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Whistleblower Holiday Cheer 2011!

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

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. M

Colonic Hydrotherapy and Colon Cleansing; Time to Bend Over?

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

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

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. Teach

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

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

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

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

Joe Paterno Fired: Proper Punishment or Political Correctness?

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 medi

Medical Malpractice Reform Losing Physician Support

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 tha

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

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.

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

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

Ten Questions to Ask Your Doctor?

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

Health and Wellness Programs: Medicine or Marketing?

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

Secret Shoppers in Doctors' Offices: Placebo Medicine for Physicians

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 w

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

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 beh

Minute Clinics Threaten Doctors: Who Wins?

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

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Overtreatment Alert! Antibiotics Fuel Medical Overutilization

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 o

Should Patients Join the Pay-for-Performance Circus?

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?

Tort Reform for Medical Malpractice System Another Study Needed?

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 compensate

Greedy Insurance Company Backs Down: The Little Guy Wins!

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

Is Cost-Effective Medicine on Life Support?

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 tha

Will Wireless Capusle Endoscopy Replace Colonoscopy?

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

Pharmacy Benefit Managers vs Physicians: Let the Games Begin!

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 rel

An iPhone App for Medical Checklists?

 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

Health Care Reform and Obamacare: Lessons from the Last Century

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 t