Sunday, August 1, 2021

CDC Reverses Indoor Mask Policy - Are We Getting the Whole Truth?

Depending upon your politics, the Center for Disease Control and Prevention (CDC) has either shamelessly reversed course or simply issued a new guideline in response to new medical evidence. Indeed, many are hostile to the agency’s recent 'new & improved' recommendation that those who have been vaccinated against COVID-19 mask up when indoors in regions where the Delta variant is highly prevalent. The dissenters point out that this directly contradicts very recent CDC and public health expert advice that clearly stated that those vaccinated could be safely liberated from their face masks.  In fact, this demasking was offered as a direct incentive to those who remained hesitant to roll up their sleeves.  The CDC and its supporters maintain that their new policy on masking the vaccinated is based on a sound review of recent data, which they tarried in releasing. 

I am a rationalist who practices gastroenterology guided by medical evidence.  Despite some missteps, I have largely supported the CDC and have heeded and disseminated their advice.  But, in this instance, I don’t think they are being straight with us.



Making a comeback!

Here are some facts. The vaccines are performing very well including protecting against the Delta variant.  The overwhelming majority of COVID-19 cases, hospitalizations and deaths are occurring in those who have not been vaccinated.  It is within this population – not among the vaccinated – where the pandemic now lives.

We also know that ‘breakthrough infections’ in vaccinated individual is extremely rare, a fact that the CDC admits.  For example, breakthrough rate is estimated to be 0.098% for symptomatic infections, in other words, very close to zero.  The CDC now argues for vaccinated folks to mask up to prevent them from transmitting the virus if they become infected, although this seems like overkill considering that the breakthrough rate is about zero.  What is the quality of evidence that suggests that the few infected vaccinated individuals can transmit the infection?  What does make sense, of course, is for unvaccinated folks to don a mask since this is how the disease is being perpetuated. 

Since there is no way to enforce the more rational strategy that unvaccinated people wear a mask indoors, the CDC is asking all of us to do so in order to capture the unvaccinated within the new policy.  Otherwise, how could a retail store, for example, know that some unmasked customers were vaccinated or not?  They couldn’t.  In my view, the CDC has unnecessarily rolled the vaccinated into the new mask group to eliminate this conundrum.  If all of us are masked, then we know that the unvaccinated are also masked.  If I am correct about the CDC’s motives and strategy, shouldn’t they have told us the truth rather than exaggerate and mislead us about how dangerous vaccinated individuals might be?  It’s the CDC’s explanation that needs to be unmasked.

And masks won’t end the pandemic anyway.  This is a half measure at best.  The right approach is to increase vaccination rates and I anticipate that the government, employers, schools and others will be leaning hard in this direction in the near term. 

Sunday, July 25, 2021

Should COVID-19 Vaccines be Mandatory?

 I think we’re headed in that direction.  There are various angles and positions to consider.  But, as in so many disputes, it’s not a matter of right and wrong but an issue of which side has the better argument. When a judge rules for one party in a dispute, this does not mean that the other side had no legitimate position.  If means that the judge concluded that an analysis of the facts and the law tilted toward one side.

We must acknowledge that an individual has a right not to be forced to accept a vaccine or any medical treatment.  The doctrines of informed consent and patient autonomy are bedrock pillars in American medical care.  If, for example, I recommend a colonoscopy to a patient with symptoms highly suggestive of a serious colon condition, the patient is free to decline my advice.  While I may feel strongly that this decision – referred to as informed refusal – is unwise, no medical practitioner or ethicist would argue that I should be able to compel compliance with my advice. 



Patient autonomy and the right to refuse medical treatment becomes murky when there is a public health dimension to the issue.  The patient cited above who declines a colonoscopy may be incurring personal risk but his decision does not threaten the community.  In contrast, an individual who refuses a vaccine threatens others and is a direct obstacle to public health efforts to protect the citizenry.  So, while the individual has rights so does the community.  The issue then become which side’s rights should prevail?

In America, there has been great reluctance to mandate COVID-19 vaccinations for various reasons.  The vaccines have still not been granted formal approval from the Food and Drug Administration. Initially, there was not sufficient vaccine supply to meet demand.  Employers were concerned over legal exposure to mandate the vaccine for employers.   And, just as we saw with face masks, the vaccines became highly politicized. 

The hope was that Americans would achieve the task voluntarily.  But we haven’t.  Even now, less than half of all Americans have been fully vaccinated.  Does this fact astonish you?

The calculus regarding mandating vaccines is changing.  The Equal Employment Opportunity Commission (EEOC) has concluded that employers may mandate vaccines providing that there are exceptions for medical disability and religious reasons.   This gives cover to businesses and organizations who are ready to take the next step. Increasingly Republican political leaders and conservative commentators – after months of silence or actual support for anti-vaxxers – are now advocating for the vaccine.  And most importantly, we are now seeing a sharp spike across the country with rising cases that are filling up hospital and intensive care unit beds in nearly all 50 states.  And it’s going to get worse.  And we know why it’s happening.  The vast majority of these cases are occurring in unvaccinated individuals.  All of this was preventable.

So, which side do you think has the better argument?

 

Sunday, July 18, 2021

A New Kind of Stress Test

Readers of this blog, and those with whom I have shared my philosophy of medical practice, know that I am a conservative practitioner.   I rail against overdiagnosis and overtreatment.  Less medicine results in more healing and protection.  In an example, I have explained previously why I advise patients not to undergo total body scans, despite the lure that they offer a cancerophobic public. 

I’ve never undergone a CXR in my life.   I’ve never entered medicine’s Tunnel of Adventure, also known as a CAT scan.  My fear would be that the scan would show various internal imperfections of no meaning that would generate anxiety, expense and a cascade of medical tests to follow up on the ‘abnormalities’.  Any real patient reading this who has been around the block once or twice, will validate my scanophobia.   Not a week goes by in my practice, that I am not facing a worried patient who was found to have some trivial finding on a scan that nearly always is entirely innocent.  Often, the scan was not necessary in the first place.

Not surprisingly, I have never had a stress test.  I should say that I have never had a cardiac stress test.  As a living breathing human being, I face stress tests every day.  Not sure what I mean here?  Consider the last time you called an airline’s customer service representative.   If you have done so and have not suffered angina during process, then you are likely to have no significant coronary artery disease.  You have passed the stress test.

As I write this, I am seated in the Detroit airport, waiting for my connecting flight to take me to Boston.   Every aspect of air travel is a stress test; from the moment that I book tickets on line to the time that I sink into the plush and spacious seat that can comfortably accommodate a skinny gerbil. 

I have just discovered that my flight is delayed 50 minutes, or so they say.  I fear that the dreaded Delay Creep (DC) might set in here.  Here’s how this works.  They announce a 50 minute delay.  Forty minutes later, the delay is extended 35 minutes.  A half hour later, an announcement advises the smiling passengers that an update will be forthcoming at a time of their choosing.   DC in its purest form ends hours later with the flight’s cancellation.   My mom had this exact experience  on her way to visit me in Cleveland.  Did the $14.00 food voucher make her whole?


Air Travel is Stressful
The Wright Brothers - 1903

Patients have complained long before I earned a medical degree about unreasonable waits to see their doctor.  We do our best to run an on time shop, but there are times that we miss the mark.  Sometimes, it is our fault.  We come to the office late.  We squeeze patients into the schedule rather than add them on at the end of the day or tomorrow.  We don’t build in ‘firebreaks’ into the schedule knowing that every day brings delays that are not anticipated.  For example, if at the conclusion of a patient’s office visit, the patient’s tells me that her husband has cancer, should my response be, “Our time is up today, but please give him my best wishes”?

Sometimes, patients cause delays by arriving late or not doing the paperwork that we request to be done in advance.   Additionally, some of our elderly need extra time at home to get ready and need transportation to get to our office.  For the most obvious reasons, sometimes they just don’t make it on time despite their intentions to do so.  When this happens, which of the following responses do readers advise?

“Glad you made it!  Take a few deep breaths in the waiting room and we’ll be with you as soon as we can.”

“Back of the line, Granny!”

Some emergency rooms are using Twitter and other means to update their patients on the wait time.

Can physicians improve in their on-time performance?  We have seen in recent years that there is a potent force that can influences physician behavior.  Reimbursement.  If payment is linked to how long you have to wait for us, then our schedules will run like a Swiss chronometer.

Everyone’s time is valuable.   The next time you’re in the waiting room, consider any extra waiting time to be a gift.  This is your opportunity to collect your thoughts, read another chapter or two of a gripping novel, write a thank you note to someone in longhand or consider buying a gift for a special person for no reason.   Don’t make it a stress test.

Sunday, July 11, 2021

Why I Cancelled a Colonoscopy

This morning, as I wrote this some time ago, a patient came to my office for a colonoscopy.  I sent her packing.  Here’s what happened.

In our Ambulatory Surgery Center (ASC), in my prior private practice, we introduce light into dark spaces every day.  This is where we perform colonoscopies and upper endoscopies.  We have a program in place where referring physicians can have their patients contact our ASC and schedule a procedure without seeing us first in the office for a consultation.  Obviously, we have to have a vigorous screening process in place  We do not want to meet a person for the first time for a colonoscopy and discover that he has complicated medical issues and is dragging an oxygen tank behind him.

Our screening system works extremely well, but it is not perfect.  On occasion, it misfires  The patient arrived at our office at 7:00 a.m. after a 45 minute drive.   She had ingested the required purge,  often the highlight of the experience.  I hadn’t seen her for years.  She was suffering from severe pulmonary disease, smoked cigarettes and used supplemental oxygen at night.  Clearly, this was not an appropriate patient for our out-patient facility.  Our nurse anesthetist and I conferred and agreed that we should not proceed because of safety concerns.

I explained to the patient, her husband and her daughter our reasons for cancelling the case.  It was a long conversation.  At first, she was disappointed for all of the obvious reasons.  She had endured a day of a clear liquid diet followed by ingesting our prescribed liquid dynamite to cleanse her colon.  She and her family had taken an early and long drive.  After she had ventilated her transient exasperation, she quickly came to understand that our sole objective was to protect her.

Why am I sharing this vignette?  Every doctor could relate similar anecdotes.  I share this typical scene from our practice, which I offer as an example of sound medical judgement.  We did the right thing and protected a patient’s health.  We considered the risks and benefits of the procedure and sedation, and chose safety.  Doctors (or patient) shouldn’t try to get away with stuff.

When the Medical Quality Police evaluate me, as is being done by our hospitals, insurance companies and the government, how will they measure our performance this morning?  They won’t and they can’t. So much of the good work that a doctor, a policeman or a teacher does, can’t be measured.  I work with great nurses every day, but there is no formula that exists that can measure what they do.  What has happened is that these professions are now assessed by box-checking bureaucrats who are charged with measuring all kinds of silly stuff that doesn’t matter.   Do I get any credit, for example, when I advise a patient that he doesn’t need a colonoscopy or a CAT scan?  Ask your doctor about this issue during your next appointment, but bring some Maalox with you because your physician’s esophagus will start sizzling.

Medical Quality Measuring Device

Look up Pay for Performance on this blog and elsewhere to find out more about this scam.
Incidentally, there’s happy ending to the woman whose case we cancelled.  Since she was prepped for a colonoscopy, we sent her to the hospital where I did the case safely later in the day. 

How do you define a high quality physician?  If you are able to define it, how would you measure it?

Sunday, July 4, 2021

Independence Day 2021

 We have nearly emerged from the pandemic's abyss, but we have not yet reached the other side.

The wily virus tries daily to morph into other variants to slide past our defenses.

The politics of division and personal destruction have not yet been set aside.

The surreal scenes of January 6th are seared onto our memories.  

The recent horrors in Surfside, Florida leave us all gasping.

We are still a divided nation.

I want to believe that there is an ache and a hunger to come closer together.

July 4th is upon us.  Might this be an occasion when we might begin the process?


”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 27, 2021

Transitioning to a New Doctor - Challenge or Opportunity?

 Over the past few weeks, several patients I saw faced a common challenge.  This is a situation I have confronted in the past, but what was unique recently is that multiple patients in a short period of time were in the same situation.

This was not a medical issue.  In fact, many of the individuals were feeling perfectly well.  This was not a financial issue, such as the patients were in the dreaded ‘doughnut’ or their particular medications were not covered by their insurance companies.  This was not a second opinion request from patients who suspected that their gastroenterologist (GI) of record may have missed something.

Here’s what happened.  A gastroenterology practice that had been in the community for decades closed down.  Suddenly, tens of thousands of patients with an array of digestive maladies were let loose to find a new digestive nest to occupy.  I’m sure that every GI within 20 miles of my office has been affected.  Many of them have landed on my schedule and I expect this will continue over the weeks and months to come.

Finding a new nest

This is a challenge both for the patients and the new GI specialists.  The patients I have seen all loved their prior GI some of whom were treated by their practice for decades.   These were not dissatisfied patients who were seeking advice elsewhere.  They were happy and satisfied where they were.  And now they were forced to sit across from a new doctor – a perfect stranger – who faced the task of trying to lay out a pathway to a new relationship.

This isn’t easy and both parties must contribute to the success of the effort. The physician must be mindful of how disruptive and anxious this process is for the patients and their families.  Patients must recognize that the physician cannot be expected to quickly replicate a rapport that may have taken years to establish.  Additionally, physicians, as individual human beings, cannot be expected to have similar personality trains and practice philosophy.  Patients and physicians need to exhibit some understanding and flexibility as they both enter the new nest.

Change is always challenging and particularly so when it is unexpected.  There may also be some unexpected upside.  The new physician, who brings no bias to the case, may offer some fresh insights on some old and stubborn medical issues. 

The doctor-patient relationship is the foundational unit of medical care.  Like all relationships, it needs to be cultivated and nourished from time to time.  Both sides need to give the other some space to maneuver and shift a position when necessary in order to make progress together.  So, if life conspires to put you in front of a new doctor, consider it an opportunity rather than a challenge. 

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.


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