Sunday, June 20, 2021

Changing Physician Behavior - A Difficult Challenge

How many actions do we take in our lives simply because this is how we and others have always done them?   In these instances, shouldn’t we at least pose the question if there might be a superior alternative?   I admire innovators who view the world through a prism that aims to shake up and disrupt the status quo.  You know who I mean; the folks who hear the music in between the notes.  

Medicine is riddled with practices that have remained in place for decades and are, therefore, hard to change. 
  • Acute appendicitis is treated with surgery.  Why aren’t antibiotics an option here as they are for other similar infections in the large intestine?
  • Diverticulitis has been treated for decades with antibiotics?  Only recently, have experts wondered if this treatment should be reexamined.
  • For a generation, children with red eardrums received antibiotics presuming that this was a bacterial infection.   Ultimately, a skeptic started asking questions, and most of these kids are now left to heal on their own.
  • During my earlier years of medical practice, we would obtain liver biopsies – an invasive procedure – on patients with unexplained abnormal liver blood tests.  We did this because this is how it was done.   Why has it become rare now?  Because folks who challenged the status quo recognized that the liver biopsy result only rarely changed our medical advice or patient outcomes. 
Of course, this phenomenon is not restricted to the medical profession.  There are many ossified policies and procedures throughout society that are simply left in place.  Has our public school educational system, for example, truly evolved responding to new research?  Seems to me that the high school experience today isn't that different from mine a few decades ago.  In general, we need disrupters who lead us to contemplate other pathways.


Sometimes, we need someone to crack through the concrete.

We physicians try to rely upon sound scientific advice when we are advising you.  But  often there are no medical studies on your specific medical issue.  Or experts may be in conflict on which course of action is preferred.  When the science is absent or in dispute, then we rely upon our judgment and experience.  This is as it should be. This is not the same as practicing by rote as we glide along a groove that has been carved by our predecessors and never challenged. 

Why for so many decades did patients and the medical profession endorse a yearly physical examination with all the trimmings?  Where's the evidence?

Maybe doing something the way it’s always been done works well.  But, if we are to make progress, then we need to take heed of the medical dissenters who are blowing the whistle from time to time.


Sunday, June 13, 2021

Where's the Civility in Everyday Life?

Here follows a true vignette from a few years ago.  After giving a patient the pleasure of a colonoscopy, I left the hospital and headed for my office.  As there was 45 minutes until my first office patient was due to arrive, I stopped at a coffee shop for my default hot beverage - café mocha.  I strongly prefer independent coffee shops and routinely will take a long drive to reach one. 

I approached the counter and discovered that my phone, always holstered in the inside pocket of my sport jacket, was AWOL.  For many folks, especially physicians, their smart phones are beyond essential.  It serves as my pager, my appointment calendar and my communication nexus.  It is a portal to the medical site that we doctors consult for difficult cases – Wikipedia!  It is my lifeline to my offices and the hospitals I serve.  Sure, my brain may still be functioning even when I am phoneless, but the phone  supplies the fuel and power to make it all happen.  Your auto mechanic may be a knowledgeable professional, but without his toolbox…

Here's How Gastroenterologists Keep Up.

I asked the teenager behind the counter if I might borrow the phone to verify that my own phone was safe and secure.  I did not identify myself as a doctor – which I never do – as this was not relevant.  She seemed slightly hesitant with respect to this innocent request, which I attributed to her youth and inexperience in life.  By her expression, one might have thought that I had asked her to empty the cash register and place all the paper money in a brown paper bag.  Clearly, this issue was above her pay grade so she consulted with the proprietor.  Request denied!  The phone was for the business only.  I was shocked.  A slow burn started to simmer within me.

I asked the customer behind me in line if I might borrow his phone.  With no hesitation, he ran out to his truck and brought me his device.  After my 10 second call, I returned his phone with my thanks.
That’s the last café mocha, or any other beverage, that I will purchase in this establishment.  I contemplated expressing my displeasure to the owner, but decided against it. 

Where’s the civility?  Where’s the kindness?  Even if he were not inclined to do the right thing for the right reason, one would think he would fake it in order to please a paying customer.  Loaning a stranger a phone isn’t an act deserving of great praise.  Refusing to do so, however, is more newsworthy.

I have always felt that small vignettes give a wide view into someone’s character, especially when the person doesn’t know he is being watched. 

I’m not suggesting that I am more civil or generous or charitable than anyone else.  Of course, there have been many times that people have seen me miss the mark.  I think and hope that my aim has improved somewhat over the years.   Or, maybe a kind person has simply set up a bigger target for me to shoot at.

Sunday, June 6, 2021

Why Won't My Doctor Give Me A Medication Refill?

One of the perennial patient gripes I confront is why on some occasions I refuse to refill a patient’s medication that I have previously prescribed.  Usually, but not always, when I offer my explanation for this roadblock, the patient understands why I advise a face-to-face meeting.

Here is a sampling of patient feedback I’ve received over the years.

Why do I need to come in?  I’ve been on the same prescription for years?

Why should I have to pay a copay when all I need is a refill?

I live 45 minutes away.

The doctor doesn’t have an appointment for 2 months and I only have 4 pills left!

I don’t drive anymore and I can’t get a ride.

This doesn’t happen with any of my other doctors.

Here’s how I see it.  Of course, I understand the sentiments expressed above from the patients’ perspective.  Certainly, when a patient I know whom I have been in regular contact with asks for a refill, I send it right through.  If, however, I feel that too much time has lapsed since I’ve had personal contact, then I will request an office visit so that I may determine that the refill still makes sense or if there are other digestive issues to address.  In general, I’ll ask refill seekers who haven’t seen me in a year to make the trek to my office, but I admit that my 1 year interval is arbitrary and that other capable physicians may have a different standard. 


Patient Getting Refill in the 14th Century

Here's a sampling of what might transpire at the yearly refill appointment.

Let’s try a lower dosage of your medicine which might be just as effective.

I’m not sure you need the medicine anymore.  Let’s hold on the refill and see how you do.

The medicine you want refilled hasn’t been working as well as it used to?  Perhaps, something else is going on.  I think we should look into it.

Since you were here last year, a new medicine is available that might give better results than your current medicine.

Since your visit last year, your brother developed colon cancer.  I’m glad that he is doing well. This new family history means that your next colonoscopy is due now, not in 5 years as we originally planned.

The yearly refill visit isn’t to hassle or inconvenience you.  And often, this will be a quick visit where I send the refills through.  But not always.  Many times, these seemingly routine yearly visits can really be time well spent.

 

 

 

 

 

  

Sunday, May 30, 2021

Memorial Day and America First

 I’ve never served in the armed forces.  Therefore, I can’t possibly grasp the depth of meaning that Memorial Day holds for families who know what service and sacrifice really mean.

My father served for 39 months during World War II, but was fortunate to have been kept from harm’s way.  He was part of a generation, perhaps the greatest generation, that was not preoccupied with self.  The trite phrase, ‘we are all in this together’, was a touchstone of that time.  No more.  Back then we crossed oceans to serve not only our nation’s interests, but also to preserve world peace.  Now, we have become much more self-oriented, both as a nation and as individuals.  America First has captured the sensibilities of tens of millions of Americans, a phrase that harkens back to Charles Lindbergh who was a speaker and supporter for the America First Committee.  Lindbergh was an American hero who was also an anti-Semite who received the Service Cross of the German Eagle by Hitler’s government.  

Charles Lindbergh - Champion of America First

I’ve thought a lot about freedom this past year. I’ve seen it championed and exploited and attacked and misunderstood.  Indeed, it has been downright weaponized.  Heretofore, it has been a unique and unifying American concept that has bound us together.  I fear now that it is often wielded to strike and divide us. Consider a few examples.

No mask for me.  I won’t let you attack my freedom.

Freedom of speech?  We found your tweet from 10 years ago.  The security guards will now escort you to your car.

You expressed a contrary view on college admission processes with the intent of engaging in civil discourse.  Our response?  You are a racist.

A free nation accepts the results of fair elections.  Consider the conspiratorial chaos we have witnessed since Election Day 2020.  Is this coming attractions?

A new interpretation of Freedom of Assembly is to storm the Capitol wreaking destruction and death.

Freedom of the press does not support tendentious and slanted coverage in print and on the airways.  I have seen too much of this and lament the lack of accountability and contrition by the journalism profession.

There is no conscription now which was a patriotic and unifying experience for young citizens.  If today's generation faced the existential challenge that my dad's generation faced, what would we do?  While I do not advocate for a return of the draft, I do wish there were a year or two of required national service.  I can think of a dozen reasons why it’s a great idea.  Why haven’t we done this?

To those of you who have served, and to your families, I honor you all.  Continue to set an example for the rest of us of what freedom truly means and why we must so zealously protect it.




Sunday, May 23, 2021

Job Interviewing Techniques in Medicine and Beyond


It would seem self-evident that an applicant for a job should be scrupulously honest.  First, it is the right thing to do.  Secondly, in our digital era, one’s academic record can be accessed back to kindergarten.  Yet, many applicants will embellish their credentials or claim a skill level that may exceed reality.  Thirty years ago, I was applying for my first job in New Jersey after completing my 2 year gastroenterology (GI) fellowship.  I was not competent to perform ERCP, a complex scope examination that GI practices desperately still want to add to their practices' skill sets.  Yet, I was advised by a practicing GI physician to simply claim that I could do the procedure.  Otherwise, he said, they would simply pass me by.  I queried the practitioner on my proposed course of action after being hired if I were summoned to perform an ERCP.  Decades later, I do not recall his response.   I can imagine what my new employer’s response might have been upon discovering that I had misrepresented my skills.. 



Should Applicants or Employers Take a Polygraph?


How honest should an interviewer be with a job applicant?   On the day that I wrote this, I read of a technique where an interviewer who is meeting a job applicant at a restaurant, secretly arranges for the applicant’s meal to be messed up in some way.  The justification is to see how the applicant reacts in real time to an unforeseen and unfavorable event.   It reminds me of my initial interview at NYU School of Medicine, when the interviewer, among other slippery questions, asked me “what is the death rate?”   The correct answer, which I luckily knew, is 100%.  Perhaps, this demonstration of my nimble intellect explains why they accepted me. 

I do not support subterfuge in a job interview to gauge applicants’ behaviors.   It’s certainly fair game to present hypotheticals, but outright trickery should be out of bounds.  And, if an interviewer is overtly dishonest, can this person be trusted after the hire?  If we sanction employer legerdemain, then should we not permit the applicant to play tricks on the interviewer to gauge his or her behavior and the company’s culture? 

I’ve always played it straight.  It’s all I know.  As for the position in New Jersey referenced above,  I didn't get the job.  And, so my life in Cleveland began.

Sunday, May 16, 2021

Is Your Physician a 'Spin Doctor"?

Recently, I read about a judge’s decision on a legal dispute.  The facts aren’t important here.  As I read my newspaper’s summary of the decision, it was clear to me that one side won and the other side lost.  Yet, both sides claimed victory.  This is commonplace in the public square where a clear loser boasts of a victory that even a casual observer recognizes to be magical thinking.  In the case above, the loser who claimed victory wasn’t a corporate PR spinner, but was the county prosecutor.

Folks seem to have such a difficult time admitting error, poor judgment or failure. 

Here’s a hypothetical.  A man sues a company alleging wrongful termination.  In addition to demanding that he be re-hired, he has asked for an apology, a public clearing of his name in boldface on the weekly company newsletter, back pay with benefits, and $5,000 to cover medical and psychological expenses incurred as a direct result of his firing.

The judge awards the man all of his demands, but reduced the $5.000 demand to $3,500 as he felt that the larger amount was excessive.

Is there any doubt here who won this case?  Yet, here’s what we might expect the company’s PR magpie to crow in a press release.

All of us at Termination Enterprises are delighted with the judge’s decision to reject a disgruntled former employee’s demand for excessive payment.  In the spirit of reconciliation, we have decided to rehire the worker in accordance with the values of our company.

Magpie

Spin is everywhere.  If a politician is queried about sagging poll numbers, here is what you won’t hear.

My poll numbers are down because my policies stink.

You are more likely to hear bromides such as the following:
  • I don’t pay attention to the polls.  Polls go up and down every day.
  • Considering how we are being outspent, it’s amazing how well we’re doing.
  • We’re exactly where we expected to be.
  • Our campaign doesn’t want to peak too early.
  • The only poll that matters is Election Day.
How does my profession handle the truth?  Now, I don’t regard myself and my medical colleagues to be liars, but we have been known to massage a phrase from time to time, as I have written in a prior post.   Similar to the hypothetical company referenced at the top of this post, physicians sometimes claim victory with irrational enthusiasm.

Claim: We are very pleased that the tumor has decreased in size. 
Truth:  This result will not change your life expectancy.

Claim: I recommend fiber supplements for your irritable bowel syndrome.
Truth:  Every doctor does this despite no proof of benefit.

Claim: I agree with you that an antibiotic makes sense here..
Truth: Antibiotics do nothing for colds except risk complications and cost money.

Claim: I’m sorry I’m late.  Something came up at the hospital.
Truth: I overslept.

Just because something is not true does not make it an outright lie.  Nevertheless, when your doctor makes a recommendation to you, ask about the medical evidence that supports the advice.  If the evidence is beyond a reasonable doubt, then you may decide the case accordingly.  If the evidence falls short, then you may decline the advice and claim victory.

Sunday, May 9, 2021

Taking a Moment to Say Thanks

 

If we are lucky, then we have someone in our lives who loves us no matter what, who makes us feel a little smarter than we are, who sees a resemblance between us and some swashbuckling actor who looks nothing like us, who laughs at our jokes, who delights when we call or visit, who takes great pride in our accomplishments, who overlooks our flaws and who reassures us that the obstacle that has unexpectedly confronted us can be overcome. 



Thanks, Mom!

(And to moms everywhere.)


Happy Mother's Day!



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