Showing posts with label Physician Quality. Show all posts
Showing posts with label Physician Quality. Show all posts

Sunday, July 20, 2014

When Should Doctors Turn Patients Away?

A few days before this writing, a 32-year-old woman came to see me for an opinion on stomach pain.  Why would I refuse to see her again?  Abdominal pain is an everyday occurrence for a gastroenterologist.  She was accompanied by her mother.  I had never met this woman previously. 

She had suffered abdominal pains for as long as she could remember.   She recalled frequent visits with the school nurse when she was a young girl.

Illu stomach.jpg

The Stomach - Usually Not the Source of 'Stomach Pain'

She has abdominal distress of varying severity every single day. Despite this medical history, she was not ill and appeared well. Why did I refuse to take on her case?   She seemed like a very appropriate patient for my practice.  I have expertise in evaluating and treating abdominal pain.  The patient was pleasant and cooperative.   I believe she would have been comfortable with me as her gastroenterologist.

I learned that the patient lived in another state and was only in Cleveland to spend the holidays with her family.  In fact, she was leaving Ohio the day after my visit with her.   I advised her that it was not in her medical interest to have a chronic condition managed by a physician hundreds of miles away. 

Sure, I have some folks in the practice who live in other parts of the country, but I don’t manage their chronic conditions.   These people return to Cleveland with some regularity, and I will do their periodic routine colonoscopies.    Conversely, if one of my patients with active Crohn’s disease is off to Arizona to escape the oppressive Cleveland winter, I insist that he consult with a gastroenterologist there.

I know we are entering the era of telemedicine.   I certainly do a lot of medicine on the phone every day, and many evenings.  But, for many medical issues, there is no substitute – nor should there be – for a face to face visit with a doctor.   Chronic abdominal pain, particularly in a new patient, can’t be solved in a visit or two.   It takes serial office visits over time to deeply grasp the patient’s symptoms and understand the patient as a person.    It needs regular physical examinations, which is a crucial piece of data for the doctor that can’t yet be acquired through cyberspace.

Managing chronic disease is a wandering journey for the patient and physician with unforeseen pitfalls and challenges.  Such a patient may awaken one morning with new symptoms or a flare in his condition and may need to see a doctor on that very day.   Even when the patient’s condition is relatively stable, there may be phone calls in between visits, or phone calls to determine the necessity of an office appointment.

So, I didn’t cure her in a half hour, but I did offer her advice.  I recommended that she select a gastroenterologist where she lived.   I forecasted the conversations  that I anticipated she and the new doctor might have over the ensuing months.   She and her mom understood why local medical care was the proper option for her. 

Maybe eventually, my iPhone will have an app that can palpate an abdomen, discern body language and gauge if a patient ‘looks sick’.   Until then, for most patients I will rely upon my eyes, my hands and my gut. 

Sunday, February 9, 2014

Does is Matter if Your Doctor is Liberal or Conservative?

In the medical world, when a physician, a scientist, a hospital, a drug company or a panel of experts issues a report, the games begin.  If one agrees with the statement or benefits from it, then the report is heralded as breakthrough brilliance.  If, however, the report suggests a new medical pathway that diminishes your relevance or reimbursement, then the report and its authors are regarded as misguided.  Yes, I am generalizing somewhat here, but you get the point.

As readers of this blog know, I am a conservative medical practitioner.  I do not mean conservative as in supporting the NRA, prayer in public schools, self-deportation of illegal aliens (or should I say ‘undocumented residents?), ‘clean coal’ and lower taxes for millionaires and billionaires.  Conservative physicians describe those who are extremely judicious with regard to medical treatment and diagnostic testing.  We don’t lurch to treat or test unless a high threshold of necessity and effectiveness is crossed.  Before ordering a medical test, two questions should be considered.

Will the results of the test under consideration potentially change the medical management of the patient?

Is the change in medical management referenced above in the patient’s best interests?


Let me illustrate why the 2nd question above is so critical.   For example, assume a surgeon orders an ultrasound on a patient with abdominal pain to determine if gallstones are present.   This test seems reasonable as the result of the test may change the medical management of the patient – the point raised in question 1.  So far, so good.  If gallstones are present, then the surgeon removes the gallbladder.  But, if this is not the correct treatment (because the pain is not caused by gallstones), then the principle in question 2 has been violated. In this example, the physician feels that the ultrasound  test was needed as it led to gallbladder removal.   He feels that the test changed the management of the patient – which it did – but it led him down the wrong path. So, the test was not reasonable and should not have been ordered in the first place.

I make this point as for years during medical training and afterwards, I have been told and have read that tests should only be done if they might change medical advice.  This is true but not the whole story.  Left out of this medical maxim is the more important point that the new medical advice must advance the patient’s medical interest.

An oncologist may recommend a CAT scan because if new cancer is found, then new treatment will be prescribed.  Does this strategy pass the two question test I have raised here?  Sometimes yes, and sometimes no.

Is there anyone out there who doesn’t believe that we are testing and treating patients excessively? 

This same two-question strategy can be applied to a medical commentary blog to assess its worth. 

Does the blog potentially change your point of view?
Is this new viewpoint enriching you?

As always, readers’ views are earnestly solicited.  

Sunday, January 12, 2014

Measuring Medical Quality: Move Over Pay-for-Performance

Obamacare has promised to provide all of us with quality medical care that is affordable and accessible.  The very name of the law is the Affordable Care Act, which I have maintained will be short on both affordability and quality care.  Most of the country agrees with me.  The postponement for a year of the  corporate mandate to provide insurance in businesses with at least 50 full time employees was a great relief to these businesses and to Democrats across the country who were shivering from fear that voters would hold them accountable in 2014 when the country witnessed the debacle.  Was this solely a policy decision independent of politics?  I won’t insult readers’ intelligence by weighing in here.

Mandate Postponed from Electoral Anxiety?

How will the Obama and insurance company vanguards of bureaucrats ensure quality?  They will measure of bunch of silly stuff that is easy to measure but counts for almost nothing.  What really counts can’t be easily counted.  But, these guys will count what is easy to count and pretend that it matters.

Let’s have readers try their hand at measuring medical quality.  Depending upon your responses, you might gain a position with the Department of Health and Human Services.

Which of the following is the best measurement of quality of an obstetrician?
           (1)    The percentage of Pap smears done on his patient population
           (2)    The percentage of mammograms done on his patient population
           (3)    Judgment of when a Caesarean section is appropriate
           (4)    Patient satisfaction score

Which of the following is the best measurement of quality of a ccardiologist?
(1)    The doctor puts heart into his work
(2)    The doctor and his staff have a good rhythm
(3)    The doctor has a good beat
(4)    The doctor knows when chest pain is serious

Which of the following is the best measurement of quality of a pediatrician?
(1)    All appropriate vaccines are administered
(2)    The physician rates very highly on surveys grading compassion and caring
(3)    The practice uses a nurse practitioner available for same day appointments
(4)    The pediatrician knows when a sick child should be hospitalized. 

How can the government and insurance companies use your responses in measuring physician quality?  Is it possible that what truly counts in medicine isn’t that easy to measure?

Sunday, January 5, 2014

Do Physician Rating Sites Make the Grade? Find a Doctor on Angie's List

I’ve never logged onto Angie’s List, but I might be on it.  Physicians are now routinely rated on various internet sites that the public can view before making appointments, or just as a parlor game.  You can look up doctors just as you would check ratings on toaster ovens, snow blowers, cars and restaurants.

Are these sites truly useful?

Can a grading site inform the public about a physician’s medical quality?

Can a visitor to the site be confident that the view expressed is true and objective?

I’m skeptical.

Easier to rate a fridge than a doc

I’ve thought deeply on the issue of medical quality since I was a medical intern in 1985.  Indeed, it was my preoccupation with this subject that led to the birth of this blog years ago.  Review the blog’s categories at the right of your screen and note how many labels include the term ‘quality’.   A recurrent theme here is how difficult it is to measure medical quality, even for medical insiders who know the blood and guts of the business.  Pay-for-Performance is an example of the government’s feeble effort to measure medical quality.  I have devoted several posts to exposing this sham and explaining its systemic flaws.

If physicians and health care experts can’t define and measure medical quality, then I am deeply skeptical that on-line rating sites can succeed where the medical profession has failed.  That this sites are filled with advertising communicates that their true mi$$ion may be unstated.

Nevertheless, these programs are here to stay and we can expect more competitors to materialize.  Let’s face it.  The public loves rating everything.  Each year, parents of high-schoolers race for the U.S. News and World Report annual college ratings, even though seasoned educators know that this is a poor resource for choosing quality higher education.   Throughout the country, there are lists of our best doctors, hospitals, athletes, musicians and chefs.   Sometimes, these lists defy logic.  How many #1 cardiologists can one city have?

Just ‘google’ the phrase ‘list of the 100 best…’, and see what pops up.

Doctor rating sites are likely to be sites where disgruntled patients express themselves.  This creates an indelible stain on a doctor’s reputation who cannot expunge the false claim.   It is well accepted that dissatisfied customers are more likely to speak out, which creates an unbalanced record of performance for doctors and various businesses.  I acknowledge that some on line criticisms may be valid, but others may false and defamatory.  How can a reader discern the truth? 

Consider the following hypothetical criticisms:

Keep away from this doctor.  He’s only in it for the money.
Perhaps, this is a patient who wouldn’t pay his bill.

I’ve never seen a doctor so insensitive to my pain.  After seeing him, I had to go to the emergency room for some relief.
Perhaps, this a patient who demanded narcotics, and the doctor declined to accommodate this request.

Warning!  This doc is in the pocket of insurance companies.  He was pushing me to try a different medication.
Perhaps, this patient was offered an inexpensive alternative that was medically equivalent.

Remember, one thing that on-line grading sites do not offer is both sides of the story.  Readers are counseled to assume there is another side, which may be where the truth lies.

New companies are emerging that promise to combat on-line attacks against physicians and others.  A component of their strategies is to encourage favorable comments to be added to the sites to provide balance and to suggest that a negative comment is an outlier.  All this sounds more like a game to me than true quality assessment.

Who’s grading the grading sites?  Will Angie take this on?

Sunday, November 17, 2013

Medical Overtreatment: Why Doctors Like to Slay Dragons

Saint George slaying the dragon. Bernat Mortorell, 15th century

I’m sending a patient downtown to see a pancreatic expert.   He’s a young man who didn’t fully appreciate the health risks of a former alcohol addiction.  He’s been sober for well over a year, but alcohol toxicity can be unforgiving and permanent.   We don’t fully understand why some alcoholics develop cirrhosis and other complications while others seem to skate by without a scratch.  While I want folks who have the strength to conquer addictions to regain lost health and opportunities, many life choices lead to irreversible consequences.   Life is often an unfair mystery.  We witness this in medicine often.  Some smokers live well into their 80s, while others become tethered to oxygen tanks or contract cancer.   Trim athletes who eat seaweed salads seasoned with probiotics keel over while obese Whopper-swallowers wallow their way into old age. 

My guy has chronic pancreatitis, a known consequence of alcohol abuse.  Most of us don’t pay much attention to our pancreas, until it’s not performing well.  His is sick and is causing him pain.  He’s got a ball of fluid hanging off the tail of the pancreas, which shouldn’t be there and is not going way.  In fact, it has enlarged some as seen on his most recent CAT scan.
There are three things that doctors love to do.

Enter any orifice possible.  Why do you think that gastroenterologists, ENT (ear, nose and throat) , urologists, proctologists, gynecologists and pulmonologists are always smiling?

Stretch any narrowed tube in body.  If a cardiologist finds a narrowed coronary artery on a cardiac catheterization, the impulse to stretch it will be overpowering convinced that this has to be a good idea even if medical studies have refuted this. 

Drain Fluid.  Doctors like to do this because it’s cool and it always sounds right to patients and their families.   We welcome telling patients afterward that we’ve successfully shrunk their fluid collection by 50%.  Patients then become 50% relieved.  It sounds right that we should attack an abnormal fluid collection and that eliminating it is the ideal objective. 

Here are the unasked questions?

Does the orifice need to be violated or do we do just because we can?

Is the narrowed artery, bile duct or artery actually a medical threat that needs to be stretched, or do we widen these narrowed structures because we can convincing ourselves and others that we have averted a medical crisis?

Is the fluid we drain actually bothering or threatening a patient or should it have been just left alone?
My patient is not getting better under my care and I want the advice of an expert.  I cautioned the patient that the mere presence of abnormal fluid doesn’t mandate its removal.  I am hopeful that he will receive a sober assessment.

Sure, we all like men  of action, medical swashbucklers wielding tools and weapons to slice into our diseases and make us well.  Would we rather watch a warrior slay a dragon or a farmer plant seeds?

Sometimes, a quiet contemplative man of inaction is the true healer.  

Sunday, October 27, 2013

Should Michael Jackson's Doctor Practice Medicine Again?

Before Michael Jackson, most folks didn’t know what propofol was.  Now, patients are asking me for it by name.  It’s an awesome drug.  It provides a beautiful sedation, is extremely safe and rapidly clears after the procedure.  Under its effects, colonoscopy has become a sublime experience. 

We administer it in a different manner than Conrad Murray did.  For those who may have just awakened from a 5 year coma, Conrad Murray was Michael Jackson’s personal physician who administered propofol to Jackson in his home to promote sleep.  Murray succeeded and received the modest salary of $150,000 per month for his medical services.

Sleep Aid?

Administering propofol in a patient’s home without necessary monitoring and training is an egregious breach of standard medical practice.  Those of us who use the drug properly were shocked to learn of this doctor’s reckless and indefensible care.   Here are a few hypothetical examples of similarly negligent care.
  • A surgeon removing your appendix in the back seat of your car.
  • A psychiatrist hanging up on a patient who is threatening suicide.
  • An internist invites recovering alcoholic patients to a wine tasting event.
Murray will be released this month after serving time for involuntary manslaughter.  At present, he does not have a valid license to practice medicine, but hopes to be reinstituted into the profession.
Should he be barred from medicine for life?   I believe that the depth of his negligence warrants expulsion from the profession.  If fact, if his conduct doesn’t result in permanent loss of a medical license, then what would? 

Is there a different outcome that would allow this man to use his medical skills and serve the greater good?  What if he were given a medical license with stringent restrictions and strict oversight?   If he were required, for example, to practice in an underserved community and was tightly supervised by a physician, would we support this outcome?  

I have my own view here, but I’d like to know yours.

Sunday, September 1, 2013

Unnecessary Colonoscopies: Confessions of a Gastroenterologist

We gastroenterologists are regularly summoned to bring light into dark places.   We are the enlightened ones who illuminate anatomical shadows.   Sure, we have ‘tunnel vision’, but we like to believe that we can think broadly and creatively as well. 

We are the scope doctors.

Am I Just a Tool?

We are commonly consulted by primary care physicians and hospitalists to perform colonoscopies, upper endoscopies (EGDs) of the esophagus and stomach and other gastrointestinal delights.  We deliver a probing element to patient care. 

We are called to serve as technicians – plumbers, if you will - although we actually have cognitive knowledge of our specialty.  Yes, we can think.  Often, we have tension over what we are asked to do and what we think we should do.

Do I think that every procedure I am asked to do is medically necessary.  Of course, not.  Before you target me for investigation and professional censure, realize that every physician in America and beyond would fall under indictment.   Indeed, a legal defense often offered by accused individuals is that they have been unfairly and selectively targeted.   For example, if a company’s human resource officer puts an employee on warning for habitual tardiness, her case may be weakened if others who commit the same offense are left alone.

So, before you throw me in the dock for pulling the procedure trigger prematurely, I will depose physicians across the land to respond to the following interrogatory. 
  • Have you ever prescribed an antibiotic that was not medically essential?
  • Have you ever admitted an individual to the hospital who could have been safely treated as an out-patient?
  • Has every CAT scan you ordered been medically essential?
  • Has every cardiac stent you have placed been in accordance with best practices?
  • Do you consistently practice evidence based medicine?
  • Has every batch of chemotherapy you prescribed been reasonably shown to improve patients’ lives?

My point is that the system is riddled with overdiagnosis and overtreatment and it won’t be easy to clean the rot out.  While physicians have responsibility here, they are not exclusively culpable.  Indeed, no player at the table has clean hands.  Whistleblower readers have endured many posts on these issues.  Those who are new to this blog, can't even imagine what they have been missing and are encouraged to invest the time necessary to memorize prior posts.

I wish that physicians who consult me would ask more often for my head and not just for my hands.   Typically, we are asked specifically to do a colonoscopy or some other procedure.  We usually acquiesce in the same manner that radiologists perform every x-ray test that they are asked to do, whether it is needed or not. If you order an ultrasound of the gallbladder, it will be done even if it makes no medical sense.  (Good doctors consult regularly with radiologists in advance so the correct radiology exam can be arranged.  Radiologists, who can also think, find these conversations to be useful and refreshing.   In my case, they have often spared my patient from the wrong test.)  Referring physicians order a colonoscopy in the same manner that they order a chest x-ray.  They expect that the test will be done on demand.   A scope, however, unlike an x-ray, has risk of harm and should not be blithely done. 

Medicine is not a math problem that has a single solution.  Just because I might not advise a colonoscopy that another physician has requested, doesn’t mean the procedure is a wrong choice.  There’s nuance and judgment in the medical world.  Of course, if a procedure would be reckless or idiotic, then we keep our scope securely holstered.

On those occasions when my opinion is being sought, I consider a few issues before greasing up the scope.

  • Is the scope essential to the patient’s care?
  • Is there a safer alternative to answer the clinical question?
  • When should the procedure occur?  (We are often asked to do routine procedures on very sick hospital patients that should be deferred until after the patient is discharge and has recovered.)
  • Has the patient provided informed consent to proceed?

Do you want my advice or don’t you?   Or, am I just a tool using tools?

Sunday, August 18, 2013

Does Your Doctor Know Advanced Cardiac Life Support (ACLS)?

Folks must think than all doctors know all things medical.  I know this is true by the questions that I have been asked over the years.  While my expertise spans hemorrhoids to heartburn, I am routinely queried on medical issues well beyond the specialty of gastroenterology.  When I can’t answer questions about a new medicine for hypertension or if an MRI of the shoulder makes sense, folks look at me quizzically as if I must not be a real doctor.

Today, more than ever, physicians are highly specialized with a very narrow medical niche.  There are ophthalmologists, for example, who only treat retinal disease.   Perhaps, there are even retinal specialists for the left eye only.   It wouldn’t surprise me. 

My partners and I perform routine gastroenterology procedures in an ambulatory surgery center.   Patient safety is our priority and our staff and us are dedicated to this mission.  All of us are required to be certified in Advanced Cardiac Life Support in the unlikely event that a medical urgency develops.  We re-certify every two years, and recently did so.


Ordinary readers will view this requirement as sensible.  Physicians who perform procedures should be conversant with advanced life support measures including defibrillation and cardiopulmonary emergencies.   At our recent re certification, an experienced paramedic spent 4 hours in our office transferring ACLS knowledge to us and pointing out all of the new doctrine that had developed in the past two years.  In other words, the stuff from two years ago that we had long forgotten was no longer operative.  At the conclusion of the session, we all passed the re-certification examination.

Does this really make sense?  Physicians understand that clinical skill depends upon case volume.  Indeed, medical research has confirmed that physicians and institutions that perform surgeries and procedures more often do so with greater skill and fewer complications.   While volume is not the only consideration when choosing a surgeon, one who does the operation regularly has a clear edge.

How often do gastroenterologists like me practice ACLS?  Never.  The only time this is on my agenda is every two years when I must re certify.   In the interim, I don’t read about it, witness it or practice yet.  This is why ACLS should be performed by professionals who are in the ACLS arena regularly.  Should a physician who hasn’t been responsible for reading electrocardiograms (EKGs) for decades, be asked to interpret complex heart rhythm disturbances on the spot and then know immediately what the treatment should be?  This is absurd and we know it. 

ACLS is not just performing chest compressions and mouth-to-mouth resuscitation, skills that should be known by everyone. (Note that the latter feature of basic life support (BLS) has been revised by the American Heart Assocation. ).

ACLS is s complex specialty requiring  deep knowledge and regular exposure if its practitioners are to remain sharp.  Gastroenterologists need not apply.   Leave it to the professionals.

Sunday, April 7, 2013

Does Medical Resident Work Hour Reform Reduce Medical Errors?

One of the points I offer in this blog and elsewhere is to be skeptical to assume that something is true because we think it should be.

We’ve been brainwashed to believe that obesity is a killer, despite research performed this year concluding that a little more weight may add years to your life.  Many argue that an assault weapons ban will save lives despite the absence of social science research that supports this.  Fewer guns should save lives, right? When skeptics like me point to Chicago which boasts extremely strict gun control legislation while being a murder theme park, we are given excuses to reject the data that contradicts gun control dogma.  Isn’t the term assault weapon itself unfairly charged and loaded?  I have supported medical education reform advocating that medical residents and interns should not be worked to exhaustion and yet be expected to administer high quality and compassionate care to ill patients.  I had believed that somnambulating medical interns were more likely to harm patients with careless care.  I believed that this was true because it seemed entirely self-evident.

Two recent studies published in the 3/25/13 issue of JAMA, the Journal of the American Medical Association, suggest that I was wrong.  

What should one do when a study contradicts a long held view? Two choices to consider.

(1) Reflect, consider the quality of the new information and modify your view.

(2) Attack the study as a Big Government, Big Oil or Big Anything conspiracy and hold your ground.

The latest information suggests that interns and residents who work fewer hours commit more errors.
Reasons include:
  • While residents work less at the hospital, they aren’t sleeping more.
  • Residents are now required to do the same amount of work in fewer hours.
  • Shorter shifts mean more ‘hand-offs’ of patients to the next crew of eager interns.
Obviously, cramming in the same amount of high-pressure work into fewer hours invites errors, particularly with relatively inexperienced physicians who may not be adequately supervised at night.  Medical handoffs are the event when interns who are leaving the hospital sign over the care of their patients to the next crew who must assume immediate responsibility for patients they may have never seen.  Hospitalized patients are complex.  The nuances of their condition cannot be seamlessly transmitted to doctors-in-training in a few sentences.  An intern may have to assume care of 10 or so new patients as he comes on shift.  Would you feel at ease if you were one of these patients?  Indeed, one of the defenses of the pre-reform system when interns were real men and worked until exhaustion was that there were fewer dangerous medical handoffs.

Now, these two studies are not determinative.  The increased error rates with shorter work shifts were volunteered by the doctors themselves, which is not scientifically rigorous.  I’m not ready to abandon my view that interns in my day were unnecessarily overworked, but it may be that the reforms that are in place left now have left us too far from a humane end zone.

Not every hypothesis needs to be tested.  Do we need a study to determine if highway driving while wearing a blindfold is dangerous?   Are we still entertaining the notion that it is better for patients and young physicians to meet when the doctor is disoriented from sleep deprivation?    Is there really a need to torture interns to buck them up for their later years in medical practice when they will likely sleep soundly through most nights? 

I’m against torture, even though I know its definition has been a matter of public debate.  Indeed, I’m pleased that my views coincide with national policy.

"We Do Not Torture"  

 "We Waterboarded U.S. Soldiers so it’s not Torture"

What if our senators and representatives had to legislate on four hours of sleep each night?  Care to predict the outcome?   Would the quality of legislation, comity and bipartisanship flourish?  One would surmise that exhausted congressmen would commit more errors, but who knows?  I say, let’s try the experiment for a year to test this hypothesis which may ultimately improve the political process.  I think there’s a reasonable prospect that congressional sleep deprivation may improve quality considering that these self-promoting, self-aggrandizing, self-serving and self-protective scoundrels have already hit bottom.  There’s only one direction they can go.  No need to sleep on this one.

Sunday, November 4, 2012

Does Doctor to Doctor Communication Protect Patients?

One of the gripes that patients have about the medical profession is that we physicians don’t communicate sufficiently about our patients. In my view, this criticism is spot on. Patients we see in the office often have several physicians participating in their care. The level of communication among us is variable. While electronic medical records (EMR) has the potential to facilitate communication between physicians’ offices and hospitals, the promise has not yet been realized. The physicians in our community, for example, all have different EMR systems which simply can’t talk to each other. We can access hospital data banks from our office, but this is cumbersome and burns up time. Ideally, there should be a universal system, an Esperanto approach where all of us utilize the same EMR language.

On the day I wrote this post, I participated in a direct conversation with the treating physician at the hospital bedside which vexed me. This scenario would seem to be ideal from the patient’s perspective. At the bedside were the attending physician, the gastroenterologist (the Whistleblower) and the anesthesiologist who were conferring about the next appropriate diagnostic step in a patient who had experienced upper gastrointestinal (UGI) bleeding.

I was asked to evaluate this patient with UGI bleeding and to arrange an expeditious endoscopy to examine the esophagus and stomach region in order to identify a bleeding source. Hours prior to seeing the patient, I scheduled the procedure that I knew would be needed, a short cut that every gastroenterologist will do in order to be efficient. As the patient had other medical conditions, I requested that the sedation be administered by an anesthesiologist, rather than by me, to provide greater safety to the patient.

I arrived and became acquainted with the medical particulars. I agreed with the diagnosis of UGI bleeding and also that an endoscopy was the next logical step in this patient’s care. These observations are not sufficient, however, to proceed with the examination. There are other criteria that must be considered.

  • Does the procedure need to be done now?
  • Do the risks justify performing the procedure?
  • Has the patient provided informed consent for the procedure?
After I arrived on the scene, the anesthesiologist approached me and advised me that the anesthesia risks were extraordinarily high. He was concerned that performing the case could have a disastrous outcome. My reaction to his frank assessment? Thank you! The decision then fell to me to decide on whether to proceed. For me, this was an easy call. The patient did not need an endoscopy at that moment to save his life, the only reason that would justify subjecting him to the prohibitive risks of the procedure. Before discussing this decision with the family, who were awaiting an endoscopy, I summoned the attending hospitalist to relate to him our revised plan. In my view, when an anesthesiologist and the gastroenterologist advise an attending doctor that it would be unsafe to proceed with a planned procedure, the response should be, ‘thank you’! But, it wasn’t. This physician wanted the test and seemed irritated that the set diagnostic plans had been set aside. He wanted a diagnosis, and we declined to proceed after concluding that the risks exceeded the benefits. I was as comfortable with this medical decision as I have been with any other decision I had made in my career. On other cases, when a consultant advises me against a planned course of action for safety reasons, I am so grateful that a patient has been spared from danger.

We got to the right answer here, but had to set aside an unforeseen obstacle to get there. Communication means listening to another point of view and being able to change your mind. As a doctor, when it’s my finger is on the trigger, I call the shots.  I this case, a doctor misfired.

Sunday, April 29, 2012

How Many Tests Do Doctors Need to Make a Diagnosis?

History matters. I didn’t realize this as a kid, but I sure do now. I endured 2 years of U.S. history in high school, as New Jersey state law required. Can you say, soporific?

Only years later, as an adult, did I realize that history is a potent intoxicant that lured me into a deep addiction. Along with my Dad and brother, we sojourned many times across the country to many of our nation’s historical treasures. Most of these were civil war sites, which we properly regarded as hallowed ground.

Through happenstance nearly 2 decades ago, I learned of an aging physician in Saginaw, Michigan, Dr. Richard Mudd. I read that he had spent nearly his entire life trying to clear the name of his grandfather, Dr. Samuel Mudd, who was convicted as a participant in the conspiracy to assassinate Abraham Lincoln. My Dad and I drove up to Dr. Mudd’s home and listened to him tell his stories in in his parlor. The memory of this wonderful afternoon is vivid and indelible. This man, just 2 generations removed from the civil war, led me straight back to Lincoln.

As a physician, I also believe that history matters deeply, but it has been devalued. The medical history, the narrative that physicians elicit from our patient, remains the cornerstone of high quality medical care. Experienced physicians know, even if we often deviate from this practice, that a thorough medical history is the most significant and relevant data that will be available to us. Too often, short circuiting occurs, such as the hypotheticals listed below.
  • A patient with chest pain is summarily referred for a cardiac stress test
  • A patient with abdominal pain is whisked off for an ultrasound of the gallbladder (GB)
  • A patient with a headache is sent for an MRI of the head
I’m not suggesting that these diagnostic tests may not be the proper responses to the listed patient complaints. But, they may be premature or unnecessary. Medical tests are often ordered mechanically in a reflexive mode rather than after reflective moments. Medical tests are not tools for obtaining a medical history. In contrast, it’s the history that determines which test, if any, is necessary to narrow the diagnostic possibilities. Patients have a hard time grasping this concept and have come to believe that lots of medical tests, particularly imaging studies, define high quality care. This is not their fault. Who taught them these lessons?

Using chest pain as an example, in many cases, a thorough history can lead to the diagnosis. While many diseases can be sly and masquerade as other conditions, experienced physicians can usually obtain solid evidence that chest pain is cardiac, pulmonary, gastrointestinal or muscular simply by listening to the patient’s story. A medical test should be ordered to answer a specific and significant question that remains after the medical history and a physical examination. (While the physical examination has real value, in general, it does not approach the worth of the medical history.) For example, we do not order an ultrasound of the gallbladder because a patient has a stomach ache. We do so because the history is suggestive of gallbladder pain, and the ultrasound will confirm the specific diagnosis under consideration. Here’s why this is so important. If an ultrasound of the GB is ordered casually on a patient with stomach pain, and gallstones are discovered, then it may be falsely assumed that an explanation for the pain has been found. This patient may be referred to a surgeon for a ‘curative’ cholecystectomy, or removal of the gall bladder. What should have happened at the initial visit was a careful medical history, which may have excluded the gallbladder as the culprit. Most gallstones found these days are innocent bystanders, and not a cause of symptoms.

Israeli researchers showed how powerful physicians’ basic clinical skills and acumen were in making a correct diagnosis, without scans and other imaging studies. It’s nice when a study confirms our gut instincts.

If a medical test is ordered, ask what specific question it is designed to answer. Is it a fishing expedition? Will it decide between 3 competing diagnoses? How will the test result change the care? If the results won’t change anything, then should the test be done?

Medical history counts in a big way, even if the pay-for-performance schemes can’t measure it. Will physicians still be taking old fashioned medical histories four score and seven years from now?

Sunday, June 26, 2011

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

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.

Sunday, June 5, 2011

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

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?

Sunday, February 20, 2011

Health Care Reform in the Crosshairs

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.

Sunday, July 4, 2010

Should Physicians Give Up and Surrender?

Photo Credit

More and more, I read about physicians who are ready to give it up. I hear similar views in the physicians lounge and in hospital hallways. These conversations are a modern phenomenon; they did not occur when I entered the profession 20 years ago.

They have germinated as a result of rising forces that have demoralized many practitioners. Some of them include:

• Loss of autonomy
• Loss of income
• Loss of stature and prestige
• Required ‘Quality’ initiatives
• Health care ‘reform’
• Infighting within the medical profession
• Medical liability system
• Insurance company hurdles to get paid
• General gerbil wheel existance

Luckily for me, I am still happy on the job. Of course, I am not immune to the above realities, and would readily accept a vaccine to protect against them, if one existed. I try to focus on the core purpose of being a physician, and work to sequester the noise and static, at least while a patient is seated before me. Since I am a member of the human species, I do not always succeed. Sometimes, stuff creeps out of a compartment at the wrong time, and I try to stuff it back in its place. It’s a struggle, but I usually prevail. So, with regard to being a practicing physician, I am not ready to give up.  I keep my 'white flag' in the closet.

There is a part of the profession, however, that I have given up with zeal and enthusiasm. For me the decision was easy, but for some colleagues it is agonizing. A few years ago, I gave up performing a procedure that is essential for many gastroenterologists. It is called ERCP, which stands for a term that is so long, that I wonder if its practitioners thought they would be ‘paid by the letter’. To save you googlers a key stroke, here’s the term in full.

Endoscopic Retrograde CholangioPancreatography!

This is a fancy endoscopic event when the gastroenterologist passes one of our flexible black serpents down your throat and snakes it around corners to reach the small intestine. Then, tiny tubes can be inserted through the scope into the liver and pancreas to accomplish tasks that previously required surgery. This invention is a towering milestone in the practice of gastroenterology.

How important is this skill in my trade? Peruse the ads at the back of any medical journal under the gastroenterology section and you will read phrases, ERCP required or ERCP preferred.

Why would I give up performing a test that distinguished me in my specialty and made me a more marketable gastroenterologist? Would we expect a professional basketball player to eliminate 3 point shots from his game? Would we expect a concert pianist to declare a moratorium on playing any piece in the key of A flat? Would we expect a congressman to vote on legislation that he hasn’t read? (Yes, you may snicker now.)

It seems odd to voluntarily surrender skills that allows one to occupy a higher orbit in his profession; yet this is exactly what I have done. I gave up ERCP because I simply wasn’t good enough at it. I never killed anyone, and my complication rate was within the expected range for this procedure. It certainly was exhilirating when I was successful, and quite demoralizing when I couldn't get the job done.  More and more, I realized that the ERCP field was advancing, but I wasn’t. My skills were acceptable, but stagnant. Why didn’t I simply incorporate the evolving technology and gadgetry into my practice?  This response is a blog post in itself, but the summary statement is that it is extremely difficult for a practicing community gastroenterologist to stay current with evolving technical procedures.

So, I gave it up, not the professsion, but an important aspect of my practice. It was liberating as I now knew that any of my patients who needed ERCP skills would be referred to someone who did it much better than I could. The quality of a physician – or any occupation – is determined by the weakest element of his practice. I hope that pruning my practice has made it sturdier.

These are vexing issues. When does someone give up an essential element of his occupation? Sometimes, the answer is obvious. We don’t want cardiac surgeons with flapping tremors to perform delicate heart surgery. We don’t want airline pilots who suffer from sudden blackouts to be at the controls. However, sometimes the deficits are more subtle, and it is not clear that the practitioner is impaired to the extent that a professional change is required. Where is the boundary line and who should set it?

Quality measurers from the government, insurance companies and professional medical societies will soon be unleashed on a mission that they can't succeed at. They will fan out across the countryside claiming they can measure the unmeasurable. Those of us who understand the guts of medical care realize that what really counts, in medicine can’t be counted. For example, these qualitycrats might have deemed my ERCP skills to be acceptable, using their check-off boxes and quality rubrics. Indeed, I was granted privileges to perform this procedure in my local hospitals every 2 years through the perfunctory recredentialing process. The reasons that impelled me to set the ERCP scope aside are real and legitimate.  But,  they can’t be weighed and measured.

I hope that the quality buzzards who will suffocate the medical profession give up before we physicians do. I can loan them my white flag.

Sunday, May 9, 2010

How Do Physicians Choose Consultants? Looking ‘Under the Radar’

Professional sports has never been a dominant personal interest, although I admit that I become more engaged if my town’s teams reach the post season. Here in Cleveland, folks assign a priority level to sports that is just a notch below breathing. I do make it a point to know enough of what is happening within the various stadiums and arenas so that I am not ostracized or placed in a stockade in the public square to serve as a deterrent. If the Cleveland Cavaliers do not emerge as national champions this year, then northeast Ohio will sink into the Sea of Melancholy

There is an aspect of professional sports that I greatly admire. This transcends the athleticism and skill of the athletes, the work ethic, coaching expertise, teamwork and the thrill of the game. This is one of the only institutions that is a pure meritocracy. The philosophy is simple and not blurred by arguments for diversity or massaging the qualifications for admission to serve another agenda. Coaches, managers and owners want the absolute best performing individuals for the job. And so do the players. I wish this ethos were contagious to the rest of us.

The practice of medicine is not a meritocracy, either in the manner that students are accepted into medical schools, or in how we physicians practice. For example, what criteria do physicians use when they select a consultant? The ideal response is self evident. A consultant should be chosen because that specialist is the best qualified and is readily available to serve the patient. Medicine, however, is not an ideal universe. Consultants are not routinely selected solely for clinical skill. In my experience, availablity trumps clinical acumen for many referring physicians who want their patients seen expeditiously.

These points apply to all physicians who consult colleagues, but primary care physicians are the primary source of specialty consultations.

Here are some reasons, beyond medical quality, why certain medical specialists are chosen.

• Reciprocity – patients are referred in both directions
• Personal relationships
• Corporate enforcement keeping consultations within the network
• Economic pressure exerted by consultants to maintain referrals.   I have seen this happen.
• Specialist willingness to do tests and procedures on request
• Habit
• Patient or family request

Even if a consultant is selected for some of the above reasons, the patient may still be ably served. For example, if a patient needs a screening colonoscopy, it does not matter that the gastroenterologist be a world class endoscopist. A simple community scoper, even one who blogs, may be sufficient.

In my experience, most patients receive high quality consultant care. However, patients are entitled to know that there may be unseen reasons why their physicians choose specific consultants. We specialists are not entirely righteous either. When we consult other physicians, we are also responding to forces that are under the radar. I personally admit to this in my practice.

When I entered private practice 10 years ago, after 10 years of a salaried position, I naively believed that conscientious care and availability would be a winning strategy to build my practice. I have learned that the dynamics between primary care and specialty physicians are more complex, and that the path to private practice success is not linear.

In sports, it's all about winning.  In medicine, it's also about how you play the game.

What’s your view?

Sunday, August 2, 2009

Emergency Room Medicine: Model for Excellence or Excess?

The concept of medical excess is very difficult for ordinary patients to grasp. The medical community has worked hard for decades teaching them that more medicine meant better medical care. The public has learned these lessons well. Physicians who sent their patients for various diagnostic tests or specialty consultations were regarded as conscientious and thorough. Patients approved of doctors who prescribed antibiotics regularly for colds and other viruses believing that something beneficial was being done for them.

We can’t expect a patient to know if a CAT scan a physician orders is medically necessary. From a patient’s perspective, a test is medically necessary if the doctor orders it. However, physicians, with professional training and experience, know whether medical testing is urgent or optional. Isn’t that our jobs?

Of course, the practice of medicine often resides in the murky gray area where there is no single correct answer. In these instances, there can be several rational medical options available. Often, different medical studies examining a clinical question reach opposite conclusions. Sometimes, the medical issue at hand hasn’t been scientifically studied so there is no authoritative medical evidence to rely on. In these examples, differing medical recommendations are to be expected.

The bulk of excessive medical care I witness is not within the nebulous medical arena described above. These unneeded medical tests and treatments are black and white, not gray. It occurs every day in every doctor’s office, including mine. The most dramatic example of it, however, is the care rendered in our emergency rooms. The volume and expense of care given there routinely is absolutely astonishing. It is wasting a fortune of money and exposing patients to the risks and anxieties of extensive testing, even for minor medical conditions. Whenever one of my patients sees me in the office to review a recent ER visit, I try to disguise my amazement, as I look through all the lab results, x-ray reports, CAT scan interpretations and EKG tracings – often performed for some innocent complaint that has already resolved on its own. While this patient may believe that this medical pile on was great care, it wasn’t.

A serious risk of this buckshot-style medicine is that any one of the ultrasounds, CAT scans or other tests will detect an irrelevant and innocent abnormality that drags the patient to a brand new avenue of medical adventure. These new ‘abnormalities’, found by accident, create anxiety, cost money and mean more medical testing. This vicious circle is no merry-go-round carnival ride.

Why do ER physicians practice this way? Are they dumb? Hardly. In general, they are extremely capable and well trained. They perform well under pressure that can rival the tension found in any operating room. They make decisions routinely that determine whether a patient survives or succumbs. They have all of the necessary tools to practice judicious and conservative medicine, but they don’t.

They claim that the ER is a different medical universe, unlike primary doctors’ offices. They argue that they can’t miss serious diagnoses like heart attacks, strokes and blood clots to the lungs, all of which can be fatal. They need to test extensively because they have only one visit with the patient to get it right. Additionally, they point out that some of their patients may not follow up afterward with their primary physicians, even though they are advised to do so. Understandably, these physicians fear lawsuits against them if a patient they saw deteriorates after discharge. This latter reality motivates them to test patients aggressively.

I reject these arguments. In fact, the same ones could be applied to patients I see every day in my office. ER physicians should practice the same style of medicine that we all were taught to do during our medical training. Take a thorough history, perform an examination and then make appropriate recommendations. As a gastroenterologist, I see patients with chest burning in my office several times a week. The medical history allows me to determine if the chest discomfort is innocent or suspicious. In most cases, these patients don’t need a stat cardiac work up. Yet, if this same patient were seen in an ER…

Physicians, being members of the human species, are not perfect. It is not our task to test for every conceivable diagnosis in one visit. If an ER physician, or any doctor, thinks his patient’s abdominal discomfort is from constipation, then treat it accordingly and arrange for proper follow-up in the office. Don’t start a scan attack just because you can’t exclude appendicitis with 100% certainty. When we shoot for perfection, we are target our own profession.

I don’t think that the ER needs a different playbook. It just needs to play differently.

Tuesday, March 3, 2009

Finding the Good Doctor!

Here are some pointers in how to choose a good physician. Remember, while these tips offer guidance, there is no guaranteed method to rely upon.

  • Ask friends and coworkers who their doctors are and why they like them. Keep in mind that they may like their doctors for the wrong reasons. If a neighbor recommends his doctor, because “he prescribes antibiotics over the phone whenever I want them”, then you may have learned something important – choose another physician. Conversely, a person may be dissatisfied with a doctor who truly performed well. For example, a patient may complain because his doctor wouldn’t give him a refill on addictive sleeping pills. While I encourage canvassing opinions about local physicians, use these recommendations cautiously.
  • Ask hospital nurses for their advice. They see physicians working when doctors don’t know they’re being watched. They are an unrivaled source for obtaining a candid review of medical professionals. They know who is caring and conscientious, who spends time with patients and families, who communicates with consultants, who returns to the hospital when necessary and who puts patients first. Contact a few nurses at your local hospital and ask for 3 physician references. They will be delighted to speak with you. This is my hottest tip, yet, nearly no one follows it.
  • Generate a list of 4-6 physicians to consider. Contact their offices and find out when the next available appointment is. If it’s in 3 months, then this physician might be too busy for you.
  • Ask how much time the doctor allots for a new patient. If it’s 15 minutes, and you have chronic medical issues, then this might not be the right choice.
  • Find out the logistics of the practice. Does the doctor see patients in multiple offices some of which may be far away? If a patient needs an urgent appointment, does one of the physician’s partners or a nurse practitioner see the patient? Does the doctor treat his patients in the hospital or does he refer them to other physicians?
  • Who takes the doctor’s calls after hours? The doctor who will be taking your emergency call at night might be much more important to you than your regular physician.
  • Narrow your list to 2 or 3 doctors and interview them. Get a sense of their style and manner. Does the doctor listen? Do you feel rushed? Is the office staff courteous and attentive? Can you picture yourself as a patient in this particular practice?

These tips will take you far, but not necessarily to the goal line. You may not get it right on the first try. Nevertheless, this is likely a better strategy to select a doctor than flipping through the yellow pages or resorting to eenie, meenie, miney moe.

Remember, you are not just trying to find a good doctor. You want to find one who is right for you.

Monday, February 23, 2009

Are Prestigious Physicians the Right Prescription?

If it were easy to know how to choose a good physician, then everyone would have one. As discussed in prior postings, it’s tough just to define a good doctor, let alone find one. There is no surefire way to select a high quality physician. Methods and advice that sound like a winning strategy, just don’t reliably deliver. For example, you are ecstatic to have an appointment with a renowned doctor at a prestigious medical center, but his fame might be from rat research, not from patient care. You feel privileged to consult with a medical school’s chief of surgery, but it may be residents and other training physicians who are actually doing your operation. You feel fortunate to have an appointment for your asthmatic son with a specialist who lectures widely on lung diseases and has authored several textbooks. However, he might be a much more skilled writer and public speaker than he is a treating physician. You are reassured that your cardiologist is a wizard at placing stents in clogged coronary arteries. However, while he might be a technical magician with his medical gadgetry, he might be less skilled in determining who actually needs them. While technical skill is important, medical judgment is paramount. I’d rather have no stent, than to have one placed by the world’s leading stent placer. The irony is that a patient, who receives a stent that is not truly needed, feels that he has received excellent care and has averted a catastrophe. The doctor, the patient and his family and the hospital all feel like winners, but I’m not so sure.

So, if fame, notoriety and prestige are not the prescriptions for choosing a doctor, what should patients do? Check the next posting for some pointers.

Sunday, February 15, 2009

Quality Physicians - The Real Deal

Here’s a list of attributes that define high quality physicians. This is not a controversial posting. After each entry, you will be nodding in agreement that it is an essential element of a high quality physician’s skill set. Here’s the unsolvable challenge. After reading each listing, decide how you could accurately rate a physician on the specific item and compare him to colleagues. I’ve been a physician for 20 years, and I have no idea how to do this. Perhaps, smarter folks can figure this out, since this is where true medical quality can be found, not in mindless, meaningless and downright dumb data and statistics.

Great physicians have many of the following skills and qualities.

  • They are skilled at palpating abdomens and hearing subtle cardiac and pulmonary abnormalities with a stethoscope.
  • They know when not to prescribe an antibiotic.
  • They know when a symptom can be safely observed and not investigated immediately.
  • They know whether a CAT scan finding should be ignored or pursued.
  • They are expert communicators who sense when a patient harbors an additional concern.
  • They have an adequate and current core of medical knowledge.
  • They can skillfully manage a medical issue on the phone after hours.
  • They understand and counsel that more consultants and tests often mean less care and healing.
  • They tell the truth when a patient asks if the surgeon he has seen is the best choice.
  • They are compassionate.

    Of course, this list could be longer. The point is that what truly defines good and great doctors, can’t be calculated and entered on a spreadsheet. Don’t let the government or the insurance companies fool you on this one. Besides, are these institutions of such high quality that we should trust them to measure medical quality?

    On the next posting, some physicians who might be too good to be true.

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