Sunday, April 18, 2021

Is My New Doctor Qualified?

When one applies for a job or a position, it is expected that the interviewer will assess if the applicant has the necessary skill set and experience. Doesn’t this make sense?  Consider these examples.

A clarinetist applies for a position in a symphony orchestra.  While many criteria will be assessed, he will surely need to audition to demonstrate his musicianship.  Would he ever be hired without playing a note?

A college student wants to join the swim team.  The applicant can expect to show off her speed and technique as she cuts across the pool.  Would any coach accept a new swim team member without watching her swim?

A journalist for a town paper applies for a job at a large metropolitan newspaper.  The interviewing editor will surely review the applicant’s prior work product to gauge his competence and suitability for the new position.  Would an editor bring on a new reporter without ever reviewing his writings?

A college graduates applies to the State Department as a translator.  Would such a hire ever occur without determining if the applicant has the requisite language skills?

Want the job?  
You'll have to show you know how to use this.

So how does the medical profession hire on new medical professionals?  I should certainly know this since I’ve been in the trade for 3 decades and have had enough job interviews to know how the process works.  I’ll ask readers to peruse the following 5 sample gastroenterologist applicant questions. Can you spot the ones I was asked during my prior job interviews?   

Which antibiotics do you typically prescribe for diverticulitis?

What is your age cutoff for offering screening colonoscopies?

What is your complication rate for colonoscopy and other medical procedures?

When is the right time to prescribe steroids in Crohn’s disease?

Does a patient who is having a gallstone attack and a fever need to be hospitalized?

Which ones were I asked?  None of the above.  For reasons I cannot easily explain, I have never been asked any medical question during any prior job interview.  Similarly, when I have interviewed job applicants myself, I have never queried them on any medical issue.  The profession, at least in my experience, assumes that physician applicants have all of the necessary medical skills and knowledge, even though this does not seem to make much sense.  Shouldn’t the applicant at the very least be asked to review case histories of assorted patients and to comment?  It seems it’s a lot tougher to get a job as a clarinetist than as a gastroenterologist.  Does this put your mind at ease?





Sunday, April 11, 2021

Overutilization of Colonoscopy - An Unusual Suspect

A week or so before writing this post, a patient came to my office requesting a colonoscopy.  Nothing newsworthy so far.  An individual wanted a service that our practice routinely provides.  Yet, I was reluctant to accede to her seemingly reasonable request.   She wanted a screening examination of her colon in search of a benefit that humans have pursued for as long as humans have existed – peace of mind. 

I have found that ordinary folks are often confused by the meaning of the term screening.  Screening exams can be performed on various organs of the body.  When a physician uses the term screening, it means that the patient is not having any symptoms whatsoever.  For example, if I advise a colonoscopy on a patient who is having rectal bleeding or diarrhea, this is considered a diagnostic exam, not a screening test.   

"You're paying the bill?  I'll have the steak!"

Why does this matter?  Insurance companies often reimburse screening and diagnostic exams differently.  Often, but not always, a patient’s financial obligation is higher for a diagnostic exam, when symptoms are present.   There have been occasions when a patient had contacted us after receiving the insurance company bill for a diagnostic colonoscopy, asking if we will ‘revise’ our documentation stating that the test was a screening exam.   Even an infrequent Whistleblower reader would know our response to such a request.

The patient who wanted a screening colonoscopy felt entirely well.  Her bowel pattern was unchanged.  She had no special risk factors for developing colon cancer.  My review of her record indicated that she was due for a screening colonoscopy in 3 years, not now.  I advised her of this, but she wanted to proceed anyway.

We have freedom of commerce in this country.  I can purchase goods and services according to need, desire or even whim.   If a person wishes to buy a meal, a vehicle, an appliance or a vacation, the seller’s role is not to discourage the transaction or point out that the buyer is making a foolish or unnecessary purchase.   Isn’t an individual who wants a colonoscopy, and is properly informed of the risks and benefits of the test, and is made aware that she is not yet due, entitled to the exam?

I thought that she was.  But, I didn’t think that her insurance company should pay her bill.  I explained to her that I would schedule her for the requested exam, but that she should expect that her insurance company would hold her financially responsible for the entire bill.  

Once the patient understood that the cost would be hers, she elected to wait an additional 3 years, as I originally advised.   The lesson?  When folks have skin in the game, they make different decisions.  In my view, this concept needs to be systemically incorporated into our health care system.  

If you are out to dinner at an upscale restaurant, and an insurance company would be paying the bill, would you order differently?

Sunday, April 4, 2021

Are We Ready for the Next Pandemic?

 While most of us prefer order and routine, life can turn course unexpectedly and randomly.  Of course, we all know this.  For many of us, our occupation, our choice of mates or where we live are the result of some chance occurrence, not the product of diligent planning.   Indeed, this reality adds some excitement and wonder into our existences.  Would we really want to live according to a prescribed routine like a train schedule?   For me, I am most satisfied when my days include my daily routine pleasures seasoned with some spontaneity.  I suspect that this is true for most of us.  However, we differ in the ratio of random/routine that we prefer.   Some of us plan a trip, for example, with each day carefully planned while others prefer to simply land in their destination and explore untethered to a guidebook or a rigid schedule.

And no force can set order aside more forcefully than nature.  Here is the scene from our window earlier this week.  Does this look like a typical spring day?  Apparently, Mother Nature has her own order of things.

Is Mother Nature Out of Order?

There are certain tasks for which a specified order is the optimal option.  When an airline pilot is preparing for take off or when a surgeon is preparing for surgery, each of these professionals proceeds through a check list of requirements to verify that all safety protocols have been followed so that the risk of a misadventure is minimized.  These safety checks have been devised over time with revisions performed as necessary.  They are born from experience.  Each item on the list is to prevent a specific adverse reaction which was at higher risk of occurrence prior the check list era.  For example, prior to a medical procedure, it is now mandatory for the medical team to verify the identity of the patient.  Any idea why this ID verification came about?

We don’t want airline pilots simply to bring spontaneity to their flights letting them ‘wing it’.  “Maybe today will fly this bird right over the coast so the folks can get a great view.” 

We are still trying wrest ourselves free from the gripping tentacles of the pandemic.  And one of the lessons, which we still haven’t learned is that there is a specific order of measures and mitigation that must be followed to prevail.  As we look around the world, we see that some nations are much closer to the end zone than are others.  Europe is behind the U.S. and we should be much farther ahead than we are.   If we had followed public health directives early and consistently, opening up the economy and schools according to science, rejected distracting political interference, where might we be today?   Has this experience persuaded to use the pandemic check list next time?


Sunday, March 28, 2021

Should Doctors Pay Patients When We Are Late?

Some time ago, I flew with my youngest kid, then a high school senior, on a college visit.  He’s the last of 5 youngsters, so I’ve had my share of these visits to various centers of knowledge where young minds are molded to face uncertain and unknown futures.   While I’ve never found these visits to be substantively valuable, they were of great value to me as it was fun to be with them on these exciting excursions.

The Hallowed Halls of Higher Learning

The formats of the school presentations are superimposable.  There’s an information session, which serves as an infomercial that tries to draw students to apply.  Schools favor receiving large volumes of applicants so that their acceptance rate will be lower and they will appear to more selective than they actually are.   How cynical of me to suggest that there are forces in academia that might be pursuing a self-serving agenda!

These sessions are led by effervescent young cheerleaders who present a power point of smiling students who are having fun, doing world class research and shaking hands with world leaders.  Parents are reassured that the only criminal activity within the past 5 years in this urban campus was pick-pocketing. 

Afterwards, prospective students proceed on a tour where they are given critical data they will need when making their ultimate education decision.

“Here’s the cafeteria.”
“Here’s the chem building.”
“Here’s where we play Frisbee.”

In case any of my kids read this post, which is as likely as any of them admitting to being a Republican, I want them to know that I loved every minute of these visits with them. 

When my last kid and I flew on a college visit, we enjoyed the joy and relaxation of air travel, a subject that has crept onto this blog previously.   Was there a flight delay?  Ok, stop laughing now.   I asked my son if he felt that airlines should provide some form of compensation for delays of certain specified time intervals.  For example, if a flight is delayed 30 minutes, possible remedies might include:
  • 2 bags of honey roasted peanuts
  • Handshake with the pilot
  • Special 1-800 customer service phone number which states on the record that ‘your call is important to us…”
  • Guaranteed middle seat so you can enjoy a lively conversation with 2 happy travelers.
  • Travel voucher for $30 (one dollar per minute of delay) that may be used for any First Class non-refundable ticket that is booked within 36 hours of your plane landing at your destination.
My son did not think that the airlines would endorse the concept that travel delays were compensable.
For a generation or two, patients have lamented that their doctors keep them waiting habitually.  How many times can our staff explain to them that we were saving 7 folks’ lives simultaneously?  What is our patients’ time worth?  Aren’t they often missing work or making special arrangements to see us?  Even if they are retired and have open schedules, doesn’t their time have value?

Should physicians compensate patients when their appointments are delayed?  If so, what remedy would you suggest from a gastroenterologist?
  • Extra lube on the next colonoscopy?
  • Buy One-Get-One-Free hemorrhoid cream?
  • Waiting room magazines that were published sometime in the past decade?
Seriously, do we doctors owe you something when we keep you waiting?
Don’t be too harsh here.  We should also address how you should compensate us when you are late or don’t even show up.  I beseech you to be ‘fair and balanced’, a cable news network’s motto that all of you should know well. 

Sunday, March 21, 2021

Why I Don't Advise Patients to Quit Smoking

I don’t advise patients to quit smoking.

I don’t exhort alcoholics to stop drinking.

I don’t preach to my obese clientele to slim down.

And I don’t lecture patients to get the COVID-19 vaccine.

This may be the point were some readers are wondering, “What kind of doctor are you?”

For the record, I do not endorse or advise cigarette smoking, alcohol addiction, obesity or careless behavior during the pandemic.  I favor temperance in my own life.  I exercise.  I am attentive to my BMI. And I wear a mask and have received my COVID-19 injections with enthusiasm.

But it has never been my style, either professionally or beyond the office, to tell people what to do.  Once folks reach a certain age, which for many are the teenage years, you just can’t make them do stuff.  Every parent understands this. This does not mean that I don’t have influence over people who trust me.  I do and I use it.  However, it’s a process issue.  How best can we help individuals make sound decisions?  Are issuing edicts and threats our best weapons?  Are lecturing and hectoring our most effective tools?  Should we devise a reward incentive to motivate folks?  Cash for pounds lost? 


Who is stronger, the sun or the wind?

I am more comfortable laying out the facts – the cold hard truth without judgement – and allowing folks to make their own decisions.  Sometimes, multiple conversations are necessary.  When any of us ultimately makes our own decisions freely, they are more likely to be durable.  It just works better if folks are vested with their own choices.  Achieving ‘buy-in’ is critical to maximize the chance of success.  Don’t you feel better when you have made a decision yourself rather than have been directed to act?   I certainly do.

Do you really think that my smoking patients are not aware that this habit poses serious health risks? Do they not know that quitting would likely deliver major medical benefits?  Will a finger-wagging doctor accomplish anything?  Can you imagine a smoker who is advised to quit responding, "Really, doctor?  I had no idea that cigarettes are bad for you!"

Recall Aesop’s fable when the sun and the wind competed as to which of them could separate a man from his cloak.  The wind unleashed all of its strength and fury, but the traveler managed to hold on to his covering.  Then the sun poured down heat to the point that the man removed his cloak and sought shade to get some relief. 

Gentleness and persuasion win against force and coercion. 


Sunday, March 14, 2021

Tolerating Uncertainty in Medicine

Uncertainty makes everyone anxious, although each of us has a unique threshold for uncertainty tolerance.  In other words, different folks may react quite differently if they are confronted with the same set of facts. 

Consider this hypothetical.  Two patients who are of similar age and enjoy excellent health undergo a CAT scan for a stomach ache.  By the time they follow-up with their physicians to review the results, their symptoms have resolved and they feel perfectly well.  A small spot is seen in the liver which the radiologist suspects is an innocent cyst, but he cannot state this definitively.  Each of the patient’s physicians explain that minor accidental findings like this are common and are very unlikely to pose any health threat.

Patient #1: “Ok, doc. I feel great and if you’re not worried, neither am I.”

Patient #2:  “Are you sure it couldn’t be serious, like a cancer?  Should I have it cut out just to be safe?”

First of all, let me give readers an inside tip on how to pose inquiries to your doctors.  If you begin your question with,  “Doctor, are you sure that…”, the physician’s response will be, “No, I can’t be 100% sure…”  If you begin your inquiry with, “Doctor, is is possible that…”, your doctor will answer, “Yes, anything is possible…”

Life is a casino.  We play the odds every day.

There are no guarantees in medicine or in life.  Uncertainty is everywhere and we all have our own uncertainty tolerance levels.  While there is no correct uncertainty threshold, your own level will determine if you spend most of your time at peace or on edge.  If you demand certainty, for example, then you will be forever seeking more testing and evaluation to eliminate doubt, and you may never reach your destination.  This principle may also apply when making investment choices , considering legal advice, buying a used car, eating street food abroad, considering an extended warrantee on an appliance as well as choosing among medical treatment options.   If I reassure a patient that his colonoscopy is normal and published data suggest that the chance that a lesion was missed is about 5%, will the patient accept the test’s inborn imperfections?  Will I?  Should everyone undergo 2 colonoscopies in order to decrease the miss rate?  How much effort and resources are worth achieving small incremental benefits?  I’m only posing the question here.

And individuals who have excessive risk tolerance may risk unfortunate outcomes.  Cashing in retirement funds for chips to place on the roulette wheel would make most folks uncomfortable. 

A patient I saw recently is eligible to receive the COVID-19 vaccine but does not wish to proceed.  He is aware of the safety and efficacy data but is concerned over potentially unknown adverse reactions that may emerge over time. This is not a right or wrong issue; it’s a matter of judgement.  He isn’t certain that he his making the right choice, but he is certain which option feels more comfortable at present.  Many others would decry his decision as a risky roll of the dice.  Remember, however, we’re all gamblers as we journey through life placing our daily bets and hoping at least most of them pay off.  


Sunday, March 7, 2021

Lockdowns and COVID-19 - Is the Cure Worse than the Disease?

 There’s been lots of talk about lockdowns lately.  This issue, like masks, has become politically contaminated.  It’s been one of the fascinating lessons of the Pandemic of 2020 – the recognition that issues that would seem to be ‘immune’ to political interference became instead potent partisan weapons.

Consider two rather distinct reactions to the recommendation to don a mask when frolicking about in public.

Citizen #1:  Of course, I will mask up.  This will keep me and others safer.  In a small way, I feel I’m doing my part on the journey to the other side.

Citizen #2:  Mask?  Hell no!  Just more encroachment by the government to rule our lives.  

Similarly, locking down the economy, both here and abroad, has provoked bitter reactions from all sides.

'No mask for this patriot!'

As I have written, I feel awful about the hundreds of thousands of businesses who have closed or are barely hanging on.  I also feel that their plight has not been given the attention it merits from the national press.  We have been regularly informed – as we should be – about the health risks of the virus and the need for all of us to behave responsibly.  But I do not think we have been as fully informed about the economic pain and irrevocable consequences that the nation is enduring.   Additionally, the press tends to villainize political leaders who argue for loosening up on their lockdowns and laud those who call for tight control.  Many businesses who have faced stringent restrictions have been infuriated as other businesses in their communities have been permitted greater latitude for reasons that defy common sense. 

There is a balance between maximizing public health and mitigating economic catastrophe and good people can disagree on where to draw the line.  While I don’t pretend to know how to thread this needle in motion, I do think that both sides deserve consideration and respect.  For example, if hypothetically we were to adopt a total national lockdown, we might stifle the virus much faster but have little to return to afterwards with a nation facing collective bankruptcy.  And the converse is also true.

I also feel that if all of us had uniformly adopted the public health measures advocated by medical experts a year ago, that many lockdowns could have been avoided or have been less onerous  That’s on us.  If folks are packing into bars and clubs at night, what do we expect local and state authorities to do?

Texas and Mississippi have recently opened up their economies in a big way with bravado.  They have been vilified and I share the concern of the critics.  If the COVID-19 cases rise, as many expect, then these political leaders will deserve all the vicious incoming they will receive.  But if no viral surge develops and an economic surge results, will the critics and the press admit they were wrong and celebrate the success?

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