Sunday, July 3, 2022

Independence Day 2022

We are not, thank the Almighty, engaged in a civil war.  But it does seem that we are waging a war on civility.  Rage, anger, violence, division, hate and fear have crept into every corner.  Politics is increasingly regarded as a zero sum game.  Compromise and accommodation are considered by many to be signs of weakness.  If I can't get everything I want, then you will get nothing.  Should this be our modus operandi?

And the country is in pain.  We are still suffering from the aftershocks of a horrendous pandemic.  Our kids lost a year of education.  Inflation is roaring ahead with no clear end in sight.  A recession with rising unemployment may be just around the corner.  Folks are scared.   A war in Europe reminds us that democracy is at risk. Political campaigns have taken on a coarse vulgarity that mirrors the erosion of etiquette and decorum at large.  The January 6th hearings, while necessary, are only further dividing a fractured nation.  And as all of this was boiling over, the Roe decision was handed down by the Supreme Court.

Tomorrow is Independence Day.  Can we pause for a few hours and collectively reflect on the birth of this nation and what it has meant to us and the world?   There were spirited disagreements among the colonies who had competing priorities and interests.  They knew that the greater good was worth the compromises that would be necessary to achieve it.  How would we fare if we faced such a challenge today?

Independence Day


”I am apt to believe that it will be celebrated, by succeeding Generations, as the great anniversary Festival. It ought to be commemorated, as the Day of Deliverance by solemn Acts of Devotion to God Almighty. It ought to be solemnized with Pomp and Parade, with Shews, Games, Sports, Guns, Bells, Bonfires and Illuminations from one End of this Continent to the other from this Time forward forever more.”

John Adams

Sunday, June 26, 2022

The Difference Between a Screening and Diagnostic Colonoscopy.

Many patients are confused by the difference between a screening and a diagnostic colonoscopy.  While the actual procedure is the same, the distinction between the two depends on why the colonoscopy is being done.  While you might think that I am wading into a sea of nonsense and absurdity, I am offering you a glimpse of the rational and reasonable world of medical insurance!  Try to follow along.

Here’s a primer.

A screening exam means that you have no symptoms or relevant laboratory or x-ray abnormalities that justify a colonoscopy.  Consider this to be a simple check-up for your colon.  You are being screened to determine if you have a hidden abnormality or lesion.  Get it? 

A diagnostic exam means that the doctor is investigating an existing or suspected abnormality. A medical condition is under consideration and a colonoscopy is advised to investigate.   For example, if you have bowel symptoms, weight loss, blood in the stool, a personal history of colon polyps or a CAT scan that shows an abnormal intestine, then your colonoscopy will be considered diagnostic, not screening.   Get it? 

Large Intestinal in diameters

Diagnostic or Screening?
It's a Question of Motive.

Why does this even matter?   Do not expect that my response will make sense to you, since it makes no sense to me, and I’ve been in the business for a few decades.

In general, most insurance companies will cover screening colonoscopies fully, but most diagnostic colonoscopies will be subject to deductibles and co-insurance.  In other words, even though a diagnostic colonoscopy is the exact same test in every way as a screening exam, the diagnostic version may cost patients more.  Make sense?  If so, please leave a comment so you can explain it to me. 

And, permit me to offer an example when the absurd transforms into the insane.  If a polyp is found on a screening colonoscopy, then the procedure will be changed from a screening to a diagnostic colonoscopy automatically!  So, such a patient who believed that his screening procedure will be fully covered, may have a $urpri$e awaiting him.  The federal government's position that even if a polyp is a discovered, this should not impact patients financially, although not all insurance carriers are on board with this.

Before you have your colonoscopy, it is important to contact your insurance company about your benefits so that you understand the coverage prior to undergoing the procedure.  Ask if your financial obligation changes if a polyp is removed or any biopsies are taken.   I always advise that you write down the name of the insurance company representative and make some notes of the conversation just in case. 

On occasion, patients will contact us after the fact and ask us to change our code from diagnostic to screening, for reasons that readers will now understand.   While we may sympathize with their plight, we are not in the business of altering medical records or otherwise gaming the system. Such behavior would risk a whistleblower turning me in.   

Sunday, June 19, 2022

Practicing Medicine in the Gray Zone

Many issues have clear and obvious solutions.  Consider some illustrative examples.  If a light bulb has burned out, then most of us would agree that popping in a new bulb should be the enlightened response.  If a flower bed is dry, then we reach for a hose.  If our car’s fuel gauge is nearing empty…   I think you get the point here.

Here's a slightly more complex scenario.  Let’s say that your car has a rattle.  The mechanic may not know the cause or the solution, at least initially, but we can all agree that there is a specific malfunction that can be remediated with a targeted intervention.  As with the dead light bulb example above, there is a specific, reparable defect present. 

Unlike in the automotive world, other disciplines operate with a loose, flexible and proprietary framework.  Consider the financial industry.  One need only read a newspaper’s business section for a week to appreciate the divergence of opinions on financial and investment matters.  Experts cannot agree on the diagnoses or the treatments of sundry economic ailments.  Over the past year or so, for instance, we have seen widely differing explanations of rising inflation and how to combat it.  Of course, political considerations regrettably affect people’s views here, so we may not know what they are really thinking.

If you solicit investment advice from 10 financial experts on where to place funds, you would likely receive a smorgasbord of advice.  Individual stocks?  An annuity?  A managed mutual fund?  Real estate? Tax free municipal bonds?  Or maybe keep as cash for now?   You would be offered an array of financial products with each firm arguing that it would best meet your portfolio’s objectives, after considering market trends, your risk tolerance, age and other factors.   And here’s the confounding part; there is no single correct answer here as there is with a rattle in your car.  Some or even all of the investment firms may be ‘right’.


Everything is not black or white. 


This is the same murky terrain that medical professionals occupy.  Patients’ symptoms are very different from an engine squeak that will disappear after oil is squirted in the right spot.  Consider routine medical symptoms including fatigue, depression, ‘brain fog’, stomach aches, headaches, sleep disturbances, dizziness, nausea or joint pains.  Skilled medical practitioners may disagree on the cause of these stubborn complaints and the preferred path forward.  And similar to the investment industry, various differing medical approaches may be ‘correct’, which can be a vexing reality for patients and their families who have a false sense that there should be a single correct medical response.  Patients who have consulted various physicians for fatigue can corroborate that they have received divergent and conflicting advice.  

If you see 10 gastroenterologists like me with stomach pain, should you expect an unanimous response?  (Hint: answer ‘no’ here.)

When you enter a gray world, don’t expect a black and white solution. 

 

Sunday, June 12, 2022

Is My Stomach Pain in my Head?

Stomach Pain and Mind-Body Relationship

This is a delicate issue and must be approached by medical professionals with care.  Of course, it is an established fact that psychic distress can be responsible for physical ailments.  Did you ever get a headache after having an argument?  Were you one of those students who experienced diarrhea before final exams?

This past week, I saw 3 new patients in my practice with abdominal distress all of whom volunteered that they felt that emotional stress and anxiety were the culprit, or at least a major contributor to their gastro issues.  Obviously, when the patient has this level of insight and expresses it to the physician, it paves the way for a fruitful conversation.

But, this is not always the case.

When I see new patients with long histories of unexplained abdominal complaints, I do not initially raise the possibility of a psychic connection.  I think this is arrogant and has the potential to communicate the wrong message to the patient, even if stress-induced gastro distress is ultimately diagnosed.  My obligation as a gastroenterologist is to consider medical explanations of patients’ symptoms.  Patients with bipolar disease, anxiety and PTSD can develop ulcers, Crohn’s disease, cancer and appendicitis, etc.,  just like everyone else.  I do my best to keep my mind open so as not to miss a lurking medical condition.

And if a doctor raises the ‘mind-body connection’ too soon, it risks rupturing the doctor-patient relationship.  Once this relationship is better established, then deeper conversations become possible.

Is my headache real or just in my head?

Is my headache real or just in my head?

Consider a patient who comes to see me for the first time with a history of anxiety and abdominal pain.  She has seen a digestive specialist who has been unable to explain her distress.  Should I suggest that her anxiety may be responsible and direct her toward treating this disorder?  Here are some of the pitfalls of that approach. 

  • She may have a medical diagnosis that was missed by the prior specialist.
  • Suggesting that anxiety is the cause, if done at the wrong time and in the wrong manner, risks communicating to the patient that the ‘pain is in her head’.  This forfeits any opportunity to help this individual.
  • Anxiety may be a contributor, but there may be other contributing medical conditions such as irritable bowel syndrome or constipation, which can be successfully addressed.
  • Invoking anxiety in a general way may miss an important path forward.  For instance, the patient may have a fear of  a specific illness, beyond general anxiety.  Discovering this takes physician effort.  Knowing, for example, that a patient is scared that she may have an esophageal tumor is extremely useful to the doctor, who can address this directly.  A simple question of, ‘are you scared that you might have something serious’, can expose a healing opportunity.

And while physicians need to tread this terrain carefully, patients have a responsibility here also.  Both sides need to be open to all reasonable diagnostic possibilities as they contemplate the complex tangled web of the mind-body relationship. 

 

Sunday, June 5, 2022

Medical Ethics -vs- Medical Behavior

When a judge hears a case, neither party is 100% correct.  Each litigant may have a meritorious claim, but one of them will be found to have the better argument. If the dispute could be easily and amicably resolved, or one party was clearly wrong, then the matter would be unlikely to have reached a courtroom.  One litigant may be found to be 'more right' than the other


Which litigant's right will prevail?

Medical ethics has a similar construct.  Rarely, is an issue clearly and easily decided.  For example, with limited financial resources, tough decisions must be made on how to ethically allocate these funds.  Those who will not receive any funds may still have an ethical right to receive them, yet other groups may have a stronger right.  If our society decides that it will not pay for dialysis in moribund individuals, it does not mean that these individuals have no right to this treatment.

These complex decisions create winners and losers.  Those who are ruled against are likely to view the process as unfair.  Conversely, those whose wishes are granted will gush about the reasonable and just decision that served their interests.  Such is life.   In these matters, we need an advisory process with many voices to assure that medical ethical recommendations are made fairly and equitably, recognizing that these imperfect human beings are operating in a world where unfairness lurks.  Medical ethicists and their colleagues struggle to do right when every choice seems wrong.

Sometimes, the ethical issue is agonizing and painful.  Should a child with an aggressive cancer be approved by the insurance company for a promising, yet experimental treatment?  Do we feel differently if the patient is our kid? On other occasions, the ethical path is clear.  Should a physician write a prescription under the spouse’s name who has met her deductible to save the patient money? 

What is your judgment on the following hypothetical ethical scenarios?
  • A family demands and receives intensive care treatment for an ailing loved one.  The medical care team has advised hospice.  Leaving aside the futility aspect of the case, the insurance company is spending thousands of dollars each day.  Is this ethical?  Should the family be told that if this care is continued, that they will be financially responsible?
  • A physician routinely gives out drug samples to his patients.  These are left in the office by pharmaceutical representatives who want their products within easy reach of physicians.  Many patients who receive these free samples have drug coverage, but receive the samples anyway. Obviously, pharmaceutical companies must raise their drug prices in order to pay for these office giveaways.  Is this fair to the rest of us?
  • A nurse on an evening shift at the hospital is told that he will be responsible for 2 additional patients since they are understaffed.  The nurse feels that this workload is excessive, but has little recourse but to submit to the request.  No additional compensation will be provided.  Is this ethical to the nurse or to his patients?  
We often know what the right choice is, and yet we often choose differently.  Why do we stray when we know what is right?

Sunday, May 29, 2022

Memorial Day 2022 - Honoring the Fallen

 After the Civil War, which had more casualties than in any other American conflict, Decoration Day was established to honor the war dead.  Over time, this sacred commemoration transitioned to Memorial Day, which became a federal holiday in 1971.  This day honors all who have fallen in the service of the nation’s armed forces. 

Although our debt to them can never be satisfied, we can at least pause and reflect on the inestimable sacrifice that they and their families have offered this nation.  We salute you all.


Gettysburg National Cemetery on the 50th Anniversary of the Battle.


As we all see at this very moment in eastern Europe, freedom is never guaranteed.  It must be protected and defended from those who fear it and aim to destroy it.  Threats may emerge both from without and within.  

It’s easy and understandable that we take our freedoms for granted – the freedom to criticize the government, the right to equal justice under law, the right to peaceably protest, the right to worship without interference and the right to author a blog without fear of arrest or censorship.

On Memorial Day tomorrow, let’s honor the memories of those who died so that we can live in freedom.