Thursday, September 24, 2009

Should Patients Email Their Doctors?

This is a less controversial issue than patients ‘friending’ their doctors on Facebook, which I oppose. Although most physicians’ offices are not emailing with patients, perhaps they should. There are several obvious advantages.

  • Decompress phone lines, which are suffocating nearly every medical practice in America.

  • Relieve patients of the cruel and unusual punishment of languishing on ‘hold’ listening to elevator music or dead air.

  • Allow office staff to efficiently respond to patients’ cyber inquiries at scheduled times.

  • Eliminate the need for the ubiquitous phone menu system, a torture chamber that tests the mettle of even the most robust and seasoned patients

  • Facilitate documention of patients’ inquiries, which is not reliably accomplished with phone calls.

  • Permit staff and physicians to access patients’ emails from remote locations.

  • Allow for emails to be forwarded to other staff and physicians with a keystroke.

  • Available 24/7.

Sure, email communications between physicians and patients makes great sense, but it costs doctors dollars. Should this be a free service? The current culture of medical practice in this country is not to charge a fee for patients’ phone calls. Like every doctor, I spend hours each week on the phone with patients. This is free medical care. Patients feel entitled to this pro bono service, as I do when I call my doctor or dentist. But is this fair? If a patient calls me to ask a medical question, then why shouldn’t I be compensated for giving professional advice that requires medical training and experience? Is this free medical care a service that we should provide to our existing patients? What about patients whom we have never seen who call us after hours with a medical issue? Should this be a freebie also? Many phone calls morph into phone office visits, which not only are free, but also may not provide optimal care to the patient.

When I call my lawyer there’s always a ticking sound that I hear in the backround. For lawyers and other professionals, phone calls are fair game. Ironically, while physicians don’t charge for phone calls, we are still legally liable for the medical advice that we offer during these gratis exchanges.

Will emails be the next generation of donated physician time? Emails and phone calls to physicians should be reimbursed. Primarily, because it is fair to pay people for the work that they do. In addition, charging a fee would help reduce many of the unneccessary calls (or future emails) that deluge our office.

I welcome differing opinions on this issue. If I respond back, it will be free of charge.

Friday, September 18, 2009

Tort Reform for Drug Companies? Huge Loss for Wyeth in Supreme Court

Every physician knows what a black box warning is. This is a special Food and Drug Administration (FDA) requirement to warn doctors about potentially severe drug reactions. Most medicines do not have any black box warnings. Wyeth, a pharmaceutical company, will have to place a black box warning for their drug Phenergan, a medication routinely given for nausea. Phenergan has been on the market for over 50 years. I’ve prescribed it for years with excellent results, and I have never witnessed an adverse reaction.

The catalyst for the black box development was a tragic side-effect that a woman experienced in 2000 after receiving an injection of the drug. A physician’s assistant injected the medication improperly into her arm. As a result, she developed gangrene and her right forearm had to be amputated. She argued in court that she was not sufficiently informed about the drug’s risk and the jury awarded her $6.7 million. This past week, the U.S. Supreme Court rejected Wyeth’s appeal.

What will a black box warning accomplish? The currently published product information on Phenergan already addresses the proper dosing and method of administering the drug. Would a higher level warning have saved the plaintiff’s arm? If she knew in advance about a catastrophic side-effect that occurs in far less than 1% of injections, would she have refused the drug? I don’t think so.

Of course, patients should be advised about potential side-effects of drugs we prescribe. But, how much information is reasonable to impart? I confess that I do not warn patients before prescribing Phenergan about risks of gangrene and limb amputation. Should I? (I also don’t mention the risks of death from penicillin.) Look up the list of known or suspected side-effects of any prescription drug. You will discover pages of small print that list dangerous, and even deadly drug reactions, most of which are far more serious than the medical condition being treated.

If physicians reviewed these side-effects with patients, including extremely rare events such as Phenergan-induced gangrene, then patients would be too spooked to take any medication. How would you respond to this caveat from your physician?

“Here’s an antibiotic for your sore throat. I should warn you that this drug has caused severe colitis that has resulted in emergency surgery to remove the entire colon, leaving patients with a bag. A few folks have died, but this is very rare. Have a nice day and remember, don’t skip any pills!"

If patients were excessively informed about the harm that drugs could inflict, then they wouldn’t take them. This would be bad news for many patients, pharmacies and drug companies. It would also be an unwelcome development for lawyers, who troll the countryside for bad medical outcomes and try to concoct a pathway leading back to a doctor, a hospital or a pharmaceutical company. They prevailed against Wyeth, who had nothing to do with the improper injection of Phenergan. We physicians, who are similarly victimized with unfair allegations of medical malpractice, can empathize with their plight. Tort reform can’t come soon enough, but we won’t see it under President Obama’s watch. The president and the Democrats candidly admit that they don’t believe that medical malpractice reform is necessary.

Tragic outcomes are tragedies, not a priori evidence of medical negligence. True, the Phenergan medication may have been improperly injected, but how far should the shadow of blame extend?

Until the government injects some sanity into the medical malpractice system, then we will never achieve the health care reform that we all deserve. This is my black box warning.

Friday, September 11, 2009

Should Doctors Use Facebook with Patients?

When it comes to Facebook, I will offer full disclosure, a policy I’ve advocated in my medical ethics postings; I am neither a friend nor a fan of this godfather of social media. In my 7 member nuclear family, 6 of us use Facebook as a portal into their personal worlds. Once again, I am the outlier. I just don’t have the time to create and maintain another universe in my life. It would eliminate the scant discretionary time that is still available to me.

Bloggers at the American College of Physicians and KevinMD and have mused about physicians using Facebook to communicate with patients. Earlier this year, Sachin Jain, M.D. wrote a commentary in The New England Journal of Medicine discussing his ambivalance to ‘friend’ a prior patient. While the public might be receptive to ‘friending’ doctors, most physicians won’t be in a hurry to use social media with their patients. Physician Facebookers would not want patients to have access to their vacation photos and personal vignettes, many of which are private for a reason. Reading comments on a doctor's Facebook wall might show how that the physician is really ‘off the wall’. Conversely, do we physicians really want to enter our patients’ Facebook worlds? I think that this would corrode the patient-physician relationship. There should a line between patients and their physicians. While this barrier is not inviolable, I don’t see how blurring or eliminating this separation enhances their health care, which is our designated role. We are their physicians, not their pals. In fact, it is challenging when folks choose physicians who are within their social circle. While some doctors I know welcome this, I try to avoid having friends as patients. My objectivity would be diminished. In addition, depending upon the medical circumstances and outcome, the friendship may be at risk, which could have consequences that extend far beyond the exam room.

Physicians have always been strict guardians of confidentiality and patients’ privacy. Indeed, when I have performed a colonoscopy on a real friend (not a cyber pseudofriend), not even my wife knows that this occurred, unless the patient himself relates it to her. Could physicians who become a patient’s Facebook ‘friend’ maintain confidentiality? The doctor, of course, could make no Facebook reference to the professional relationship. Other ‘friends’, however, might recognize the medical identity of the doctor, which might lead to a line of questioning or speculation that could be problematic.

“Hey, I see that MDWhistleblower is your ‘friend’ now. Isn’t he a gastroenterologist? Are your hemorrhoids acting up again?”

I know that Facebook is a social media empire. It’s being used by tens of millions of individuals, marketing organizations, politicians, government agencies and corporations across the country. It is a powerful tool for personal and business networking. But, it lacks the intimacy of human contact, the mother’s milk of the doctor-patient relationship. Physicians and patients don’t need Facebook time; we need more face time. Is anyone else a ‘fan’ of this?

Friday, September 4, 2009

Physician-assisted Suicide: Constitutional Right or Just Plain Wrong?

This past week, the Montana Supreme Court heard a right-to-die case where the plaintiff argued that there is a constitutional right to physician-assisted suicide. A Montana physician had refused this request from a terminal cancer patient, who died in December 2008 without medical assistance. No state in the union currently has a constitutional right to die, although physician-assisted suicide is a legal practice in Oregon and Washington. In 1997 the U.S. Supreme Court ruled that there is no fundamental constitutional right to physician-assisted suicide, although it did not prohibit the practice entirely. Once the balance of the U.S. Supreme Court shifts leftward in the coming years, perhaps a constitutional right to medical euthanasia will be ‘discovered’ in the U.S. Constitution.

If the Montana plaintiff’s view prevails, would physicians there be breaking the law by refusing to assist a patient who requested a doctor-assisted death? Would such principled doctors be denying a patient a newly established constitutional right? We are all familiar with lawsuits alleging wrongful death. Would the term wrongful life be invoked by a patient who claimed physical and psychological damages because a doctor wouldn’t facilitate his demise?

While the courts can opine on these controversies, this is a moral question for society and the medical profession, not a legal issue. Just because an action or behavior is legal, doesn’t make it right. Physician-assisted suicide is wrong and no court decision can make it right.

I expect some to claim that my categorical view against this practice is callous and dogmatic. I reject these arguments. There are some moral lines that simply must not be violated. The medical profession is sworn to relieve suffering and to comfort those who cannot be healed. This is our mission. Our patients trust us with preserving and protecting their lives. If we were to hasten or cause death, regardless of the motive, we squander this trust and sacrifice the essence of what it means to be doctors. It would change how we physicians view our own profession and would certainly change how society view us. Euthanasia would conspire with overzealous organ procurement in intensive care units and nursing homes as forces that distort how we view these human beings. If physician-assisted suicide were to become accepted, then it will inevitably enter the minds of physicians, nurses and family members who are caring for dying, or even chronically ill patients. Once this becomes an option, then it becomes legitimatized. It’s easy and frightening to extrapolate where this could lead us. The medical profession must remain guardians of life, not expediters of death. We need to keep our mission pure.

Sadly, there are patients who are suffering miserably, and we must do all that we can to help them. They have a right to effective pain control. They have a right to receive expert palliative care. They have a right to refuse treatment. They have a right to pray to the Almighty for final relief. They don’t have a right, however, to expect me to answer their prayers. While I might pray for their eternal rest also, I can’t push them forward on this journey. If I did, then I will have crossed a moral and ethical boundary with no way back.

All sides to an issue claim rights. In ethics, like law, the rights of all players are weighed against each other. These analyses can be vexing as competing parties argue persuasively that their rights are paramount. Depending upon the circumstances of the ethical dispute, one right will prevail. No right, however, is absolute. The right to free speech does not permit us to scream ‘Fire!’ in a crowded theater. Similarly, if a desperately ill individual has a right to a doctor-assisted death, then it is outweighed by society’s right to life.

If the Montana Supreme Court decides for the plaintiff, then this state will become the ethical Wild Wild West.