew his poisonous propaganda, which might include coded language to awaken sleeper cells.

What punishment would be just for such a demon? Gitmo? Solitary confinement in a federal prison? Perhaps, an entire year requiring Ronald to swallow 3 Happy Meals a day would be enough to rehabilitate him and to flip him to our side.

Once Ronald has been taken out, then we can focus on other villains who are plotting evil against us. Do you really think that Mickey Mouse and Goofy are just innocent cartoon characters?

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A Near Miss ‘Never Event’: A Truly Futile PEG Tube

2011-05-15T06:27:00.001-04:00

Photo Credit

I barely escaped from an embarrassing situation recently in the hospital. I was consulted to place a feeding tube, called a PEG, in an ICU patient. We gastroenterologists are rarely consulted for our opinion on whether these tubes make sense, which they often don’t. We are recruited to these patients simply to perform the technical function of inserting the tubes, so that Granny, or Great-Granny, or Great-Great… , won’t starve. Multiple medical studies have demonstrated that providing this nutrition to individuals with advanced dementia doesn’t benefit them. In addition, while it may seem intuitive that artificial feeding provides comfort, this may not be the case. It may provide more comfort to the physicians and family than it does to the patient.

The above paragraph is not a rigid presentation. Obviously, the decision to place and accept a feeding tube must be individualized. Regardless, it is inarguable that too many of these tubes are being placed for the wrong reasons.

An ICU nurse contacted me to place a feeding tube in one of her patients. There was a large group of visitors hovering around the bedside. As is every physician’s custom, I asked the nurse to summarize the patient’s hospital course and the active medical issues. The consulting physician had requested a PEG feeding tube and a tracheostomy tube. This latter tube is inserted surgically into the windpipe and is connected to a ventilator. (Patients who cannot be weaned off of respirators often have these ‘trach’ tubes inserted as the original breathing tubes cannot remain in the throat beyond a few weeks.) I asked how long the patient had been on a ventilator, and she replied that she was breathing on her own. Even a concrete thinking gastroenterologist thought it was odd to place a ‘trach’ tube in a patient whose own lungs apparently were functioning adequately. This would be analogous to placing a PEG tube in a patient who had just supersized his fast food order.

While this scenario never achieved ‘never event’ status, it does illustrates how medical mistakes can happen. The consulting physician confused two of his patients. The patient assigned to me needed neither a PEG nor a trach, but one of her neighbors did. I was relieved that I didn’t enter the patient’s room to discuss the pros and cons of feeding tubes to the large group assembled there. What if I did enter the room and there were no visitors? What if the patient was demented and wasn’t eating well? One can imagine how a ‘never event’ can happen, especially if necessary safeguards and checks are bypassed or ignored.

I have already expressed in a prior post about why unnecessary PEG tubes are placed. I left one reason off the list. Luckily, it didn’t happen in this case.

New York Times Charges Web Readers: Whistleblower Wondering

2011-05-08T06:00:00.000-04:00

A few months ago, the publisher of my beloved New York Times issued A Letter to Our Readers, which presumably includes many Whistleblower readers.

Non-subscribers to The New York Times will no longer be permitted to use the Times website without limit. I always wondered why they gave it away for free. I have paid my fair share for the past several decades as I wanted the ink and newsprint version in my hands every morning. The Times internet version has been an all-you-can-eat news smorgasbord, where everyone was invited for free. If you build it, and it’s free, they will come. And they did.

Now, frequent freeloaders will have to pay $15 for a month’s subscription to the Times website, still a bargain to gain access to great reporting and hyperpartisan liberal columnists that raise my blood pressure several times weekly. The first 20 articles accessed from the website are gratis. Once you click on article #21, you will be greeted by an invitation to pony up. (Times articles accessed through search engines are not counted toward the 20 article limit, but there are restrictions here as well.)

This gives me an idea.

Why should I be handing out weekly Whistleblower masterpieces for free? I would publish my weekly blog stats here, but I don’t want to provoke envy from überbloggers Kevin Pho and Val Jones, who are racing feverishly to catch up to me. (Just a joke guys. Please don’t retaliate and shut me down!) I put plenty of sweat into these weekly posts and receive only an intangible reward. There is no advertising on the site, and no charge for access. Why am I leaving money on the table?

I was considering asking readers how much they would pay for Whistleblower access, but I demurred as I feared the responses. Here were some proposals that were meandering in my mind.

Free access to readers who offer laudatory comments
Charge a contingency fee to plaintiffs’ lawyers. My fee would be contingent on the reasonableness of their comments
Honor system – pay me what you think the post was worth
Readers’ Reward – I pay readers for every new follower they deliver
Self-censorship fee – I charge readers who use any of the following 5 adjectives to describe my posts: Absurd, Moronic, Greedy, Idiotic or Jealous
Status Quo – Charge nothing and be grateful that anyone invests time to stop in and hear the weekly Whistle.

I hope that readers find their time here worthwhile. If not, contact me and I will be happy to provide you with a full refund.

Are Plavix and PPI Medicines Safe Together? The Surrogate Marker Strikes Again!

2011-05-01T06:10:00.002-04:00

When the medical press seizes a story, it can become an obsession. Any physician who is reading any journal is aware of the reported interaction between clopidrogel (Plavix) and proton pump inhibitor (PPI) drugs, including Prilosec and her cousins. PPI medicines are not exotic elixirs known only to medical professionals. They are known to any person with a working TV set or who still reads a newspaper, since ads for these drugs are omnipresent. Just google ‘purple pill’ and begin your entrance into the PPI Chamber of Advertising.
PPI medicines are highly effective for peptic ulcers and gastroesophageal reflux, although I suspect that most patients on these medications do not have any true indication for them. (Disclosure: I’ve pulled the PPI trigger too quickly on many patients who do clearly require acid blocking medicines.) PPI medicines are prescribed to hospitalized patients almost by reflex, and are often administered by the intravenous route, even when patients can swallow pills adequately.

Medical studies in 2009 reported that PPI medications appeared to make Plavix less effective. Since thousands of patients are on both of these medicines, this drug interaction could affect a large cohort of patients. Plavix serves to keep coronary stents open and to prevent heart attacks and strokes. Clearly, any force that could diminish Plavix’s potency could have serious ramifications for patients. But, is it really true?

Various studies gave conflicting results, as is typical in medical science. Some showed that PPI medicines had no effect on Plavix efficacy and others suggested that a true interaction might be present. Of course, some data that supported that PPIs weaken Plavix were from ‘test tube’ experiments, and not in studies with real patients. Beware the danger of the surrogate endpoint!

At first, this was causing consternation for PPI-loving gastroenterologists and Plavix-pushing cardiologists. Who would prevail in this conflict?

The endoscopers?
The cardiac catheterizers?
The plaintiffs’ lawyers?

It was nearly impossible to peruse a medical journal that was not reprocessing this issue. Search this subject on the internet, and then take a month off so you can read through all the hits. Of course, after reading the first half dozen, you will then be reading reruns.

While I now offer speculation, which is not data, I doubt that combining these drugs, as is done thousands of times every day, will harm patients. I expect in the next year or so to read medical studies that will argue that the PPI-Plavix combo meal will not lead to doomsday, and that the initial reports were hyped. The FDA, despite the weak evidence, has issued a warning regarding prescribing Plavix and Prilosec (omeprazole) together. These government caveats are like tattoos; they are easier to affix than they are to remove.

We have read about other PPI risks over past years. They are associated with pneumonia, C. difficile colitis, vitamin B12 deficiency and hip fractures. Once again, the FDA issued a warning regarding PPI and associated bone fractures, despite the absence of persuasive medical evidence that these drugs can actually break bones.

As journalists know, ‘if it bleeds it leads’. Well, we gastroenterologists know that Plavix causes plenty of bleeding. I guess that’s why it became front page news.

End Medicare As We Know It

2011-04-24T06:00:00.003-04:00

The intractable Israeli-Palestinian conflict has been raging and smoldering since I was born, over half a century ago. This suggests that it is an insoluble conundrum, yet all parties to the conflict and others admit that they know what the contours of the final peace would be. This reality heightens everyone’s frustration. The process is frozen within close view of the end zone.

The Medicare crisis is analogous to Middle East peace process. The challenges are well known and the solutions are obvious. Yet, decades go by and politics have kept politicians, and those they serve, out of the end zone. They’ve been fumbling the ball for a generation. Now, it’s 4th down and they want to punt again.

The problem is that the Medicare program is headed toward insolvency. The solution? Here’s three Mensa suggestions:

Scale back benefits
Spend more money
Raise the age of eligibility

Most folks support scaling back benefits, as long as it’s someone else’s benefits that will be adjusted. Similarly, Americans are prepared to pay more to keep Medicare viable, as long as it’s on someone else’s tab. Everyone supports raising the eligibility age, as long as it applies to folks younger than they are.

This is why reformers are proposing that changes in Medicare would apply only to those who are younger than 55-yrs-old. Of course, the proper Medicare reform proposal would be to implement changes on everyone, or perhaps excepting those who are current Medicare beneficiaries. While no one wants their existing benefits to be cut, this is happening in the private and government sectors throughout the country. Consider the new paradigm for public workers’ collective bargaining rights in Wisconsin and Ohio. With regard to Medicare reform, sparing the over 55 crowd is purely a political calculation. This transparent maneuver is designed to insulate politicians from the wrath of those in the Medicare program and those who are on-deck to enter it.

Representative Paul Ryan, Republican from Wisconsin, has proposed a Medicare reform plan where those under the age of 55 would be given a voucher that could be applied toward private insurance. This was the response from Democrats and President Obama.

This would end Medicare as we know it.

This response is clearly a product of Democratic focus groups, as the same phrase is coming out of so many different mouths.

Considering that American are living and working longer, shouldn’t the age that we become eligible for Medicare be raised, particularly since the program in its current form is not sustainable?

Is the Ryan proposal a panacea? It’s hard to judge the proposal on its merits since the Medicare issue is permeated with politics. I credit him and his supporters for a bold opening to a conversation our government needs to have with us. Instead we’ve been given their version of straight talk, which is as straight as the image below.

I’m under 55-yrs-old and I am willing to delay my entrance into Medicare and to accept reforms that will prevent the program from heading over a cliff. If that happens, and the system crashes to earth, wouldn’t that be a worse outcome than accepting some Medicare modifications?

I’ve conducted my own focus group. When folks ask me why I would change Medicare and toss our elderly overboard, here’s my response. If we don’t implement meaningful structural changes in the program, then

Medicare would end as we know it.

A ‘Never Event’ in Alabama: Did Nine People Have to Die?

2011-04-17T06:07:00.002-04:00

Recently, nine patients died in Alabama when they received intravenous nutrition that was contaminated with deadly bacteria. This type of nutrition is called total parenteral nutrition, or TPN, and is used to nourish patients by vein when their digestive systems are not functioning properly. It is a milestone achievement in medicine and saves and maintains lives every day.

What went wrong? How did an instrument of healing become death by lethal injection? What is the lesson that can emerge from this unimaginable horror?

This tragedy represents that most feared ‘never event’ that can ever occur – death by friendly fire. No survivors. Contrast this with many other medical ‘never events’ as defined by the Centers for Medicare and Medicaid Services, such as post-operative infections, development of bed sores in the hospital or wrong-site surgery. Under the ‘never events’ program, hospitals will be financially penalized if a listed event occurs. Many physicians and hospitals are concerned that there will be a ‘never events’ mission creep with new outcomes added to the list that don’t belong there. Medical complications, which are unavoidable, may soon be defined as ‘never events’.

Do we need a new category of ‘never ever ever events’ to include those that lead to fatal outcomes?

The facts of the Alabama deaths have started to emerge. Apparently, a water faucet in the pharmacy was contaminated. Protocols and processes are violated every day in all spheres of professional life; and we usually get away with them. The absence of serious consequences breeds complacency, which is shattered by an occasional tragedy. Isn’t it after a horrible traffic accident that a local government decides to erect street lights that were requested by local residents for years? I read earlier today that the Federal Aviation Administration is requiring extensive inspections of a few hundred airplanes when small cracks were discovered in a few of them. This followed a near disaster when a 5 foot hole burst open in the roof of an airplane during flight. The plane landed and all survived. Of course, a very different outcome was possible.

A few weeks back, an airline pilot was puzzled and perturbed when he couldn’t make contact with an air traffic controller at Ronald Reagan Washington International Airport. This wasn’t a mechanical failure but was a matter of zzzz’s. The controller simply nodded off. I suppose it’s preferable for the controller to take a catnap than for the pilot, but there is a process defect in the tower. Afterwards, the Secretary of Transportation announced a new policy that middle school kids could have devised. Air traffic controllers shouldn’t be manning the fort solo. Wow! Real genius advice here from our government. Are these the same brainiacs that make me take off my sneakers before I board an airplane? (No, these Mensa folks are Department of Homeland Security experts.)

In past years, several people have contracted hepatitis C after undergoing medicine’s most elegant medical procedure – a colonoscopy. These events were not Acts of God but were Acts of Man. They occurred when established procedures were breached for various reasons, none of which are defensible.

While we often cut corners with impunity, on occasion a small and seemingly innocuous deviation can result in unforgiving consequences. The concept of Universal Precautions means what it says. It means do what you are supposed to do every time without exception. Here’s what a list of Partial Precautions might include:

Wear seat belts on long car trips only.
Physicians should wash their hands only before seeing ICU patients.
Do not leave infants alone in the bath on odd numbered days.
Give your children two-thirds of recommended vaccinations.
Never drive under the influence of alcohol during daylight.

So, the water faucet was dirty.My kitchen faucet isn't sterile either. However, while I'm no TPN expert, should tap water be used to clean a container that would be used for preparing TPN, which must be 100% germ free? Similar mistakes are made daily throughout society without causing harm. Lighting a match won’t lead to havoc and destruction. But, when the same match lights a fuse, then the world can go dark.

Any corner cutters out there who want to come clean?

IPhone Apps for Physicians: Medical Apps I Want

2011-04-10T05:13:00.003-04:00

Your humble Luddite Whistleblower has leapt across the sea to reach the Isle of Technology. I now own and operate an iPhone, which identifies me as groovy, hip and cool, three adjectives that none of our 5 kids ever use to describe their technophobic father. I’m told that my text messages are too long and too frequent. I am admonished that it is not necessary for me to photograph moments of high drama, such as a kid eating breakfast, and then to disseminate the image to my contact list. I am reminded often that I am slow to grasp the mechanical intricacies of the device, such as switching from ring to vibration mode.

You may wonder how it was possible that I, who consider using an ATM to be a high level computer operation, could make the iPhone, my phone. I knew I couldn’t fail, despite my trepidation of all things cyber. I had a secret weapon, a ‘Plan B’. Actually, I had Plan Z, the most powerful asset that anyone in my situation could hope for. Z stands for Zachy. One sentence will explain all and may provoke screams of envy from those who have no available similar resource.

Zachy is our 14-yr-old kid!

Zachy is our youngest son and lives and dreams in the cyberworld. Like his contemporaries, he relies on computers to communicate and interact with the world. He is excited to devise new mousetraps that seem unnecessarily complex. When he receives a phone call, he can reroute the call so that it the caller’s voice will emerge out of a speaker from another techno-contraption in his room. Is this cool? Yes. Is it easier than simply answering the phone? You decide.

Of course, the real appeal of the iPhone is the Apps. Since App to me means appendectomy, I assumed that the iPhone was a well-designed physician’s tool. Relax readers, I have since become educated and have increased my Apptitude. I can now spend time I don’t have searching for cool Apps that will solve problems I don’t have.

Some Apps I Have

Dragon – This is a must-have App and is well worth the price. It’s free. It permits you to dictate directly into the contraption and then transforms your voice into text with reasonable accuracy. This is great for TWD, or texting while driving, an act that no responsible physician has ever committed.

Epocrates – Another gratis App, although the company hopes you will upgrade to one of their premium products. I’ve used Epocrates for years, and consult it nearly every day. It’s a quick and easy resource for all medications, including dosage, adverse reactions, drug interactions, contraindications and cost. How many medications do we really need to take care of patients? Probably, 2 dozen or so.

Liver Calc – My partner is always showing off when he rounds on liver patients and calculates the MELD score in his progress notes. Who can remember this stuff? It reminds me of the Ranson criteria for pancreatitis that we medical students were forced to memorize. (I remember Dr. Ranson from my medical school days. He was warm & fuzzy – NOT). Do these liver scores help actual patients or merely provide grist for board examinations? With this App, I can now calculate on the spot a variety of scores for liver patients, most of which this board certified gastroenterologist has never heard of. Anyone out there heard of the RUCAM criteria?

Medscape – This is a very comprehensive site, but seems to cruise more horizontally across the medical landscape than vertically. Will I ever use it? Not sure. The goal, I am learning, is not to use Apps, but just to collect ‘em.

Epocrates Disease Game – This is a cool way to spend time in the airport when your flight is delayed and the smiling airline personnel will not divulge the updated departure time regardless of threat or bribery. Tap the App and a medical image appears in stages, until the entire screen shows the finding. Choose the correct diagnosis among the 3 given choices. For those who were born during the Eisenhower era, this game reminds me of solving the rebus in the classic TV game show Concentration.

Apps I Want

Colon Cleanse App – This is a double plug in App. You plug in the device into the headphone jack of the iPhone and plug the larger end into the rectum. Attach the accessory funneled cleansing tube to a standard faucet, and watch the toxins disappear.

Medical Coding App – This turns your iPhone into a high voltage device, similar to the Invisible Fences that are used to restrain pets to a given area. Tap the App and then place the iPhone in your front pocket. After seeing a patient, if you code higher than you should on your EMR, you will get a light shock. The intensity will increase until you have expressed remorse, atoned and coded properly. I expect that Medicare will provide incentives for using this technology in the coming years.

Formulary App – This will be fun for the entire office. When the physician guesses the drug that is on the patient’s formulary, carnival music starts blaring from the iPhone. Since this occurs rarely, do not worry that this App will be disruptive to your office routine.

Am I getting just a bit slAPP hAPPy? Probably, so. The APPendix may be a vestigial structure, but the iPhone Apps are like the oxygen drive. You can try holding your breath, but how long can you hold out?

Medical Turf Wars: Truth vs Turf

2011-04-03T06:00:00.000-04:00

Prototype 'BS' meter.

So many folks express views that are obviously self-serving, but they try to masquerade them as altruistic positions that benefit some other constituency. These attempts usually fool no one, but yet these performances are common and ongoing. They are potent fertilizer for cynicism.

Teachers’ unions have been performing for us for decades. Their positions on charter schools, school vouchers, merit pay and the tenure system are clear examples of professional advocacy to protect teachers’ jobs and benefits; yet the stated reasons are to protect our kids. Yeah, right. While our kids are not receiving a top flight education, the public has gotten smart in a hurry on what’s really needed to reform our public educational system. This is why these unions are now retreating and regrouping, grudgingly ‘welcoming’ some reform proposals that have been on the table for decades. This was no epiphany on their part. They were exposed and vulnerable. They wisely sensed that the public lost faith in their arguments and was turning against them. Once the public walked away, or became adversaries, established and entrenched teachers’ union views and policies would be aggressively targeted. Those of us in the medical profession have learned the risk of alienating the public. Teachers have been smarter than we were.

The medical profession is full of ‘performances’ where the stated view is mere camouflage. For example, there is a turf war between gastroenterologists (GI) and anesthesiologists whether GI physicians can safely administer the drug propofol to sedate our patients before colonoscopies and other glamorous procedures. This drug may be familiar to ordinary readers as it was involved in the death of a superstar pop music legend in 2009. GI doctors insist that with proper training we can safely administer this drug to our patients. Indeed, there are numerous scientific publications that support this view. Anesthesiologists have pushed back hard and they have prevailed. “It’s too dangerous,” they warn. “No one can use this drug unless you have advanced anesthesia training,” Of course, the only physicians who have ‘advanced anesthesia training’ are anesthesiologists. I’m not claiming that my anesthesia friends don’t have a legitimate point. But, let’s be clear. Their position is not merely an effort to protect patients, it is also meant to protect their turf. See the equation below for a mathematical depiction of this issue.

Protecting(Turf) = $$$

Gastroenterology, my specialty is in the game also. This is transparent when our GI professional societies issue ‘guidelines’ for recommended GI procedure volumes and training for obtaining hospital privileges. For example, if these societies, who are dominated by academic physicians who work at medical schools and teaching institutions, issue procedure volume standards that are unreasonably high, this will serve to siphon procedures toward their medical centers where they work, and away from community gastroenterologists like me. In other words, if I do 20 procedures a year, but the ‘guidelines’ state that at 40 cases annually are required for competency, then I may be denied hospital privileges for this procedure and must then refer these patients to an academic center. The argument, of course, is to protect patients, but I suggest that there may be an unstated agenda. Interestingly, these medical centers and academicians do not issue ‘guidelines’ and volume standards for treating patients with cirrhosis, Crohn’s disease, irritable bowel disease or gastroesophageal reflux (GERD)? Why does my procedure count matter so much, but my case load for specific diseases doesn’t? Is it really only about safety? Perhaps, physician readers will offer views on this point.

National leaders in gastroenterology are very concerned about surgeons and other physicians performing endoscopic procedures, which represent a major proportion of our incomes. Of course, we don’t want untrained physicians performing colonoscopies. But, there is a turf issue at play here also.

Everyone is grabbing for a piece of turf. Politics is so rife with turf protection that it is nearly impossible to divine what someone is really thinking. So much of what these guys and gals say and do have little to do with the merits of the issue, and plenty to do with elections and self-preservation. Wouldn’t it be nice if all of our elective representatives were equipped with a B.S. (barnyard epithet) meter that could distinguish truthfulness from turfulness? Could our best engineers design such a device? I doubt it. After 2 or 3 sentences, the needles would all snap.

Do Vaccines Cause Autism? A Victory for Science

2011-03-27T06:00:00.001-04:00

Ohio made national news twice in one week, and the Cuyahoga River wasn’t even on fire.
First, Obama and his entourage flew here to headline the conference, Winning the Future Forum for Small Business, when he addressed small business leaders. He referred to the ‘reinvention of Cleveland’, a term that suggests we are experiencing a renaissance here, an event that most of us are unaware of. In any event, when a president flies in, it offers an opportunity to think, particularly if you are held hostage on the highway awaiting the presidential motorcade. Then, you can ponder how late you will be for your destination.

Education, one of my preferred issues, also made headlines. A Mount Vernon, Ohio teacher was accused of infecting his curriculum with creationism, among other allegations which readers can discover with a single click after a Google search. Ohioans follow the creationism issue closely and pride ourselves on being more enlightened than many spirited evangelists from the Sunflower State who tried to convince us a few years back to accept ‘intelligent design’ in the classroom. Their design was both intelligent and transparent. ‘Teach the controversy’, they argued. However, acknowledging that a controversy existed would provide them with a victory. There is no controversy. Creationism and its repackaged cousin intelligent design are not science and cannot be permitted to masquerade as such.

Science won a victory in Washington, D.C. recently. The U.S Supreme Court ruled that folks who claim injury from a vaccine may not sue the manufacturers and must rely upon the vaccine compensation system, called the National Vaccine Injury Compensation System (VICP), that was designed 25 years ago. The 6 to 2 vote suggests that this was not a close legal call. The case before the court involved parents who alleged that a DPT (diphtheria, pertussis and tetanus) vaccine caused permanent developmental deficits and seizures in their child. They sued first in state court and then in federal court when the special vaccine tribunal, referenced above, ruled that they did not prove that the DPT vaccine caused the injury.

The VCIP, or ‘vaccine court’ system, is an excellent institution that serves everyone’s interest. This court has special knowledge and expertise in vaccinations, much more so than would a jury of one’s peers have in an ordinary trial. If this court is persuaded that a claim meets their burden of proof, then compensation is speedily awarded. Granted, these petitioners may not strike lottery gold, as they might in traditional civil litigation, but they will be promptly and fairly compensated. More importantly, this system protects vaccine manufacturers from defending a deluge of annual lawsuits from folks who are convinced that their products have harmed them or their kids. Although I believe that most of these claims are sincere, the vast majority of them are unfounded. They are based on emotion and fueled by a vocal minority of anti-vaccine enthusiasts who try hard to transform anecdotes and vignettes into science.

We all are aware of a belief that measles vaccine can cause or worsen autism. This has been a wrenching issue for many families who are convinced that measles (MMR vaccine) or other vaccines caused their children to develop this serious illness. These anecdotes have been widely reported in the press and generate understandable sympathy from the public. Sympathy, however, is not science.
At this point, there is no scientific evidence that any vaccine causes autism, a finding that has been upheld by the VICP repeatedly.

While every vaccine, including measles, has potential side-effects, these are rare events. Health experts strongly advise that risks of harm from routine vaccinations are much less than the risks of not having immunity to various communicable diseases.

Autism is a mysterious and serious illness. We all hope that medical research will lead to understanding the cause of this disease and to effective treatments. So far, the verdict on the measles vaccine in the case of MMR vs Autism is not guilty.

Who says there is only bad news coming from the nation’s capital? The judicial branch of government performed superbly in this instance. We owe much gratitude to our founding fathers, who so intelligently designed our government.

Unneccesary Breast Biopsies: Needle Biopsies vs Scalpels

2011-03-20T06:00:00.001-04:00

This is a family blog. At times, I have had to expunge comments for inappropriate content. My criteria for comment eradication include:

Raw language
Personal attacks
Overt commercial objectives

There was a time in my lifetime when breasts were considered an inappropriate topic in public discourse. You never saw Little Ricky suckling his mother’s milk on I Love Lucy. These days, of course, breast references and actual images are chic and ubiquitous. Relax, parents. The remainder of this post will remain family-friendly, so there is no need for you to consult your 14-year-old on how to implement parental controls on your computer.

Here are 3 recent breaking breast developments that all inquiring minds will want to be abreast of.

Landmark medical study concluding that many women with breast cancer do not need to undergo pain and expense of removing lymph nodes. They do just as well if their nodes are not disturbed. Why does this matter? See prior landmark Whistleblower post.
U.S Representative Michelle Bachmann (R-Minn) pushed back at First Lady Michelle Obama’s promotion of breast feeding, in a proposal to make breast pumps tax deductible. In Bachmann’s words, “I’ve given birth to five babies and I breastfed every single one of these babies. To think that government has to go out and buy my breast pump for my babies. You wanna talk about the nanny state? I think we just got the new definition of a nanny.”
New study of breast biopsies concludes that physicians have been performing surgical biopsies of breast lesions excessively, instead of using a less invasive needle biopsy technique.

Why does this matter? If the new study is correct, then benefits to women and the rest of us include:

Hundreds of thousands of women would be spared unnecessary surgery every year.
Hundreds of millions of dollars would be saved. Anyone out there think we could use this money in the health care system?
Fortunately, only a minority of women with breast lesions have cancer. For technical reasons, a surgical biopsy can make the definitive cancer surgery trickier than if needle biopsy were used.

The New York Times article also alleged that surgeons may be motivated to perform open surgical biopsies for personal gain, as needle biopsies are performed by radiologists. Could this be a turf issue? The article reports that employed surgeons performed open surgical biopsies in 10% of cases while their private practice colleagues did so in 35% of cases. Was avarice at play here? This Times was really 'milking' this explanation for the biopsy rate discrepancy.

All of these breast developments deserve to be supported. I celebrate any medical study that demonstrates that less medicine means more healing. With regard to the Bachmann-Obama duel, I think that Bachmann has a point. With our deficit and national debt rising beyond the stratosphere, is pumping taxpayer cash into breast pumps a national priority?

To the kids reading, who were hoping that this post would include some graphic and titillating images, I’m so sorry to disappoint you. If you are seeking carnal and prurient material, then just ask your Mom or Dad to take you to a PG-13 movie.

Breast Cancer Breakthrough: Can It Break Through?

2011-03-13T06:00:00.005-04:00

Recently, every newspaper in the country reported on a landmark development in breast cancer treatment. It is now clear that certain breast cancer women do not need to undergo removal of lymph nodes from the armpit as part of their treatment. This would spare them from the risk and discomfort of an unnecessary procedure. It is welcome news, particularly for those of us who argue that in medicine, less is more. This is an example of the benefit of comparative effectiveness research, a tool that can separate what patients truly need from what the medical profession believes they must have.

Let’s hope that breast cancer breakthrough metastasizes across the medical profession. Here’s what it accomplished.

It spares women from unnecessary surgery.
It saves money.
It demonstrates that physicians and medical professionals can serve the public interest.
It gives hope that all medical specialties will critically evaluate and justify the tests and treatments that we recommend to our patients.

Ironically, when the U.S Preventive Services Task Force (USPSTF) published their mammography guidelines last year, also arguing that less is more, they were assailed as medical traitors against women.

When it comes to breasts

There’s a tug of war

Some want less

And some want more.

Every practicing physician, medical educator and researcher should examine their own practices and medical advice. On what basis do we recommend our treatments? Do we do so because we were taught these practices in our training years ago? Is it from habit or adhering to the community standard? Is it because patients have such a high expectation of a medical intervention that we feel obligated to act?

Can anyone argue that patients are subjected to too much/many

Chemotherapy
Antibiotics
Colonoscopies
Cardiac stents
CAT scans and their imaging cousins

We are overtesting, overtreating and overwhelming a system that is sagging under the tonnage of well-meaning and ineffective medical care. I am not referring here to the universe of medical care that serves various constituencies’ economic interests. I speak here about physicians who are trying to do right, but are not accomplishing their objectives. Our aim is true, but we are misfiring.

Weeks ago, I reviewed an outstanding book called Overtreated, which I would mandate every medical student and physician to read as a requirement for maintaining their licensure. This theme is the thread that winds itself through the Whistleblower blog, to the delight of some, and the consternation of others.

If this recent breast cancer message caught fire, medical quality would be launched into the stratosphere. Then, true medical quality would be out of reach of the bureaucratic bean counters and pay-for-performance charlatans who champion medical quality as they proceed to dismantle it.

Let’s hope that this breast cancer study will become the mother’s milk of medicine.

Sarah Palin and MDWhistleblower in the Crosshairs: Do I Have an ‘Image Problem’?

2011-03-06T06:03:00.002-05:00

I recently posted a piece entitled, Health Care Reform in the Crosshairs, when I opined that Sarah Palin’s political ads with crosshairs superimposed on selected congressional districts were acceptable political discourse. Click on the link above to view the image that accompanied the post.

A reader sent me a private email suggesting that the crosshairs image was distasteful, particularly as one of the crosshairs was placed over Congresswoman Giffords’ district. The congresswoman was attacked by an evil murderer, and we all pray for her continued recovery and for the other victims and their families of this unspeakable attack.

In the private commenter’s own words, I think you should take down Sarah Palin's targets map on your most recent blog post. I don't understand its connection to what you're writing in any case. But the targets are aimed at congressional districts, one of which is Rep. Giffords’. Since she was actually shot and almost died, in seems a bit distasteful... This reader gave me a relevant link, which I provide here for those interested.

I had no knowledge of the location of the crosshairs, but I think that the image was the right one for the post. Should I remove it as was suggested? I am inclined to leave it be, as I do not believe that this ad can be rationally linked to the subsequent senseless violence that occurred. Moreover, military and firearm metaphors are omnipresent, as my recent post notes. Should they all be stricken from our lexicon? Sporting events are often reported and described in military terms, as are so many other events in our society. How many times do we read or personally describe an athletic outcome as a massacre? If we sanitize our communication to remove words, phrases and images that could also exist in a violent context, then life would be rather bland. In addition, we would argue until the end of time whether a particular phrase was over the decency threshold, an issue that our courts wrestle with every day.

Even the president recently described Governor Scott Walker’s plan to eliminate collective bargaining rights for public union members as an ‘assault on unions’. I guess that the word assault was deemed acceptable by the administration and passed through focus group review. A week after the president spoke, Labor Secretary Hilda Solis remarked at a speech to the Democratic National Committee on February 27th, “We help those embattled states right now where public employees are under assault.”

The liberal organization Moveon.org issued this statement to rally protesters against efforts to curtail union collective bargaining rights.

“We demand an end to the attacks on worker's rights and public services across the country.”

In my state of Ohio, where Governor Kasich is also pushing back against unions, protesters’ statements include:

“Kill the bill.”

“They’re trying to take away what we fought for all of these years.”

The italics in the above quotes are mine.

Obviously, there is speech that is over the line. I agree with the commenter’s implication that just because we have the right to express certain speech, doesn’t mean that it is right to do so. However, I believe that if removing the crosshair image from my post is considered the proper standard, then we will be censoring vast amounts of expression that deserves to be heard.

I thank this reader, whom I know personally, for offering her view to me, and now to the readers. I hope that they will share their views here also. Was the crosshairs image over the line? Should I take aim it and take it out? Let me rephrase that incendiary query. Should I gently and respectfully delete it?

Free Drug Samples and Hospital Hotels: Which is the Greater Evil?

2011-02-27T06:09:00.008-05:00

Many folks criticize pharmaceutical companies for providing physicians’ offices with free drug samples. They claim that this giveaway harms consumers because drug companies must raise their prices to cover the costs of these freebies. Of course, this is undeniable. Any business expense, such as payroll or advertising, has to be covered and is expectedly borne by the consumer. If a company chooses not to advertise, outsources manufacturing to a country with cheaper labor, offers limited benefits to its employees, then they can sell their product at a low price. In this hypothetical example, anemic sales may doom the company quickly.

Naturally, free samples are not really free. The rest of us pay for them. While this is true, I don’t think it is evil. Unlike the U.S. government, at least drug companies are covering their costs and not simply borrowing money every year to meet budget. Interesting concept.

Two of the community hospitals I work at have undergone transformations. One is owned by the dominant health care behemoth in Cleveland and has just completed a near $200 million renovation and expansion. The other smaller hospital is one of the few remaining Cleveland area hospitals that are still independent. I’d like to sneak there at night and hoist up a ‘Live Free or Die’ flag up the flagpole, to celebrate its independent streak, but I’m sure that there are video cameras everywhere and that I would be in violation of several bylaws. The apt punishment might be that I would have to spend a cold Cleveland night chained to the flagpole reading electronic medical record manuals out loud.

Both of these hospitals have private patient rooms that look more like hotel suites then hospital rooms. Patients are just a click away from work and play as there is wireless internet. Why do patients need flat screen TVs? Perhaps, they emit healing humors to help speed recoveries. Forget about those hardback chairs next to patients’ beds where visitors would stiffly sit. Now, there is posh furniture to sink into. Artwork is everywhere. Every new hospital these days is equipped with an essential architectural structure – an atrium.

What’s the angle here? Is this a marketing war between competing hospitals? Is the new comfort standard for a hospital similar to a high end cruise ship? That gives me an idea. What if a hospital system purchased a cruise line to serve as a floating hospital across the high seas? I’m amazed we haven’t seen this yet. Remember, you read it here first.

Get that gallbladder out!

Visit exciting ports of call!

Enjoy world class entertainment!

Splurge on our decadent midnight chocolate buffet!

Where’s the outrage here? Are these hundreds of millions of dollars helping sick people get well? Couldn’t this money be directed to a more worthy objective? Why aren’t health care reform-minded folks picketing and protesting? Or, does it make more sense to carp over free Nexium samples and pizza for the office staff?

It is true that physicians who have been actual patients gain a valuable perspective. I’m willing to make the sacrifice. Put me up in one of these carpeted, plush rooms with room service and soft music. It will be tough, but if it’ll help me to be a better doctor, then I’m willing to endure the pain.

Health Care Reform in the Crosshairs

2011-02-20T05:26:00.003-05:00

Last summer, at the Cleveland Film Festival, I saw a movie called The Lottery, which is still swirling in my head. It is a documentary about the enormous obstacles that true education reformers confront when they try to help our kids learn. The film was raw and powerful and made me angry. It led to many family discussions about the state of education in America and a search for a way forward. The film is certainly not a balanced view on this issue, and teachers’ union supporters who view it will need to have industrial strength antacids available. I found The Lottery to be more powerful than the more popular movie Waiting for Superman, which addresses the same theme.

Assuming the facts are as presented, viewers are shocked to learn how long and how expensive it is to remove an incompetent teacher.

The New York Times reported that governors across the country are seizing on the public mood and are working to dismantle the teacher tenure system, where jobs are protected regardless of performance. As an aside, the Times’ headline reads G.O.P. Governors Take Aim at Teacher Tenure. You recall after the recent tragedy in Tucson, committed by an evil madman, some had criticized prior political ads that included crosshairs superimposed on political adversaries. Yes, these were Sarah Palin’s political ads. Critics suggested that these ads were not only tasteless, but created a climate of incitement. Should the Times’ phrase Take Aim in the headline above have been sanitized? Who knows? Someone might read ‘take aim’ and think it is a call to arms!

I was asked recently if the medical profession had a mechanism to verify if our older practitioners had the necessary cognitive and technical skills to practice medicine. The answer is, no we don’t. While other professions have mandatory retirement ages, we physicians are firmly on a tenure track that has no endpoint. Physicians can continue to treat patients, and even operate, without any limitation of age or requirement to certify that our skills are sufficient. I think a reasonable argument can be advanced that we could do better.

There is an emotional aspect of the argument advocating periodic assessments of physicians because lives are at stake. But many professionals who don’t wield scalpels or colonoscopes can also put our lives at risk. If an engineer, for example, designs a bridge and miscalculates, a tragedy could ensue. Before we all agree that physicians starting at age 60 should undergo testing every 5 years, let’s consider which other professions should be included in this effort. Nevertheless, I feel we have an obligation to our profession and to the patients we serve to assure them that we still have the right stuff.

Teachers’ unions have been recalcitrant and oppositional for decades and they have squandered the public trust. Their enemy is not the GOP governors or a public who is now hostile to them. Teachers are victims of their own self-interest. The medical profession has failed many times by not reforming ourselves proactively. Then, outsiders ‘reform’ us and we gripe about our loss of autonomy. Haven’t we learned what happens when outsiders heal us? I think that medical reform needs to be square in our own crosshairs before someone takes aim at us.

Overtreatment and Unnecessary Medical Care: Healthcare's Biggest Threat

2011-02-13T06:04:00.000-05:00

My daughter, Elana, home from college on winter break, offered me a book to peruse from one of her classes. She correctly suspected that her father, the Whistleblower, would enjoy reading a book authored by a Whistleblower pro.

The book, Overtreated, by Shannon Brownlee, should be required reading for first year medical students, who have not yet acquired views and habits that promulgate excessive medical care and treatment. For those of us already in practice, this book should be a required element of board recertification. The theme of the book appears as a subtitle on the cover.

Why Too Much Medicine is Making us Sicker and Poorer

Brownlee understands the medical system well and describes a culture of excess, conflicts of interests, absence of universal quality control mechanisms and fractured and disorganized care with no one in charge of a particular patient. She presents some chilling anecdotes of medical tragedies that have occurred at our most prestigious medical institutions. And she introduces us to reform leaders who understand the system’s inherent deficiencies and their proposals to remedy them.

Brownlee states that explanations for waste in the health care system include:

Cost of a gargantuan bureaucracy
Medical malpractice fear and defensive medicine
Incentives for patients with medical insurance to overutilize care
Rising medical costs

The most important cause, she argues, is unnecessary medical care, which costs the nations hundreds of billions of dollars and exposes patients to the risk of harm from medical complications. She writes: If overtreatment were a disease, there would be a patient advocacy group out there raising money for a cure. She points out numerous conflicts of interest in the system where medical incomes rise when medical outcomes decline. She shares the views of early medical reformers, iconoclasts, who are now firmly in the mainstream of medical reform efforts. She gives the history the development of the understanding of geographic variability in medical costs and outcomes. She explains why spending more on health care oven leads to worse health for patients. The reader will see the familiar statistics comparing the United States to other nations who spend far less than we do and enjoy better health.

The book was published in 2007, before the divisive national debate on Obamacare took place. But, the book is not dated and the issues are highly relevant. The book reminded me of Atul Gawande’s remarkable and influential essay published in New Yorker Magazine in 2009. Gawande’s piece impressed one reader so powerfully, that he required his entire presidential cabinet to read the article.

I haven’t finished the book yet, but I intend to. I award Brownlee’s book with the coveted Whistleblower Seal of Excellence. Even a perusal of the first few chapters would be worthwhile.

I hope that you will consider reading it and recommending it to others. Why not leave a copy in your medical office waiting room or on your coffee table at home? You might consult it before you sign up for the total body scan being advertised in your newspaper.

My deep concern is that Overtreated will be Underread.

Selling Human Organs for Transplantation: Ethics Under Siege

2011-02-06T05:45:00.001-05:00

I have previously posted on the ethics of paying for organ donation. I find this notion to be ethically troubling, but I believe the issue deserves fair debate. In general, my belief is that a personal anecdote should not drive policy in medical ethics. There are many individual vignettes that are poignant and heartbreaking that tempt us to relax our ethical boundaries. For example, permitting us to harvest organs from folks who are ‘not quite dead’, would save lives, but society’s rights outweigh this benefit, in my view. For similar reasons, I resist efforts to relax the definition of death in order to increase the reservoir of available organs. If death is redefined as a result of a search for truth, then the process is ethically permissible. Participants in these discussions would include medical professionals, theologians, ethicists, legal experts and ordinary people. If a result of this process would be that there would be more organs available for transplantation, then I would be supportive. The distinction is that increasing organ supply would not be the primary objective. In other words, I reject the approach of ‘hey, we need more organs to save lives. Let’s roll back the definition of death to get there.’

Recently, two sisters who were serving life sentences in Mississippi for a crime related to armed robbery were released by Governor Haley Barbour. They were not pardoned, but their sentences were indefinitely suspended. A condition of their release was that one woman must agree to donate a kidney to her sister.

The women have always maintained their innocence, and supporters have argued that the verdict was wrong or disproportionate to the crime. I am not knowledgeable on the facts and offer no view on the whether the verdict and sentence were just.

More details on this case can be found at Everything Health, often among the first to present medical controversies to the blogosphere.

Governor Barbour cited the estimated $200,000 yearly cost of dialysis that the state would bear as a factor in his decision to release the women. This created ethical angst for many of us. Organ donation, at least currently, is supposed to be an altruistic event, when the donor does not receive monetary or other tangible benefits for the gift. (I am not referring here to compensating donors for their time, medical expenses, lost wages, etc. But donors should not view donation as a revenue stream.) If the Governor’s rationale became established policy, then we would become ethically unmoored. The drift that began with a Mississippi prison would seep out across society. Which of the following scenarios would we support?

Paying for organs on the open market
Organ auctions
Selling your kids’ stem cells to support their college funds
Releasing female prisoners for serving as surrogate mothers or egg donors
Tax breaks for bone marrow donations
A pay raise and promotion if you give your boss a kidney
Admission to an Ivy League institution for a piece of your liver

You get the idea here. Too often in the medical ethical arena, an action precedes thoughtful discussion and debate. The danger here is that the action spreads out and becomes prematurely established as policy. It becomes harder to undo an action that has developed roots and is multiplying. Indeed, a change in medical ethics policies should be the final part of the process and not the opening act.

When do you think the proper time would be to debate human cloning? Now, or after several Whistleblowers have been cranked out in cloning farms around the country?

Two Mississippi women have been unshackled and released from prison. Is medical ethics now in handcuffs?

What's your view?

President's State of the Union Address Targets Frivolous Lawsuits: Was I Dreaming?

2011-01-30T06:04:00.002-05:00

We watched the president’s State of the Union address recently with the kids, to try and inculcate them with civic interest and responsibility. He is an inspiring and skilled speaker whose words seem to transcend partisanship and divisiveness. Nothing like an electoral ‘shellacking’ to push a politician into a Kumbaya mode. I thought the speech was long on ideals but sidestepped the pain and sacrifice it would take to reach the objectives the president outlined. I was waiting to hear the president’s plans regarding Medicare and Social Security, and I’m still waiting. The president took such a high road, that it was in the stratosphere, beyond real life.

Here’s what he said:

...by the end of the decade, America will once again have the highest proportion of college graduates in the world.

Here’s what he didn’t say:

...to save Social Security we are cutting benefits and raising the age when seniors can collect.

I’m not a journalist or a speechwriter, but my understanding is that the reverse pyramid system is used, meaning you start off with the important stuff and proceed toward the trivial. This is why The New York Times piece on the speech did not open with a comment on the president’s tie.

The following three subjects were included in the President’s speech. Place them in the order of importance.

The War in Afghanistan

The Peace in Iraq

Medical Malpractice Reform

Has the president experienced a Damascus Road conversion on the medical malpractice situation.? Not only did he acknowledge that frivolous lawsuits are real and are not simply physicians’ phantasmagoria, but he addressed the issue before mentioning Iraq and Afghanistan. Am I reading too much into this? Here’s what he said.

Still, I'm willing to look at other ideas to bring down costs, including one that Republicans suggested last year: medical malpractice reform to rein in frivolous lawsuits.

Does the president really get it, or is he the wily political pragmatist who now views life through the prism of 2012? I suspect the latter because if medical malpractice reform were truly important to the president, then he would have insisted it be included in the Patient Protection and Affordable Care Act, known to many as Obamacare. Time will tell if this plan is affordable and protects our health, as suggested by the law’s name. Put me in the deeply skeptical category.

Yes, the president is a facile orator. The State of His Rhetoric is strong. The State of the Union, however…

Why Medical Ethics Should Matter to Patients

2011-01-23T06:02:00.002-05:00

Medical ethics has properly gained a foothold in the public square. There is a national conversation about euthanasia, stem cell research, fertilization and embryo implantation techniques, end-of-life care, prenatal diagnosis of serious diseases, defining death to facilitate organ donation, cloning and financial conflicts of interest. Nearly every day, we read (or click) on a headline highlighting one of these or similar ethical controversies. These great issues hover over us.

We physicians face ethical dilemmas every day in the mundane world of our medical practices. They won’t appear in your newspapers or pop up on your smart phones, but they are real and they are important. Here is a sampling from the everyday ethical smorgasbord that your doctor faces. How would you act under the following scenarios?

A physician has one appointment slot remaining on his schedule. Two patients have called requesting this same day appointment. The first patient who called has no insurance and owes the practice money. The second patient has medical insurance coverage. Neither patient is seriously ill. Who should get the appointment?
Two hours before a doctor is to see a patient, her husband calls to relate private information that he fears the patient will not share with the physician. Should the physician disclose this conversation to the patient? What is the risk if she discovers at a later time that a confidential conversation occurred?
A patient has been non-compliant with medical care. He has missed appointments and does not take his medication reliably. The physician is contacted by a local emergency room after the patient arrives there for a medical evaluation. Can the doctor ethically decline to treat this patient who has repeatedly rejected the physician’s advice?
Many physicians dispense medication samples to their patients. Is this practice ethical in that it raises drug prices for everyone since drug companies must fund these giveaways?
An attorney contacts a physician to testify against a fellow doctor who is accused of committing medical malpractice. The physician and the accused doctor both work in a small community hospital. The facts suggest that a medically negligent act has occurred. Is the physician ethically obligated to testify against his colleague?
A cardiologist decides not to accept smokers in his practice as he views this behavior as a direct attack on his medical treatment and strategy. All smokers in his practice are notified that if they do not quit within 6 months that they will need to select another physician. The cardiologist states he will actively counsel and treat all smokers on the available options for nicotine addiction. Can this physician ethically dismiss smokers from his practice who can’t or won’t quit?
A patient asks a doctor to fill out a temporarily disability form for back pain present for 2 weeks prior to the office visit. During this time, the patient did not seek any medical care. Is it ethical for the doctor to sign off on this request?

While none of the examples above will make the front page of your morning newspapers, they are newsworthy. They are under the radar, but need to be exposed. While the public square is crowed with the monumental ethical controversies of the day, we need to reserve a small corner there for everyday ethics. Ethics in the office should not be a private matter.

Electronic Medical Records Attack Hospitals

2011-01-16T05:53:00.002-05:00

Whistleblower readers know of my criticisms of the electronic medical record (EMR) juggernaut that is oozing over the medical landscape. Ultimately, this technology will make medical care better and easier to practice. All systems will be integrated, so that a physician will have instant access to his patients’ medical data from other physicians’ offices, emergency rooms and hospitals. In addition, data input in the physician’s office will use reliable voice activated technology, so that some antiquated physician behaviors, such as eye contact, can still occur. Clearly, EMR is in transition. I place it on the 40 yard line, a long way from a touch down or field goal position.

A colleague related a distressing meeting he had at the community hospital he works at. This hospital, like nearly every hospital in Cleveland, is owned by one of the two towering medical behemoths. I’m not a businessman, but I have learned that when something owns you, it’s generally better for the owner than the ownee. This meeting was about the hospital’s upcoming EMR policy. Sometimes, these hospital meetings are ostensibly to seek physician input, but the true purpose is to inform the medical staff about decisions that have already been made. In the coming months, this hospital will adopt a computerized ordering system for all patients. In theory, this would be a welcome advance. It would create a digital and permanent record of all physician orders that could be accessed by all medical personnel involved in the patients’ care. It would solve the perennial problem of inscrutable physician handwriting, including mine.

One advantage that computerized ordering aficionados claim is that physicians’ orders can now be standardized for various medical conditions, such as stroke, congestive heart failure and diabetes. Of course, patients are unique and may not neatly fit into packaged computerized ordering templates. Will deviating from these standard order sheets by easy, or will we need a 14-year old beside us to help us over the cyber hurdles? Most of us have been issuing medical orders on paper for decades, without loss of life or limb. When I write an order with a pen for a potassium supplement, for example, I have not found the task to be onerous. Will the computerized system be another example of solving problems that I didn’t know that I had?

One of the physicians at the hospital meeting asked if the verbal order policy would remain. The response suggested that verbal orders would no longer be permitted. The physicians wondered how they would give admitting or other orders at 2 a.m. Would they have to boot up a computer at that time? What if a nurse calls for an urgent blood transfusion order when the physician is in his car? Does this enlightened verbal order ‘reform’ sound like it originated from folks who understand doctors?

I have to hope that the speaker was misinformed, as this aspect of the policy is simply too dumb to survive, at least I hope so.

I am not a Luddite who opposes EMR on ideological grounds. I believe, and have written, that once perfected, it will accomplish its mission. My quarrel is with those who already claim that the goal line has been reached, or is in sight. I also believe that many of these systems were designed by folks who don’t practice medicine or understand physicians’ needs. What’s good for billers and coders may not help physicians in exam rooms with living, breathing patients.

I am sure that most physicians who are retiring now do not regret that they will miss the steep vertical climb from paper to electronic medical practice. Personally, I am glad to be part of it, although I wish that ‘point & click’ medicine was more about medicine than about pointing and clicking.

Perhaps, this approach can be extended to blogging. Right now, it takes me a while to pound out these posts. If I could use a packaged medical ranting blogging template instead, then I could post a Whistleblower twice daily. Point & click blogging. Hmm. I can see the goal line.

Death Panels Resurrected? Medicare Pays for End-of-Life Consultation

2011-01-09T05:46:00.004-05:00

I’m blogging again while aboard an airplane. Continental demonstrated an effective strategy for bestowing a small measure of comfort onto its beleaguered passengers. The flight was on a one hour delay. Of course, time is an elastic concept to the airline industry. One hour can morph and expand into several hours. The most frustrating aspect for passengers is that we cannot rely upon the latest update to be a firm commitment. It is a modern day recreation of the Sisyphus myth, recalling the king who spends eternity pushing a boulder up a mountain, but never reaching the summit.

Are the death panels back? You remember this distortion from the political right who claimed that coverage for discussions of end-of-life care would soon lead to pulling the plug on granny? This provision was excised from the president’s health care plan, but has been resurrected by executive regulation at the end of 2010. The president has demonstrated that if you can’t get it by legislation, then grab it by regulation. Now, Medicare will reimburse physicians to advise patients on various end-of-life medical care options.

I support this policy. Of course, the time to discuss end-of-life issues is before the end of life. Without such discussions, patients and families do not make optimal and rational medical decisions. Understandably, during these times, they are not thinking clearly and are influenced by guilt, false hopes, pressure from friends and other family members and confusion about what is truly in the ill person’s best interest. Families may focus on trivial clinical events, which will not affect the outcome. I know this because I’ve been there. “Look, I think that his toe moved!” This process is made more agonizing since we physicians are rarely certain of anything, and medical miracles have occurred.

With advanced planning and discussion, folks can decide on the boundaries of their medical care and treatment. My primary reason for supporting this policy is on the medical merits. It will save patients from invasive, toxic and futile care that won’t add much time or meaning to their lives. Of course, it will also save a fortune in health care dollars, but this is not my primary objective.

Let the record show that I do not reflexively carry water for the political right, as I have been accused. I recently received the following comment from an op-ed piece published in our Cleveland newspaper. I offer excerpts of the kind and gentle comment below, for your amusement.

Did a Google serach (sic) for Michael Kirsch, M.D. -I suppose he is the second in the list (Michael Kirsch, MD Gastroenterologist in Cleveland, OH).
He has his own blog called "MD Whistleblower" where ALL he does is trash Obama and "Obamacare".
You are right. I can't believe the [Cleveland newspaper] would even publish articles by someone like this. He's got the credibility of Glenn Beck.

The title of his latest blog tells it all...
Sunday, December 26, 2010 - Obamacare Unconstitutional!
The second anyone refers to The Affordable Care Act of 2010 as "Obamacare" in an article you know what you're about to hear. Republican spin. He wastes no time - puts it right in the title. It might attract "his people" but it should be a turnoff to anyone else reading who has a mind of their own. I don't even bother reading such garbage.
More proof that he's another Rand Paul "less government in my life" libertarian nutjob (even when it comes to certification of doctors)...

SUNDAY, APRIL 18, 2010 - Does Board Certification Really Matter?
... and a believer of faith healing...
Sunday, September 19, 2010 - The Healing Power of Prayer: Faith vs Reason?

And he's got various other typical wingnut rants on everything from tort reform to EIGHTEEN different blogs ranting about the evils of healthcare reform.
NICE JOB - Keep your readers "informed" by the "professionals". Professional wingnut teabaggers that is. LOL!

Well, not everyone is a Whistleblower fan. But, sometimes the labels we assign to folks are wrong. Very few of us can be neatly categorized as liberal or conservative. Personally, I regard myself as a political moderate, although my views on Obamacare have given some the impression that I must be a Sarah Palin devotee. Do I think that Sarah Palin has been grossly underestimated? ‘You betcha!’ (Insert ‘wink’ here.) Do I think she has a political future? She will be a potent force, but she will never be a candidate for high office, in my view.

No, I don't regard the president's regulation permitting end-of-life discussion to be a 'Death Panel'. I'd call it a Life Panel.

Addendum: The president performs a backflip on this issue!

Are You at Risk for Alzheimer's Disease?

2011-01-02T05:52:00.001-05:00

The medical profession’s ability to diagnose far exceeds its ability to effectively treat the conditions discovered. Consider arthritis, Parkinson’s disease, irritable bowel syndrome, strokes, emphysema and many cancers.

When a physician orders a diagnostic test, ideally it should be to answer a specific question, rather than a buckshot approach. A chest x-ray is not ordered because a patient has a cough. It should be done because the test has a reasonable chance of yielding information that would change the physician’s advice. If the doctor was going to prescribe an antibiotic anyway, then why order the chest x-ray? Physicians and patients should ask before a test is performed if the information is likely to change the medical management. In other words, is a test being ordered because physicians want to know or because we really need to know the results?

Does every patient with a heart murmur, for example, need an echocardiogram, even though this test would be easy to justify to patients and to insurance companies?

If the test won’t change anything, then it costs dollars and makes no sense. Spine x-rays for acute back strains are an example of a radiologic reflex.

While some tests yield too little information, others provide too much knowledge. I remember as a medical student discussing if healthy patients at risk for Huntington’s Chorea, a progressive and lethal neurologic condition, should be tested to determine if they will develop the disease. Recently, The New York Times reported on a similar ethical controversy regarding testing to determine a person’s risk for developing Alzheimer’s disease, another progressive and incurable condition. Should we make efforts to identify patients with risk, or even certainly, of developing terrible diseases, which have no effective treatments? Would you want to arise each morning knowing that progressive dementia is in your future? Each time you would misplace your keys, or had trouble finding a word, you would wonder if this was the leading edge of the impending meltdown. To me, this knowledge would result in a profound reduction in quality of life, and would also affect relationships with family and others. One could imagine diagnostic panels being run on young couples who are contemplating marriage, a new twist on pre-nuptial agreements. Could life and disability insurance carriers demand access to these results?

Is there a reasonable rebuttal to this view? Of course, folks are entitled to know their genetic predispositions, if they are properly counseled beforehand. These folks, knowing of a dim future, could modify their current priorities so they could enjoy a more satisfying life. These individuals may choose not to wait until retirement to take that trip around the world.

We must also keep in mind that medical tests are not always right. A ‘positive’ Alzheimer’s test result might be dead wrong. Or, the individual might develop a very mild form of the disease. Genetics is a complex and murky universe.

Medical tests that provide too little information are wasteful and unnecessary. Those that provide too much information can be dangerous and destructive. If the plague of Alzheimer’s is in my future, I don’t want to know it now. Sure knowledge is power, but sometimes sweet ignorance is bliss.

Obamacare Unconstitutional!

2010-12-26T05:26:00.002-05:00

I begin this post a few thousand feet in the air, in the aisle seat in the rear of the aircraft. I suppose it is fitting that a gastroenterologist would be in the rear section. Fair is fair. Flying is a psychological test of one’s mettle. After enduring the security process, which is designed to find bad stuff instead of bad people, there are other layers of hassle to face. When I reached the cabin door, I was told that there was no available overhead space to store my bag. This development is often tolerable, as gate-checked bags are brought directly up to the arrival gate walkway after arrival, so you can avoid the hand-to-hand combat of the baggage claim arena. Not this time. For reasons, known but to the Almighty, my bag will be directed to the baggage claim, where I hope and pray that I will be properly reunited with it. Meanwhile, I will enjoy the luxury of an airline seat that would be quite comfortable for an average sized 4th grader. If the lady in front of me tilts her seat back, and my tray table is extended, then I will receive a Heimlich maneuver. Who knows? Maybe this could save my life if she leans back at the moment that the filet mignon I will be served gets trapped in my trachea.

Obamacare has hit an important judicial roadblock when Federal Judge Henry Hudson of Virgina ruled that the individual mandate was unconstitutional. Judge Hudson is the 3rd federal judge to rule on the constitutionality of the president’s health care plan. The first two judges gave the law a pass. Earlier today, oral arguments began in a Pensacola, Florida federal court before a judge who is suspected to harbor constitutional concerns of the health care plan. Already, 4 federal courts are involved, and it’s only 9 months since the law was signed. This is going to be a rocky road, and no one can predict the ultimate outcome. It is likely that the Supreme Court will ultimately have to reconcile various diverging views from lower Federal district and appellate courts. This emphasizes that a president who fills vacancies in the Supreme Court has a powerful tool to protect his policies against legislative threats and reversals.

Of course, courts are not supposed to make policy. They are charged to determine if an action or a law is lawful. Often, court decisions are criticized by folks who are not happy with the outcome, even though the legal issue before the judges may be arcane and not directly related to the actual issue. For example, the headline may read: “Judge Rules that Hospital May Withhold Chemo from Child with Cancer”, but the legal issue may be far removed from this emotional vignette. I’m not suggesting that judges rule in a robotic fashion without compassion or considering their own human experiences. I do feel, however, that it is not their role to depart from the law to provide extrajudicial remedies that should originate elsewhere. While the law does evolve, this is a gradual process that respects precedent and judicial restraint, at least in my view.

Is Obamacare constitutional? I have no idea. If a handful of wizened judges can’t agree, I don’t think that a mere colonoscopist in Cleveland should opine on the issue. Despite its legality, it remains a very unpopular law. Polling still shows that the majority of Americans would like the law totally or partially repealed, while 43% of us approve of the plan. This does not augur well for the president, since the tough medicine in his plan won’t appear for a number of years. Of course, Obama could dodge the fallout, which is inevitable if the law survives. He could be a ‘one termer’ and leave the angry mess to his successor.

This is how the issue appears from 30,000 feet. How does it look to you on the ground?

Whistleblower Holiday Cheer 2010!

2010-12-19T05:24:00.002-05:00

Readers immerse

In my rhymed universe

And decide if my verse

Is for better or worse.

An imam, a rabbi

Along with a priest,

Were seated together

At a holiday feast.

They smiled and they laughed

And enjoyed swapping jokes.

Can you believe

They ducked out for a smoke?

Was their bonhomie real

Or just a facade?

Didn’t they pray

To the very same God?

When together as men

Without enmity,

Walls can be broken

They realized, all three.

Can you still scorn a man

And give him the blame?

When you raise up your glass

And toast him by name?

When it’s all over

And the three of them part

Will they remember

The warmth in their hearts?

Or will the noise and the static

And political din,

Return them once more

To division and sin?

Who will you choose

To your table this year?

Family and friends

Who come year after year?

Perhaps, there are guests

Who could join you this time,

Who could sing at your hearth.

Together in rhyme.

There are friends on your list

And family, no doubt,

But, is someone missing

Who you may have left out?

Wishing you joy and peace!

Medical Ethics: President Obama Makes the Right Call

2010-12-12T06:13:00.001-05:00

I have always felt that issues should be judged by the context of their times. For some issues, however, context provides no justification. Thankfully, the field of medical ethics has evolved into a robust discipline, and there is an enormous need for it. I have read defenses of prior ethical lapses, and even some recent ones, suggesting that context matters. If a 3 month placebo-controlled study is conducted in the developing world testing a medicine that was highly effective against a serious illness, are the ethical dimensions considered and respected? Were the pharm companies choosing this study locale as a cheap test run for their drug, which will ultimately be marketed in the west? Is it ethically problematic not to provide additional medications to ill subjects after the 3 month trial ends? Can we be assured that a rigorous informed consent process was followed? Sadly, outrageous practices have been reported in the very recent past.

Our president and secretary of state recently and rightfully apologized to Guatemala for American experiments performed there in the 1940s when patients were intentionally infected with syphilis. These patients were mentally ill. While I can concoct a distorted and tortured rationale that would justify this reprehensible practice, such reasoning passes no threshold of decency. Some behaviors and practices are always wrong, in any context.

How can decent folks behave indecently? We have seen in the Holocaust how ordinary folks can tolerate, and even perform, evil during the week, and then attend religious services on Sunday. Many of these dark acts were committed by physicians, who are sworn to heal and to comfort. Here’s a perspective on this issue from a man who is known as the conscience of the world.

These are frightening notions. First, they suggest that we may not have innate inclinations to do good, despite our belief that we are all equipped with powerful superegos. If we were all good by nature, then we wouldn’t need such an expansive criminal justice system and thousands of laws telling us what not to do. The reason that the bible is replete with ‘Thou shalt nots’, is because human behavior is often ‘I shalt’. Secondly, these repeated ethical lapses and catastrophes point out that all of us are vulnerable to do wrong, even when we know what the right choice would be. While we might like to think we would push back against a black tide, it is less certain what we would truly do in that situation. Would we risk a job, for example, to take a righteous stand for another person?

I recognize that medical ethics addresses tough issues, where one person’s rights are weighed against another. The resolution of ethical issues yields winners and losers. Yet, despite these controversies, we need a firewall separating what we must do from what we must never do. The argument that the ends justify the means must be resisted. What American scientists did in Guatemala nearly seventy years ago was appalling and morally indefensible. It was wrong then, it is wrong today and it will be wrong tomorrow. The president has just ordered a review of all research involving human subjects being funded by the federal government to assure that medical ethics are being properly practiced. Recent history demonstrates that oversight is necessary. Third world citizens deserve first class ethics.

Privatizing Medicare: Caution! Highly Explosive!

2010-12-05T06:54:00.001-05:00

Photo Credit

In response to my recent post where I averred that the cigarette companies were treated as scapegoats, I have had several cyber and actual conversations about personal responsibility. I believe that folks should realize the consequences and the benefits of freely made decisions. While we want American society to be compassionate, we do not want to punish success and reward failure. Our goal is to do all that we can to maximize everyone’s success. We should be ready to assist those who need and deserve our private and governmental assistance, but personal effort and responsibility are necessary elements of these interventions.

In our gastrroenterology practice, when we see patients who are in financial difficulty, my physician partners and staff will do all that we can to help them. While it is not our policy to do colonoscopies for free, we will make whatever adjustments that are necessary to make sure that the patient receives necessary medical care. However, when patients who owe us money hang up on our calls, or express their view of medical entitlement with foul language, then we forward these accounts to a collection agency.

There is also a self-interest angle to supporting assistance for those in need.. One day, we may need a boost ourselves.

Recall the concept of privatizing social security, a sound proposal that was vilified and snuffed out during George W. Bush’s presidency. Antagonism against this modest proposal was seasoned with a large measure of arrogance, a splash of hubris and a dash of paternalism.

In summary, this proposal argued that if folks could manage a small portion of their own social security money, which they earned themselves, that it could be a force that could empower earners and reinforce the system. The political left turned white hot over the notion of the government transferring any responsibility for managing retirement funds to the citizens who earned the money. Isn’t this preposterous? They predicted doomsday when our imbecilic citizenry, who were somehow smart and industrious enough to earn the money in the first place, would squander it all, vaporizing the last remaining safety net that would keep them afloat. Then, the lefties argued, the rest of us would have to rescue them at much greater expense.

Their argument is transparent. Review some pesky facts below.

The plan only permitted individuals to invest 4% of wages that are subject to social security taxes into private accounts, with modest increases permitted in subsequent years. So, even if these investment tyros lost it all, which is hard to do in any investment, it wouldn’t be a game changer.

The government was not permitting folks to invest in hedge funds, penny stocks or junk bonds. They were required to select from a list of legitimate investment vehicles.

The program was voluntary. If an individual did not have the skill or desire to make personal investment choices, he did not have to. He could continue to allow the government to manage his money.

The program is so modest and so reasonable; it seems that it would be difficult to attack it. Why, then, did it provoke such ire and vitriol from the left?

These guys were scared. They weren’t frightened that folks would lose money and be vulnerable during their retirement years. They weren’t spooked that it would jeopardize the social security system’s financial stability. They were terrified that the program might actually work. They couldn’t tolerate any fissure in their edifice that stood for total government control of other people’s money and personal decisions. If this initial privatization effort succeeded, they knew that the public, now empowered, would demand greater control of their own money.

Yes, I am familiar with some of the criticisms. The government would have to borrow gazillions of dollars to replace the monies being deposited in beneficiaries’ private accounts. In addition, retirees would have to repay the government their privately deposited funds back, plus interest, so it is possible they would lose money if their accounts did not outperform this low interest rate. It would increase the federal deficit, and is not risk free, as stated above. As is obvious, I am not an economist or an actuary. It may be that the dirty details of the program would pose drawbacks, more dire than I realize. Indeed, many liberal advocacy groups vigorously denounced and derided this program. Yet, I support the notion that I have the right to participate in a voluntary program to manage money that I have earned.

To those who believe that the government knows best how to invest my social security retirement money, then why shouldn’t it control all of my investments? Should I be trusted to invest money that will one day be used to pay tuition for my kids? Indeed, anti-privatizers could argue that all of our money should be turned over to the government, so they can wisely manage it and then disburse it as it sees fit.

Recently, Alice Rivlin, a Democratic economist and Paul Ryan, a Republican congressman, both members of the president’s deficit reduction commission, advised consideration of privatizing the Medicare program. Of course, this is political dynamite, but their bipartisan proposal from two thoughtful public servants shows that this strategy deserves air time and public discussion.

So, when you stumble across dynamite, what should or response be? Call the bomb squad or light the fuse?

Electronic Medical Records: Medical Malpractice Shield or Magnet?

2010-11-28T06:12:00.002-05:00

Several posts on this blog have been devoted to tort reform. More than any other subject, this topic generates more heat than light. Indeed, I describe these debates and commnets on this blog and elsewhere as duels, not discussions. Many folks on various sides of this issue earnestly believe that they have the better argument. Other viewpoints are not purely held and are clearly contaminated by self-interest. I have written repeatedly that I believe that the current system is unfair and does not serve the public well. The public understands the issues and the controversies. In general, I don’t think most Americans believe that we have too few lawyers or lawsuits in this country.

It is astonishing that people can defend a medical liability system that

          Misses the vast majority of patients injured by medical negligence

          Ensnares many more innocent physicians than negligent ones.

Shouldn’t these two inarguable facts be sufficient to demand at least an examination of the current system? If a diagnostic test only detected a medical condition in 5% of cases, and caused harm in a sizable percentage of healthy individuals, would we defend it, or try to improve it?

When new medical development occurs, it has legal ramifications for physicians, patients and the plaintiff’s bar. Physicians are held to a certain standard of care – as we should be – which is evolving. It can be murky to determine when a new standard becomes established in a dynamic situation, but this is a critical legal issue. For example, a new treatment may be introduced, and even approved by the Food and Drug Administration (FDA) , against a specific disease. Does FDA approval signify a new medical standard?   Is common usage alone, without FDA approval, define the standard of care? How many physicians need to be prescribing a medicine for the treatment to be considered standard? 10%? 20%? Could a physician successfully argue that lack of FDA approval of a treatment indicates it should not be regarded as the standard of care? If a conservative practitioner like me delays prescribing new medicines until there is a longer track record safety and efficacy, could I be charged with deviating from the community standard? I recall my reluctance to prescribe a new irritable bowel syndrome medicine years ago, because I didn’t feel there was sufficient clinical experience for this new drug that was treating a benign, albeit troubling, disease. Sometime afterwards, the drug was pulled from the market after some patients died. I suggest that prescribing new treatments or diagnostic tests too soon might constitute a deviation from a judicious standard of medical care.

As Whistleblower readers know, our office instituted electronic medical records (EMR) this past September. It has been a spirited contest of man vs machine, but I think that we will ultimately prevail. The battle has been more prolonged than we anticipated. We knew there would be many challenges. We didn’t expect, however, that there would be so many unforeseen obstacles, which continue to try to derail us. When your smiling EMR vendor shows up in your office and shows you an awesome demo, think WWRD, or what would Reagan do. ‘Trust, but verify.’

EMR has been advocated as an advance that will diminish physicians’ legal vulnerability by providing much better documentation and communication with colleagues. While this may be true, the nascent technology has created gaps and fissures that are portals for lawsuits to sail through. The New England Journal of Medicine has published a review highlighting the medical malpractice risks of EMR in its November 18th issue. I have disseminated this article to my partners and staff and strongly urge readers to do the same. Here are some of the essay’s highlights, including some of my own observations.

EMR usage and reliance upon various clinical support capabilities that advise on clinical decision making and practice guidelines may change the existing standard of care. In other words, failure to rely upon these increasingly available clinical support resources could be considered to be a deviation.
EMR use may become the standard of care itself, making those who cling to paper charts legally vulnerable.
Physicians are especially vulnerable during the transition phase from paper to EMR when they are caught between the two systems. Our practice has experienced numerous snags and setbacks during this time period. I have had to repeatedly return to EMR notes to correct errors that were inadvertently or mysteriously inserted. Some are easy to identify, such as when a hysterectomy is listed on a male patient’s past medical history. Other goofs may be much tougher to spot in the lengthy and formulaic computer notes. When several individuals are responsible for entering data in a patient’s record, errors are invited.
Does the EMR software permit the physician to document his treatment plan, explaining his thinking and judgment involved in the medical recommendations? Or, is the ‘plan’ limited to a list of diagnoses? The latter might not provide much assistance to your defense counsel if you have to rely upon these thin record years after the visit.
Does your practice have a plan in place when the inevitable computer crash occurs?
How has your practice documented that all medical information in the paper record has been transferred to the EMR record?
The cut & paste technique that many physicians use in EMR risks omitting important new medical information and perpetuating inaccuracies.
Computer technology now gives access to various patient data bases at the time of the visit. Are physicians obligated to search through area hospitals’ and other organizations’ patient data bases to review all records contained there? Many patients have years of lab and imaging study results in various locales that we now have access to. The legal ramifications of this are obvious.

Of course, EMR will also protect us if we use the system well and are meticulous about our usage. If we document phone calls that direct patients to the emergency room or to a specialist, then this can stifle a lawsuit. Similarly, the EMR record can document that patients were notified of test results and were given instructions on when to follow up with us. But, I fear that, at least in the short term, the legal risks for us exceed legal protections. We need to be vigilant, not only to protect our patients’ health, but also to protect ourselves.

Alas, EMR will not be the Era of Medical Liability Reform.

Big Tobacco - The Government's Favorite Scapegoat

2010-11-21T05:20:00.003-05:00

Smokers of the world unite! It’s strange for a physician to be sympathizing with the tobacco companies, purveyors of the opium of the people. Am I a stealth nicotine addict, an apologist for Big Tobacco who supplies me with my daily fix? This scurrilous allegation can be vaporized in a one-question quiz.

Identify which two of the three individuals listed below are cigarette smokers.

John Boehner, newly elected Speaker of the House , 3rd in line to the presidency

Barack Obama, Commander-in-Chief and leader of the free world

Michael Kirsch, Hemorrhoid examiner

I’ve never smoked and I detest the habit. It kills people and separates lower income Americans from money that could likely be devoted to more worthwhile endeavors. I remember caring for folks with end stage emphysema as a medical resident and thinking that this disease was worse than cancer. I haven’t changed my mind.

Yet, I have felt for years that Big Tobacco is demonized by the press and the government as Big Scapegoat, and this blame shift has always troubled me. I am well aware that the tobacco companies are guilty of many offenses. They have lied about their corporate practices, advertising strategies and manipulation of nicotine content. These companies – like any individual or business – should be held accountable with available legal remedies. If crimes were committed, then I’m sure this nation has a few idle and altruistic attorneys who can fight them in the courts.

My quarrel is blaming these companies for the decisions that individual smokers have made. Assuming that every nefarious allegation against the tobacco companies is true, and throw in a few more, it doesn’t change the fact that smokers for several decades knew (or should have known, a favorite lawyers’ phrase) that cigarettes steal life and breath. This was common knowledge even before cigarette warnings appeared on cigarette packages. I think it an abuse of the justice system and an assault on morality when an individual who is suffering a horrible consequence of a habit that he freely began, blames the manufacturer for his misery.

We all remember the billion dollar settlements that the tobacco companies paid to the states, ostensibly to be used to reduce cigarette use, but were largely devoted to general operating expenses. The phrase ‘up in smoke’ applies here.

While I personally oppose the habit, and counsel my smoking patients to cease and desist, this is a free society. Folks can choose to engage in a variety of activities that span the risk spectrum.

In my state of Ohio, it is legal to

Ride your motorcycle in the rain without a helmet
Become an alcoholic
Flush your life saving medicines down the toilet
Hunt
Ski on a Black Diamond path when you should be on the Bunny Hill
Gorge yourself on a diet of crème brulee, cheesecake and assorted deep fried delicacies

The federal government has issued new regulations that will require cigarette manufacturers to incorporate new labels that will cover half of the cigarette pack or carton. These 36 color photos will be graphic and ghastly portrayals of the ravages of nicotine addiction. The labeling will be a veritable slide show of horror, including a corpse with a toe tag, a man blowing smoke out of a tracheostomy hole in his neck and a wasted and cadaverous individual who looks too weak to lift his last cigarette.

Cigarettes must not be entirely evil, or else the government would outlaw them. Here are some pesky realities that anti-tobacco company zealots must overcome.

The product is legal
Tobacco directly and indirectly creates jobs and income in all 50 states
Smokers pay a fortune in taxes to the states and to the federal government
Many smokers enjoy the habit

Don’t misunderstand this post. I will never smoke and hope that no person I care about will pursue this habit. I encourage all inhalers to exchange their habit for a more salubrious addiction. What I do oppose is blaming tobacco companies for the woes of their customers. I also am uncomfortable with the government slowly suffocating these companies who are entitled to advertise and sell their legal wares. If, as a matter of public policy, cigarettes’ adverse health consequences outweigh their economic benefits and the rights of smokers, then have the guts to outlaw them outright, rather than incrementally bleed the companies.

If you support the government’s strategy of pursuing the demise of Big Tobacco by a thousand cuts, then who will be the next targets? Should every product that is not on an approved health and wellness list be attacked? Who decides which companies and activities should be on the list?

Beware! We may soon see similar scenes of ghoulish horror on Hershey bars, Frosted Flakes and even Twinkies. Ronald McDonald will be behind bars, wearing a different set of stripes. Sesame Street's Cookie Monster will be in shackles. When you pop a champagne cork at your next family celebration, the label won’t be a pastoral scene of a vineyard, but will be a jaundiced alcoholic vomiting blood.

I’m not scared of the government’s new cigarette horror show. I’m scared it won’t end.

Health Care ‘Reform’ Reforms Legislature

2010-11-14T05:28:00.003-05:00

Thank you, Obamacare.

The GOP, demoralized and frustrated, as they endured the Obama liberal juggernaut that trampled across the country these past 2 years, has been resuscitated. It’s more fun to be in the majority, as Nancy Pelosi can recall. Democratic hubris and rising public disapproval provided not just a strong wind, but a tornado, behind the GOP’s backs. Obviously, there’s nothing revolutionary here, as midterm elections tend to favor the minority, with rare exceptions. What is noteworthy here is the depth of disapproval with the current administration’s policies, affecting every demographic. The gains that the Republicans achieved, particularly in the House, have left Democrats numb and glum.

Whistleblower readers will not be shocked to learn that I did not vote for Obama in 2008, but I was inspired by him. I wanted to believe that he would be the transformational figure that his campaign promised and that the country desperately needed. In particular, I was moved by his speech on race relations that he gave at Constitution Center in Philadelphia in March 2008, as a candidate. He certainly has the intellect and the vigor to serve as our chief executive. Additionally, he accomplished a political feat that I thought no living human could perform. He vanquished the Clinton political machine that assumed that Hillary’s campaign was a mere formality that would precede her coronation. As the president-elect, he spoke of collaboration, reaching out and reconciliation. Then, he was inaugurated.

What happened to the idealism and the abandonment of partisanship? There was plenty of audacity, but not the type we were promised.

The public would only allow Obama to blame George Bush for so long. At some point, the president must assume ownership of the nation’s challenges. We expect, of course, that newly elected officials always state after they take office that they didn’t realize how serious and deep our problems are. This strategy is an attempt to transfer blame to their predecessors, but the public will not provide an indefinite grace period for this buck passing The gaziillons of dollars of Obama stimulus hasn’t dented unemployment, and the public is not persuaded by arguments of ‘imagine how much worse we would have been without our bail outs’. We physicians often use this specious reasoning also.

Doctor, Granny has been on the medicine for a year, and I don’t think her dementia has improved at all.

Well, she would have been much worse without it.

Even many of Obama’s stalwart supporters have turned away. Independents and women defected to the GOP. He managed to alienate both the right and left political wings of the country, no easy feat. Our economy may be mired for years, China’s currency devaluation is costing us jobs, no progress thus far on immigration reform, Iran closing in on a nuke, cap and trade policy that many Democrats oppose and a war in Afghanistan that does not seem to be following a soaring trajectory toward victory. (Watch for the definition of victory to change.)

While the economy is the proximate cause of this electoral reversal, Obamacare receives Best Supporting Actor in the Election Day performance. Obamacare is a symptom of arrogant overreaching by Democrats to give the public what the government prescribes. This political paternalism lit the Tea Party fuse and caused rising suspicion and discontent among ordinary folks and businesses that came to realize that they were being force fed medicine they didn’t want or need. The reason that most Americans oppose Obamacare is not because the administration hasn’t communicated its message well. To the contrary, the more the public understands what Obamacare will mean for them and their families, the more vigorously they oppose it. This was a colossal misfire that helped to retire Nancy Pelosi’s gavel.

Leadership is convincing folks that they should follow a new path. It is not herding them over a cliff. Both of these tactics bring folks to new destinations, but isn’t one of these 2 methods the preferred strategy?

The public does not believe that Obamacare will save money or improve medical quality. They believe – and with good reason – that this plan will break the bank, ration care, micromanage health care delivery and create a pathway toward government control. They do not want our health care system, despite its flaws, to be dismantled.

The repudiation of Obamacare is symbolic of why Obama’s shining veneer has faded so quickly. He didn’t care what the GOP or the public thought. He was determined to force his plan through to earn a legacy for accomplishing what no president since Harry Truman could accomplish. I think health care reform will earn him a place in history, but not the one that he seeks. He will join list of American presidents who served only one term. When this happens, he won’t be able to blame it on George Bush.

This election could allow the president to have a more successful end to his first term. He will likely decide to take turn toward the center and work with Republicans and independents. Can Obama leave the left behind, or will he be left behind?

As always, your comments are welcome.

Can CAT Scans Prevent Lung Cancer? Smoke and Mirrors

2010-11-07T06:17:00.004-05:00

I still marvel at the accomplishments of CAT scans and imaging studies. These technologies have revolutionized the medical profession. Imagine foretelling 50 years ago that a new technology would emerge that could perform ‘exploratory surgery’ without an incision. This prediction would be greeted with disbelief, if not scoffing. Of course, there would be similar reactions if decades ago other technological feats, such as fax machines, personal computers, emails and internet, were predicted.

CAT scans save patients’ lives, prevent surgeries, make accurate diagnoses and refine treatment plans. This is the good news. However, as expressed repeatedly on this blog, there is a darker side of the story.

Without doubt, too many CAT scans are performed.
Accumulated medical radiation has health consequences.
Resources expended on unnecessary CAT scans could be devoted to worthy health care endeavors
Radiologists suffer from litigophobia and identify every tiny abnormality, which generates patient anxiety and more medical tests chasing these trivial results. Off the record, radiologists will confide that these ‘abnormalities’ are inconsequential, but their formal dictations always suggest that these lesions may be ominous. Their dictated recommendation? Mores scans!
CAT scans can provide patients with false security, which is the premise behind total body scans that are scamming the public.
CAT scanning and other technologies have eroded physicians’ bedside physical examination skills. Does anyone think we are as skilled using a stethoscope as our predecessors were? Of course, one can argue that we don’t really need these antiquated skills anymore.

Recently, the press went ga ga over a new study that concluded that screening CAT scans on cigarette smokers could save lives. They hyped headline of The New York Times was CT Scans Cut Lung Cancer Deaths. The study concluded that annual chest CAT scans on smokers could reduce the risk of death by lung cancer by 20%. Why is my reaction so cynical to what was heralded a groundbreaking development in oncology?

First, I am always wary when study results are presented in relative terms, such as a 20% decrease in the number of deaths. Relative percentage terms always exaggerate the clinical benefits and are misunderstood by the public, as well as the press. For example, assume that a new cholesterol-lowering medication is prescribed to 500 people who are compared with a control group of untreated individuals to determine if the drug can prevent heart attacks. If 4 folks in the medication group develop a heart attack, and 5 control patients do also, then the drug company can correctly claim it lowers heart attack rates by 20%. This sounds impressive, although the true benefit that an individual realizes is trivial, since 99% of all patients suffered no cardiac event. Can’t you just see the headline Drug Cuts Heart Attack Rate by 20%?

In the chest CAT scan study, 300 people must be screened to save one life. Is this worth it? Of course, if the lucky individual is in your family or mine, then any cost would justify the outcome. However, we cannot make public policy based on anecdotes or rare favorable outcomes. For those who argue that saving lives is worth enormous expense at the expense of others, do they also support the following positions which would save lives?

Lowering the highway speed limit to 40 mph
Outlawing air travel
Prohibiting swimming
Eliminating skiing
Forbidding contact sports

Assuming the CAT scan study’s conclusions are correct, 299 smokers have to be screened to save a fellow inhaler. Twenty-five percent of the scans had ‘abnormalities’ discovered that led patients into the medical labyrinth described above. So, in the group of 300, 1 life was saved and 75 were targeted for subsequent medical assault. When you consider that there are nearly 50 million smokers in America, imagine the billions of dollars that will be spent and the hundreds of thousands of patients who will be subjected to medical care evaluating harmless lesions.

In addition, as doctors who have been around a while know, one study shouldn’t change the course of medical practice. Over the past decade or two, many other groundbreaking studies were subsequently refuted. I’m sure that physician readers can cite many examples of these medical retreats. In six months’ time, we could learn of new study that concludes that smokers who are screened with CAT scans have a higher death rate.

A better strategy that is considerably cheaper and more effective is to try to reduce the number of cigarette smokers. The CAT screening study cost $250 million. What if those funds were used instead to treat nicotine addiction? Would this have saved more lives than annual CAT scan screening? The low tech approach, at least, is more focused on low hanging fruit, rather than aiming buckshot style at every smoker. Moreover, I would imagine that if a smoker is told that his annual CAT scan is negative, that he will have less incentive to consider quitting. For him, a negative scan may reinforce his belief that he will avoid a malignant fate.

Other bloggers, including KevinMD and Gary Schwitzer didn’t drink the CAT scan Kool Aide. My advice? When the press is serving up Kool Aide, hire a food taster.

Do I think there may a reasonable role for CAT scans in smokers? I’m not holding my breath on this one.

Plagiarism and Medicine: Should We Care?

2010-10-31T06:02:00.008-04:00

Recently, I wrote a post on plagiarism in medicine. I advocate a stringent code of ethics for our profession. Once our integrity becomes squishy, then the whole tapestry starts to unravel. We physicians are charged to search for and guard the truth.

In 1910, Sir William Osler wrote:

No human being is constituted to know the truth, the whole truth, and nothing but the truth; and even the best of men must be content with fragments, with partial glimpses, never the full fruition.

Of course, we physicians don’t always succeed in enlightening the truth, but we try. Every day, every one of us faces choices that test us. Some are easy. Most of us would not falsify billing submissions. Other choices are murkier. For example, do we coax a symptom out of a patient so that the procedure or visit becomes a covered benefit? Have we informed a patient whom we are recommending a colonoscopy about the radiologic alternatives? When a patient informs us that his primary care physician has referred him to a surgeon whom we do not hold in high regard, do we speak up? Some folks believe that dispensing medication samples to patients is improper because it encourages the use of expensive medications and raises drug prices for everyone.

I am not writing this because I am a paragon of ethical behavior. I have made some wrong choices in my career. I am also not suggesting that personal integrity is of greater worth for physicians than for others. However, although every individual and business should use honest weights and measures, personal integrity is a fundamental value of the medical profession. This is why I am so troubled about ethical lapses of pre-medical students, physicians-in-training, practicing physicians and academic researchers. Medical plagiarism targets the soul of the profession

There’s new twist on plagiarism, which makes the offense even more complicated. Which of the following scenarios do you find more troubling?

A college student deliberately enhances his research paper with someone else’s work and then submits the paper as his own. He hopes that his plagiarism will not be detected.

A college student appropriates information from various websites and ‘pastes’ liberally into his research paper without attribution. He would readily disclose his research technique as he does not recognize it as ethically problematic.

In my school days, when pterodactyls flew overhead, we all knew what plagiarism was. We didn’t need introductory college lectures to define it. When we ‘borrowed’ someone else’s work without attribution, we knew it was wrong. These days, kids, and even many grown-ups, don’t even know what plagiarism is, or when they are committing it. They have diluted the definition to such an extreme, that only a verbatim extraction of whole paragraphs from the holy bible would be considered plagiarism.

Consider two points from a recent New York Times article.

40% of surveyed undergraduates admit to have plagiarized on written work
Only 29% of students believe that copying from web constitutes serious cheating

Many cheaters today do not even regard the offense as an impropriety. Somehow, they believe that the internet and other sources are public domain information reservoirs to be ‘cut & pasted’ and presented as one’s own work. A student caught cheating in my day would be punished. Today’s offenders are likely to deny that any ethical breach has occurred. Counseling these individuals is much more difficult task. We all know the first step of a 12-step program.

Medicine, along with the rest of society, has suffered some ethical erosion. If premedical students, for example, have a relaxed ethical attitude, what kind of medical students will they become? Can we expect that these students, who plagiarize in college, would undergo an ethical metamorphosis when they become grant-seeking academic researchers or practicing physicians? What kind of role models will these researchers and academic faculty be for younger physicians and investigators?

Plagiarists, idea thieves, have chosen personal gain over the truth. If the plagiarist seeks to enter the medical profession, what is our response? Do we close the gate or escort him inside?

I don’t believe that an isolated episode of plagiarism should permanently disqualify someone from becoming a physician, or remaining one. I do think, however, that this is a serious offense that merits a designation of impaired. The offender would need to admit the failing and submit to a process of reeducation and rehabilitation, similar to what is required for other afflictions. The most critical time to address any ethical lapse would be during the undergraduate years and during medical school, with the hope that early detection could change the game.

I’m interested in the readers’ views, particularly those who disagree with me. If you like this post, feel free to ‘cut & paste’ it into your own blog, under your own name, of course.

ABIM Board Recertification Exam: Threat Level Green

2010-10-24T05:55:00.009-04:00

Photo Credit

Two Thursdays ago, I took the American Board of Internal Medicine (ABIM) recertification examination in gastroenterology (GI). Whistleblower readers have already digested some of my musings on this event. The good news is that there was no penalty for incorrect answers. The bad news is that I submitted many incorrect answers. Every one of these standardized tests that we all take becomes a mind game, where the examinee (us) tries to penetrate the psyche of the test makers (them). We’ve all been there. We torture ourselves between what we think is the right answer, and what we think that the questioners think is the right answer. Sometimes, I thought that the ‘correct’ answer on the list is out of date, which confused me. Or, what I felt was the truly correct answer, wasn’t included in the answer choices. For example, I am a very conservative practitioner, who often advises observation, rather than tossing patients into the diagnostic arena. In a few of the exam’s clinical management questions, I would have chosen ‘wait and see’, but on the test I was forced to scope, scan or operate.

I didn’t invest even one nanosecond to prepare, which I think was the proper strategy. I’ll find out in a few months. This is clearly a test that one cannot study for.

Many of the questions were reasonable. Physicians’ define reasonable as an easy question that we know the answer to. Unfair questions are all the rest. Many questions do not relate to typical GI community practice, or they ask the examinee to resurrect an arcane medical fact, that was last known to us during the heady memorization days of medical school.

Years ago, I submitted sample GI questions to the ABIM, at their request, to be considered in the internal medicine board certification exam. This wasn’t an easy task, and I recall it took considerable effort to create just a few questions. Here are some of the hurdles. Is the question’s content reasonable for an internist? Should the question test medical knowledge or judgment? Is the clinical narrative realistic? Is sufficient information included to lead the examinee to the correct answer? Should I insert an irrelevant piece of data to distract the test taker, as occurs in the real world? Has the question been sanitized of ambiguity so that examinee doesn’t develop bulging neck veins and a paroxysmal surge in blood pressure?

Is an exam question reasonable if you could find the answer by consulting a reference, as we do in everyday practice? Of course, we do not need conventional text books or journals any longer, now that we have 24/7 access to the world’s most authoritative medical resource – Wikipedia. I think that internet use should be permitted during the exam to replicate actual medical practice. Do physicians have to know the right answer immediately or simply know how to find it?

I think that creating exam questions is a useful exercise for medical students and residents, and even for practicing physicians. Try it yourself. Devise a few board questions and show them to colleagues. Be prepared for some critical reactions. It’s not as easy as it looks.

However, many medical standardized exam questions are downright silly, and are of marginal clinical relevance. On every one of these tests that I’ve ever taken, there are always a slew of patient vignettes that are literally foreign to American physicians. Patients on these exams do a lot more foreign travel than my real patients do.

Here’s a sample question, which is solely the product of my imagination. I will never divulge, even under hypnosis or interrogation, any of the copyrighted materials on the GI board exam. I do not want the ABIM enforcers to snatch me in the middle of the night and escort me on a perp walk, cuffed and shackled, while reporters blind me as their flash cameras detonate.

A patient returns home from Southeast Asia and develops a series of wacky symptoms. Chartreuse colored fluids are being ejected from various bodily orifices. He has a rash in the right nostril (see Figure A) and noticed some tingling in the ring fingers of both hands. For the last week, he has been speaking in rhyme and has developed a craving for guacamole. There is stridor present, which is quite ‘inspirational’. (Click Audio) Labs are notable for the abnormal trace element levels listed below.

Which of the following diseases that you’ve never heard of is the likely diagnosis?
The most impressive aspect of the experience was the security. When I arrived, I had to show 2 forms of identification. The testing administrator didn’t simply glance at them, he studied them. I had my palm vein pattern recorded and my photograph taken. I was advised that I would be monitored by video and audio devices. I wondered if an examinee read questions softly aloud to himself, and was caught on audio, that a trap door might snap open underneath him. Poof, another physician prematurely retiring! Every time I entered the sacred exam room, I had to empty my pockets and roll up my sleeves. You could not enter or leave the room without a photo ID check and a palm vein scan. When I returned for the final session after lunch, the proctor nabbed me trying to sneak my wristwatch into the exam room, which I forgot to remove. “It was an accident,” I protested. Was my medical career over? Fortunately, this major ethical lapse did not constitute ‘irregular behavior’. I’m sure after this incident, that I never left her site.

Of course, I agreed to the Pledge of Honesty, and was given a list of admonitions afterwards that promised to send me to the gulag if I gave any test info away.

I am not here to criticize these security personnel, but to praise them. I felt a lot more secure there than I do at the airport. In fact, the Homeland Security Advisory System assigned a Low threat level in my testing center. There were no free peanuts, but there was peace of mind.

Advanced Cardiac Life Support and Tort Reform

2010-10-17T06:00:00.001-04:00

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Two days from this writing, I will go mano a mano with a computer screen. This will be my second gastroenterology (GI) board recertification. Last week I suggested that the 490 minutes of unfettered fun might not be money well spent. A reader could infer my view that the $1200 fee has more to do with securing the finances of the American Board of Internal Medicine than it does to enhance my knowledge of GI. Perhaps, I was hyperventilating about the cost. When I calculate the GI board CPM (cost per minute), I determine that the exam only costs $2.45 per minute In other words, a full minute of quality board testing time costs about the same as a slice of pizza. Clearly, the test is a bargain, and I retract any prior Whistleblower whisperings that contradict this.

Yesterday, I took another exam, this one to recertify me as a qualified Advanced Cardiac Life Support (ACLS) practitioner. An excellent paramedic instructed me and my 2 GI partners on new developments in basic life support, medication strategies to resuscitate the moribund, airway management and proper use of a defibrillator.

Since my internship and GI fellowship, I have never had to administer life support. This is fortunate for me, and for the patients, since I am unqualified to perform ACLS, despite my certification, which I am required to have..

You recall the 3 important initial steps of basic life support. These lifesaving ABCs are

Airway
Breathing
Circulation

I have my own 3 step emergency plan that I am always ready to implement. They are

Practicing physicians are simply not skilled advanced resuscitators. If an individual collapsed, many physicians nearby would hope that paramedics would arrive before the doctor would have do any doctoring. Indeed, many physicians are reluctant to identify themselves as doctors in emergency situations. I’m not suggesting that any of us would stand aside if there was a person in dire need of urgent medical care. However, if there are 20 physicians in a theater, and a frantic call is issued for a physician, some doctors might hesitate hoping that there is an ER doctor or a cardiologist who will step up.

The public wrongly believes that a medical degree includes lifelong lifesaving skills. If someone drops while she shops, she might fare better if there is a boy scout nearby, instead of an allergist, dermatologist, psychiatrist, family doctor or even a gastroenterologist.

Jewish law mandates that an individual intervenes to save someone’s life. The Talmud teaches, "...if one sees his friend drowning in a river, or if he sees a wild animal atacking him, or bandits coming to attack him, that is he is obligated to save [his friend." This concept is not part of American jurisprudence. It is legal to stand idly by when someone needs to be rescued, even if such a choice would be morally reprehensible. While there is no law requiring that we act to save someone, there are laws in all 50 states and the District of Columbia that try to encourage us to do the right thing.

We are all familiar with the Good Samaritan legal doctrine. These laws provide immunity to folks who provide good faith emergency care to people who are at risk of death. If a man suffers cardiac arrest and needs cardiopulmonary resuscitation, the Good Samaritan law protects the rescuer from being sued if the individual dies or survives with a devastating result. We do not want fear of a lawsuit to restrain an individual from stepping in to save someone’s life. It would seem difficult to argue against this concept, but nothing would surprise me in the irrational and unfair medical liability arena.

In my medical practice and yours, if an adverse event develops, despite good faith and proper medical care, there is no Good Samaritan shield to protect me. To paraphrase an oft quoted line from the New Testament, the truth may not set me free, at least not right away.

I think that the medical liability system needs to be defibrillated, wiped clean to allow society’s moral pacemaker to generate a new rhythm. I’m ready to charge the paddles. Are you?

Board Recertification in Gastroenterology: More Fun than Colonoscopy

2010-10-10T06:00:00.002-04:00

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This coming Thursday, I will have the joy and pleasure of taking the gastroenterology (GI) board recertification exam. There will be many entertaining elements to the experience, as other board certified physicians already know. Although there will be many fun delights, some will clearly be more amusing than others.

Which of the following features of the GI board examination will be most fun? While more than one answer may be correct, choose the best answer.

(1) A 490 minute all day exam is a thrill, by definition

(2) Losing a day of income

(3) Paying the American Board of Internal Medicine (ABIM) $1200

(4) Pleasing my partners who will cover my practice

(5) Having my palm vein recognition scan to verify my identity every time I reenter the room

During this exam, each giddy examinee will be provided with a computer station. I am nostalgic already for the proctor of yore announcing, ‘pencils down!’, as there will be no pencils permitted in the examination room. In fact, many items are forbidden in the sancta sanctorum, the examination chamber. For example, portable phones, wallets and watches are classified as contraband by the ABIM Security Police. While I understand that my phone could be a secret repository of important facts on the life cycle of the hookworm, a likely exam topic on a parasite that no American gastroenterologist ever sees, what’s the fear about wearing a timepiece? Are they worried that my watch might be an upgraded version of Maxwell Smart’s shoe phone, allowing me to quietly ‘phone a friend’ whom is poised to Google my urgent request?

At the present time, the ABIM is still permitting test takers to take the exam fully clothed, although this policy is under review. Security professionals are concerned that examinees might have secret wires and antennae woven into their underclothing, which could transmit stealth information on hemorrhoids and flatulence –key board topics – to the GI board certified wannabee. Perhaps, the ABIM intel pros fear that a ‘wristwatch’ might actually be a monitor where such improper information could be displayed. This would explain the wristwatch prohibition. The solution, of course, is to require that all examinees take their recertification exams naked. While this appears to violate established social mores, this is outweighed by ABIM’s desire and obligation to secure the exam. This should be acceptable to medical professionals who confront nakedness every day. After all, we are doctors. The proctor, however, who does not have a medical degree, would have to be blindfolded throughout the exam.

I now mention a specific ABIM board examination restriction in its own paragraph to set it apart. I, MDWhistleblower, solemnly affirm that the following sentence is true and is paraphrased from the ABIM web site. Examinees are not permitted to bring suitcases in the exam room. I wish I were funny enough to make stuff like this up.

Of course, we will be warned that any ‘irregular behavior’ will be reported to the authorities, which can result in severe professional sanctions. We gastroenterologists know more about irregularity than any other physician, and we should have been consulted on this issue. We would have suggested that any first offenders be subjected to a rigid sigmoidoscopy performed by a first year surgical resident. I suspect this would serve as an adequate deterrent against temptation, and would guarantee very regular behavior.

Before the examination begins, I will have to agree to a Pledge of Honesty. I’d like the ABIM to agree to a Pledge also. Do they pledge that this examination, and the 5 required home study modules that preceded it, will make me a better gastroenterologist? I have already opined on this issue.

Do any other physicians believe that board recertification is ‘irregular’. If so, I propose a rigid response to the ABIM.