Sunday, December 26, 2010

Obamacare Unconstitutional!

I begin this post a few thousand feet in the air, in the aisle seat in the rear of the aircraft. I suppose it is fitting that a gastroenterologist would be in the rear section. Fair is fair. Flying is a psychological test of one’s mettle. After enduring the security process, which is designed to find bad stuff instead of bad people, there are other layers of hassle to face. When I reached the cabin door, I was told that there was no available overhead space to store my bag. This development is often tolerable, as gate-checked bags are brought directly up to the arrival gate walkway after arrival, so you can avoid the hand-to-hand combat of the baggage claim arena. Not this time. For reasons, known but to the Almighty, my bag will be directed to the baggage claim, where I hope and pray that I will be properly reunited with it. Meanwhile, I will enjoy the luxury of an airline seat that would be quite comfortable for an average sized 4th grader. If the lady in front of me tilts her seat back, and my tray table is extended, then I will receive a Heimlich maneuver. Who knows? Maybe this could save my life if she leans back at the moment that the filet mignon I will be served gets trapped in my trachea.

Obamacare has hit an important judicial roadblock when Federal Judge Henry Hudson of Virgina ruled that the individual mandate was unconstitutional. Judge Hudson is the 3rd federal judge to rule on the constitutionality of the president’s health care plan. The first two judges gave the law a pass. Earlier today, oral arguments began in a Pensacola, Florida federal court before a judge who is suspected to harbor constitutional concerns of the health care plan. Already, 4 federal courts are involved, and it’s only 9 months since the law was signed. This is going to be a rocky road, and no one can predict the ultimate outcome. It is likely that the Supreme Court will ultimately have to reconcile various diverging views from lower Federal district and appellate courts. This emphasizes that a president who fills vacancies in the Supreme Court has a powerful tool to protect his policies against legislative threats and reversals.

Of course, courts are not supposed to make policy. They are charged to determine if an action or a law is lawful. Often, court decisions are criticized by folks who are not happy with the outcome, even though the legal issue before the judges may be arcane and not directly related to the actual issue. For example, the headline may read: “Judge Rules that Hospital May Withhold Chemo from Child with Cancer”, but the legal issue may be far removed from this emotional vignette. I’m not suggesting that judges rule in a robotic fashion without compassion or considering their own human experiences. I do feel, however, that it is not their role to depart from the law to provide extrajudicial remedies that should originate elsewhere. While the law does evolve, this is a gradual process that respects precedent and judicial restraint, at least in my view.

Is Obamacare constitutional? I have no idea. If a handful of wizened judges can’t agree, I don’t think that a mere colonoscopist in Cleveland should opine on the issue. Despite its legality, it remains a very unpopular law. Polling still shows that the majority of Americans would like the law totally or partially repealed, while 43% of us approve of the plan. This does not augur well for the president, since the tough medicine in his plan won’t appear for a number of years. Of course, Obama could dodge the fallout, which is inevitable if the law survives. He could be a ‘one termer’ and leave the angry mess to his successor. 

This is how the issue appears from 30,000 feet.  How does it look to you on the ground?

Sunday, December 19, 2010

Whistleblower Holiday Cheer 2010!

Readers immerse

In my rhymed universe

And decide if my verse

Is for better or worse.

An imam, a rabbi

Along with a priest,

Were seated together

At a holiday feast.

They smiled and they laughed

And enjoyed swapping jokes.

Can you believe

They ducked out for a smoke?

Was their bonhomie real

Or just a facade?

Didn’t they pray

To the very same God?

When together as men

Without enmity,

Walls can be broken

They realized, all three.

Can you still scorn a man

And give him the blame?

When you raise up your glass

And toast him by name?

When it’s all over

And the three of them part

Will they remember

The warmth in their hearts?

Or will the noise and the static

And political din,

Return them once more

To division and sin?

Who will you choose

To your table this year?

Family and friends

Who come year after year?

Perhaps, there are guests

Who could join you this time,

Who could sing at your hearth.

Together in rhyme.

There are friends on your list

And family, no doubt,

But, is someone missing

Who you may have left out?

Wishing you joy and peace!

Sunday, December 12, 2010

Medical Ethics: President Obama Makes the Right Call

I have always felt that issues should be judged by the context of their times. For some issues, however, context provides no justification. Thankfully, the field of medical ethics has evolved into a robust discipline, and there is an enormous need for it. I have read defenses of prior ethical lapses, and even some recent ones, suggesting that context matters. If a 3 month placebo-controlled study is conducted in the developing world testing a medicine that was highly effective against a serious illness, are the ethical dimensions considered and respected? Were the pharm companies choosing this study locale as a cheap test run for their drug, which will ultimately be marketed in the west? Is it ethically problematic not to provide additional medications to ill subjects after the 3 month trial ends? Can we be assured that a rigorous informed consent process was followed? Sadly, outrageous practices have been reported in the very recent past.

Our president and secretary of state recently and rightfully apologized to Guatemala for American experiments performed there in the 1940s when patients were intentionally infected with syphilis. These patients were mentally ill. While I can concoct a distorted and tortured rationale that would justify this reprehensible practice, such reasoning passes no threshold of decency. Some behaviors and practices are always wrong, in any context.

How can decent folks behave indecently? We have seen in the Holocaust how ordinary folks can tolerate, and even perform, evil during the week, and then attend religious services on Sunday. Many of these dark acts were committed by physicians, who are sworn to heal and to comfort. Here’s a perspective on this issue from a man who is known as the conscience of the world.

These are frightening notions. First, they suggest that we may not have innate inclinations to do good, despite our belief that we are all equipped with powerful superegos. If we were all good by nature, then we wouldn’t need such an expansive criminal justice system and thousands of laws telling us what not to do. The reason that the bible is replete with ‘Thou shalt nots’, is because human behavior is often ‘I shalt’. Secondly, these repeated ethical lapses and catastrophes point out that all of us are vulnerable to do wrong, even when we know what the right choice would be. While we might like to think we would push back against a black tide, it is less certain what we would truly do in that situation. Would we risk a job, for example, to take a righteous stand for another person?

I recognize that medical ethics addresses tough issues, where one person’s rights are weighed against another. The resolution of ethical issues yields winners and losers. Yet, despite these controversies, we need a firewall separating what we must do from what we must never do. The argument that the ends justify the means must be resisted. What American scientists did in Guatemala nearly seventy years ago was appalling and morally indefensible. It was wrong then, it is wrong today and it will be wrong tomorrow. The president has just ordered a review of all research involving human subjects being funded by the federal government to assure that medical ethics are being properly practiced. Recent history demonstrates that oversight is necessary. Third world citizens deserve first class ethics.

Sunday, December 5, 2010

Privatizing Medicare: Caution! Highly Explosive!

Photo Credit

In response to my recent post where I averred that the cigarette companies were treated as scapegoats, I have had several cyber and actual conversations about personal responsibility. I believe that folks should realize the consequences and the benefits of freely made decisions. While we want American society to be compassionate, we do not want to punish success and reward failure. Our goal is to do all that we can to maximize everyone’s success. We should be ready to assist those who need and deserve our private and governmental assistance, but personal effort and responsibility are necessary elements of these interventions.

In our gastrroenterology practice, when we see patients who are in financial difficulty, my physician partners and staff will do all that we can to help them. While it is not our policy to do colonoscopies for free, we will make whatever adjustments that are necessary to make sure that the patient receives necessary medical care. However, when patients who owe us money hang up on our calls, or express their view of medical entitlement with foul language, then we forward these accounts to a collection agency.

There is also a self-interest angle to supporting assistance for those in need.. One day, we may need a boost ourselves.

Recall the concept of privatizing social security, a sound proposal that was vilified and snuffed out during George W. Bush’s presidency. Antagonism against this modest proposal was seasoned with a large measure of arrogance, a splash of hubris and a dash of paternalism.

In summary, this proposal argued that if folks could manage a small portion of their own social security money, which they earned themselves, that it could be a force that could empower earners and reinforce the system. The political left turned white hot over the notion of the government transferring any responsibility for managing retirement funds to the citizens who earned the money. Isn’t this preposterous? They predicted doomsday when our imbecilic citizenry, who were somehow smart and industrious enough to earn the money in the first place, would squander it all, vaporizing the last remaining safety net that would keep them afloat. Then, the lefties argued, the rest of us would have to rescue them at much greater expense.

Their argument is transparent. Review some pesky facts below.

The plan only permitted individuals to invest 4% of wages that are subject to social security taxes into private accounts, with modest increases permitted in subsequent years. So, even if these investment tyros lost it all, which is hard to do in any investment, it wouldn’t be a game changer.

The government was not permitting folks to invest in hedge funds, penny stocks or junk bonds. They were required to select from a list of legitimate investment vehicles.

The program was voluntary. If an individual did not have the skill or desire to make personal investment choices, he did not have to. He could continue to allow the government to manage his money.

The program is so modest and so reasonable; it seems that it would be difficult to attack it. Why, then, did it provoke such ire and vitriol from the left?

These guys were scared. They weren’t frightened that folks would lose money and be vulnerable during their retirement years. They weren’t spooked that it would jeopardize the social security system’s financial stability. They were terrified that the program might actually work. They couldn’t tolerate any fissure in their edifice that stood for total government control of other people’s money and personal decisions. If this initial privatization effort succeeded, they knew that the public, now empowered, would demand greater control of their own money.

Yes, I am familiar with some of the criticisms. The government would have to borrow gazillions of dollars to replace the monies being deposited in beneficiaries’ private accounts. In addition, retirees would have to repay the government their privately deposited funds back, plus interest, so it is possible they would lose money if their accounts did not outperform this low interest rate. It would increase the federal deficit, and is not risk free, as stated above. As is obvious, I am not an economist or an actuary. It may be that the dirty details of the program would pose drawbacks, more dire than I realize. Indeed, many liberal advocacy groups vigorously denounced and derided this program. Yet, I support the notion that I have the right to participate in a voluntary program to manage money that I have earned.

To those who believe that the government knows best how to invest my social security retirement money, then why shouldn’t it control all of my investments? Should I be trusted to invest money that will one day be used to pay tuition for my kids? Indeed, anti-privatizers could argue that all of our money should be turned over to the government, so they can wisely manage it and then disburse it as it sees fit.

Recently, Alice Rivlin, a Democratic economist and Paul Ryan, a Republican congressman, both members of the president’s deficit reduction commission, advised consideration of privatizing the Medicare program. Of course, this is political dynamite, but their bipartisan proposal from two thoughtful public servants shows that this strategy deserves air time and public discussion.

So, when you stumble across dynamite, what should or response be?  Call the bomb squad or light the fuse?

Sunday, November 28, 2010

Electronic Medical Records: Medical Malpractice Shield or Magnet?

Several posts on this blog have been devoted to tort reform. More than any other subject, this topic generates more heat than light. Indeed, I describe these debates and commnets on this blog and elsewhere as duels, not discussions.  Many folks on various sides of this issue earnestly believe that they have the better argument. Other viewpoints are not purely held and are clearly contaminated by self-interest. I have written repeatedly that I believe that the current system is unfair and does not serve the public well. The public understands the issues and the controversies. In general, I don’t think most Americans believe that we have too few lawyers or lawsuits in this country.

It is astonishing that people can defend a medical liability system that

          Misses the vast majority of patients injured by medical negligence

          Ensnares many more innocent physicians than negligent ones.

Shouldn’t these two inarguable facts be sufficient to demand at least an examination of the current system? If a diagnostic test only detected a medical condition in 5% of cases, and caused harm in a sizable percentage of healthy individuals, would we defend it, or try to improve it?

When new medical development occurs, it has legal ramifications for physicians, patients and the plaintiff’s bar. Physicians are held to a certain standard of care – as we should be – which is evolving. It can be murky to determine when a new standard becomes established in a dynamic situation, but this is a critical legal issue. For example, a new treatment may be introduced, and even approved by the Food and Drug Administration (FDA) , against a specific disease. Does FDA approval signify a new medical standard?   Is common usage alone, without FDA approval, define the standard of care?  How many physicians need to be prescribing a medicine for the treatment to be considered standard? 10%? 20%? Could a physician successfully argue that lack of FDA approval of a treatment indicates it should not be regarded as the standard of care? If a conservative practitioner like me delays prescribing new medicines until there is a longer track record safety and efficacy, could I be charged with deviating from the community standard? I recall my  reluctance to prescribe a new irritable bowel syndrome medicine years ago, because I didn’t feel there was sufficient clinical experience for this new drug that was treating a benign, albeit troubling, disease. Sometime afterwards, the drug was pulled from the market after some patients died. I suggest that prescribing new treatments or diagnostic tests too soon might constitute a deviation from a judicious standard of medical care.

As Whistleblower readers know, our office instituted electronic medical records (EMR) this past September. It has been a spirited contest of man vs machine, but I think that we will ultimately prevail. The battle has been more prolonged than we anticipated. We knew there would be many challenges. We didn’t expect, however, that there would be so many unforeseen obstacles, which continue to try to derail us. When your smiling EMR vendor shows up in your office and shows you an awesome demo, think WWRD, or what would Reagan do. ‘Trust, but verify.’

EMR has been advocated as an advance that will diminish physicians’ legal vulnerability by providing much better documentation and communication with colleagues. While this may be true, the nascent technology has created gaps and fissures that are portals for lawsuits to sail through. The New England Journal of Medicine has published a review highlighting the medical malpractice risks of EMR in its November 18th issue. I have disseminated this article to my partners and staff and strongly urge readers to do the same. Here are some of the essay’s highlights, including some of my own observations.
  • EMR usage and reliance upon various clinical support capabilities that advise on clinical decision making and practice guidelines may change the existing standard of care. In other words, failure to rely upon these increasingly available clinical support resources could be considered to be a deviation.
  • EMR use may become the standard of care itself, making those who cling to paper charts legally vulnerable.
  • Physicians are especially vulnerable during the transition phase from paper to EMR when they are caught between the two systems. Our practice has experienced numerous snags and setbacks during this time period. I have had to repeatedly return to EMR notes to correct errors that were inadvertently or mysteriously inserted. Some are easy to identify, such as when a hysterectomy is listed on a male patient’s past medical history. Other goofs may be much tougher to spot in the lengthy and formulaic computer notes. When several individuals are responsible for entering data in a patient’s record, errors are invited.
  • Does the EMR software permit the physician to document his treatment plan, explaining his thinking and judgment involved in the medical recommendations? Or, is the ‘plan’ limited to a list of diagnoses? The latter might not provide much assistance to your defense counsel if you have to rely upon these thin record years after the visit.
  • Does your practice have a plan in place when the inevitable computer crash occurs?
  • How has your practice documented that all medical information in the paper record has been transferred to the EMR record?
  • The cut & paste technique that many physicians use in EMR risks omitting important new medical information and perpetuating inaccuracies.
  • Computer technology now gives access to various patient data bases at the time of the visit. Are physicians obligated to search through area hospitals’ and other organizations’ patient data bases to review all records contained there? Many patients have years of lab and imaging study results in various locales that we now have access to. The legal ramifications of this are obvious.
Of course, EMR will also protect us if we use the system well and are meticulous about our usage. If we document phone calls that direct patients to the emergency room or to a specialist, then this can stifle a lawsuit. Similarly, the EMR record can document that patients were notified of test results and were given instructions on when to follow up with us. But, I fear that, at least in the short term, the legal risks for us exceed legal protections. We need to be vigilant, not only to protect our patients’ health, but also to protect ourselves.

Alas, EMR will not be the Era of Medical Liability Reform.

Sunday, November 21, 2010

Big Tobacco - The Government's Favorite Scapegoat

Smokers of the world unite! It’s strange for a physician to be sympathizing with the tobacco companies, purveyors of the opium of the people. Am I a stealth nicotine addict, an apologist for Big Tobacco who supplies me with my daily fix? This scurrilous allegation can be vaporized in a one-question quiz.

Identify which two of the three individuals listed below are cigarette smokers.

John Boehner, newly elected Speaker of the House , 3rd in line to the presidency

Barack Obama, Commander-in-Chief and leader of the free world

Michael Kirsch, Hemorrhoid examiner

I’ve never smoked and I detest the habit. It kills people and separates lower income Americans from money that could likely be devoted to more worthwhile endeavors. I remember caring for folks with end stage emphysema as a medical resident and thinking that this disease was worse than cancer. I haven’t changed my mind.

Yet, I have felt for years that Big Tobacco is demonized by the press and the government as Big Scapegoat, and this blame shift has always troubled me. I am well aware that the tobacco companies are guilty of many offenses. They have lied about their corporate practices, advertising strategies and manipulation of nicotine content. These companies – like any individual or business – should be held accountable with available legal remedies. If crimes were committed, then I’m sure this nation has a few idle and altruistic attorneys who can fight them in the courts.

My quarrel is blaming these companies for the decisions that individual smokers have made. Assuming that every nefarious allegation against the tobacco companies is true, and throw in a few more, it doesn’t change the fact that smokers for several decades knew (or should have known, a favorite lawyers’ phrase) that cigarettes steal life and breath. This was common knowledge even before cigarette warnings appeared on cigarette packages. I think it an abuse of the justice system and an assault on morality when an individual who is suffering a horrible consequence of a habit that he freely began, blames the manufacturer for his misery.

We all remember the billion dollar settlements that the tobacco companies paid to the states, ostensibly to be used to reduce cigarette use, but were largely devoted to general operating expenses. The phrase ‘up in smoke’ applies here.

While I personally oppose the habit, and counsel my smoking patients to cease and desist, this is a free society. Folks can choose to engage in a variety of activities that span the risk spectrum.

In my state of Ohio, it is legal to
  • Ride your motorcycle in the rain without a helmet
  • Become an alcoholic
  • Flush your life saving medicines down the toilet
  • Hunt
  • Ski on a Black Diamond path when you should be on the Bunny Hill
  • Gorge yourself on a diet of crème brulee, cheesecake and assorted deep fried delicacies
The federal government has issued new regulations that will require cigarette manufacturers to incorporate new labels that will cover half of the cigarette pack or carton. These 36 color photos will be graphic and ghastly portrayals of the ravages of nicotine addiction. The labeling will be a veritable slide show of horror, including a corpse with a toe tag, a man blowing smoke out of a tracheostomy hole in his neck and a wasted and cadaverous individual who looks too weak to lift his last cigarette.

Cigarettes must not be entirely evil, or else the government would outlaw them. Here are some pesky realities that anti-tobacco company zealots must overcome.

  • The product is legal
  • Tobacco directly and indirectly creates jobs and income in all 50 states
  • Smokers pay a fortune in taxes to the states and to the federal government
  • Many smokers enjoy the habit
Don’t misunderstand this post. I will never smoke and hope that no person I care about will pursue this habit. I encourage all inhalers to exchange their habit for a more salubrious addiction. What I do oppose is blaming tobacco companies for the woes of their customers. I also am uncomfortable with the government slowly suffocating these companies who are entitled to advertise and sell their legal wares. If, as a matter of public policy, cigarettes’ adverse health consequences outweigh their economic benefits and the rights of smokers, then have the guts to outlaw them outright, rather than incrementally bleed the companies.

If you support the government’s strategy of pursuing the demise of Big Tobacco by a thousand cuts, then who will be the next targets? Should every product that is not on an approved health and wellness list be attacked? Who decides which companies and activities should be on the list?

Beware! We may soon see similar scenes of ghoulish horror on Hershey bars, Frosted Flakes and even Twinkies. Ronald McDonald will be behind bars, wearing a different set of stripes. Sesame Street's Cookie Monster will be in shackles.  When you pop a champagne cork at your next family celebration, the label won’t be a pastoral scene of a vineyard, but will be a jaundiced alcoholic vomiting blood.

I’m not scared of the government’s new cigarette horror show. I’m scared it won’t end.

Sunday, November 14, 2010

Health Care ‘Reform’ Reforms Legislature

Thank you, Obamacare.

The GOP, demoralized and frustrated, as they endured the Obama liberal juggernaut that trampled across the country these past 2 years, has been resuscitated. It’s more fun to be in the majority, as Nancy Pelosi can recall. Democratic hubris and rising public disapproval provided not just a strong wind, but a tornado, behind the GOP’s backs. Obviously, there’s nothing revolutionary here, as midterm elections tend to favor the minority, with rare exceptions. What is noteworthy here is the depth of disapproval with the current administration’s policies, affecting every demographic. The gains that the Republicans achieved, particularly in the House, have left Democrats numb and glum.

Whistleblower readers will not be shocked to learn that I did not vote for Obama in 2008, but I was inspired by him. I wanted to believe that he would be the transformational figure that his campaign promised and that the country desperately needed. In particular, I was moved by his speech on race relations that he gave at Constitution Center in Philadelphia in March 2008, as a candidate. He certainly has the intellect and the vigor to serve as our chief executive. Additionally, he accomplished a political feat that I thought no living human could perform. He vanquished the Clinton political machine that assumed that Hillary’s campaign was a mere formality that would precede her coronation. As the president-elect, he spoke of collaboration, reaching out and reconciliation. Then, he was inaugurated.

What happened to the idealism and the abandonment of partisanship? There was plenty of audacity, but not the type we were promised.

The public would only allow Obama to blame George Bush for so long. At some point, the president must assume ownership of the nation’s challenges. We expect, of course, that newly elected officials always state after they take office that they didn’t realize how serious and deep our problems are. This strategy is an attempt to transfer blame to their predecessors, but the public will not provide an indefinite grace period for this buck passing The gaziillons of dollars of Obama stimulus hasn’t dented unemployment, and the public is not persuaded by arguments of ‘imagine how much worse we would have been without our bail outs’. We physicians often use this specious reasoning also.

Doctor, Granny has been on the medicine for a year, and I don’t think her dementia has improved at all.

Well, she would have been much worse without it.

Even many of Obama’s stalwart supporters have turned away. Independents and women defected to the GOP. He managed to alienate both the right and left political wings of the country, no easy feat. Our economy may be mired for years, China’s currency devaluation is costing us jobs, no progress thus far on immigration reform, Iran closing in on a nuke, cap and trade policy that many Democrats oppose and a war in Afghanistan that does not seem to be following a soaring trajectory toward victory. (Watch for the definition of victory to change.)

While the economy is the proximate cause of this electoral reversal, Obamacare receives Best Supporting Actor in the Election Day performance. Obamacare is a symptom of arrogant overreaching by Democrats to give the public what the government prescribes. This political paternalism lit the Tea Party fuse and caused rising suspicion and discontent among ordinary folks and businesses that came to realize that they were being force fed medicine they didn’t want or need. The reason that most Americans oppose Obamacare is not because the administration hasn’t communicated its message well. To the contrary, the more the public understands what Obamacare will mean for them and their families, the more vigorously they oppose it. This was a colossal misfire that helped to retire Nancy Pelosi’s gavel.

Leadership is convincing folks that they should follow a new path. It is not herding them over a cliff. Both of these tactics bring folks to new destinations, but isn’t one of these 2 methods the preferred strategy?

The public does not believe that Obamacare will save money or improve medical quality. They believe – and with good reason – that this plan will break the bank, ration care, micromanage health care delivery and create a pathway toward government control. They do not want our health care system, despite its flaws, to be dismantled.

The repudiation of Obamacare is symbolic of why Obama’s shining veneer has faded so quickly. He didn’t care what the GOP or the public thought. He was determined to force his plan through to earn a legacy for accomplishing what no president since Harry Truman could accomplish. I think health care reform will earn him a place in history, but not the one that he seeks. He will join list of American presidents who served only one term. When this happens, he won’t be able to blame it on George Bush.

This election could allow the president to have a more successful end to his first term. He will likely decide to take turn toward the center and work with Republicans and independents. Can Obama leave the left behind, or will he be left behind?

As always, your comments are welcome.

Sunday, November 7, 2010

Can CAT Scans Prevent Lung Cancer? Smoke and Mirrors

I still marvel at the accomplishments of CAT scans and imaging studies.  These technologies have revolutionized the medical profession.  Imagine foretelling 50 years ago that a new technology would emerge that could perform ‘exploratory surgery’ without an incision.   This prediction would be greeted with disbelief, if not scoffing.  Of course, there would be similar reactions if decades ago other technological feats, such as fax machines, personal computers, emails and internet, were predicted.
CAT scans save patients’ lives, prevent surgeries, make accurate diagnoses and refine treatment plans.  This is the good news.  However, as expressed repeatedly on this blog, there is a darker side of the story.
  • Without doubt, too many CAT scans are performed.
  • Accumulated medical radiation has health consequences.
  • Resources expended on unnecessary CAT scans could be devoted to worthy health care endeavors
  • Radiologists suffer from litigophobia and identify every tiny abnormality, which generates patient anxiety and more medical tests chasing these trivial results.   Off the record, radiologists will confide that these ‘abnormalities’ are inconsequential, but their formal dictations always suggest that these lesions may be ominous.  Their dictated recommendation?  Mores scans!
  • CAT scans can provide patients with false security, which is the premise behind total body scans that are scamming the public.
  • CAT scanning and other technologies have eroded physicians’ bedside physical examination skills.   Does anyone think we are as skilled using a stethoscope as our predecessors were?  Of course, one can argue that we don’t really need these antiquated skills anymore. 

Recently, the press went ga ga over a new study that concluded that screening CAT scans on cigarette smokers could save lives. They hyped headline of The New York Times was CT Scans Cut Lung Cancer Deaths.   The study concluded that annual chest CAT scans on smokers could reduce the risk of death by lung cancer by 20%.   Why is my reaction so cynical to what was heralded a groundbreaking development in oncology? 
First, I am always wary when study results are presented in relative terms, such as a 20% decrease in the number of deaths.  Relative percentage terms always exaggerate the clinical benefits and are misunderstood by the public, as well as the press.  For example, assume that a new cholesterol-lowering medication is prescribed to 500 people who are compared with a control group of untreated individuals to determine if the drug can prevent heart attacks.    If 4 folks in the medication group develop a heart attack, and 5 control patients do also, then the drug company can correctly claim it lowers heart attack rates by 20%.  This sounds impressive, although the true benefit that an individual realizes is trivial, since 99% of all patients suffered no cardiac event.   Can’t you just see the headline Drug Cuts Heart Attack Rate by 20%?
In the chest CAT scan study, 300 people must be screened to save one life.  Is this worth it?  Of course, if the lucky individual is in your family or mine, then any cost would justify the outcome.  However, we cannot make public policy based on anecdotes or rare favorable outcomes.   For those who argue that saving lives is worth enormous expense at the expense of others, do they also support the following positions which would save lives?
  • Lowering the highway speed limit to 40 mph
  • Outlawing air travel
  • Prohibiting swimming
  • Eliminating skiing
  • Forbidding contact sports
Assuming the CAT scan study’s conclusions are correct, 299 smokers have to be screened to save a fellow inhaler.  Twenty-five percent of the scans had ‘abnormalities’ discovered that led patients into the medical labyrinth described above.  So, in the group of 300, 1 life was saved and 75 were targeted for subsequent medical assault.  When you consider that there are nearly 50 million smokers in America, imagine the billions of dollars that will be spent and the hundreds of thousands of patients who will be subjected to medical care evaluating harmless lesions.   
In addition, as doctors who have been around a while know, one study shouldn’t change the course of medical practice.  Over the past decade or two, many other groundbreaking studies were subsequently refuted.   I’m sure that physician readers can cite many examples of these medical retreats.  In six months’ time, we could learn of new study that concludes that smokers who are screened with CAT scans have a higher death rate.
A better strategy that is considerably cheaper and more effective is to try to reduce the number of cigarette smokers.  The CAT screening study cost $250 million.  What if those funds were used instead to treat nicotine addiction?  Would this have saved more lives than annual CAT scan screening?  The low tech approach, at least, is more focused on low hanging fruit, rather than aiming buckshot style at every smoker.  Moreover, I would imagine that if a smoker is told that his annual CAT scan is negative, that he will have less incentive to consider quitting.  For him, a negative scan may reinforce his belief that he will avoid a malignant fate.
Other bloggers, including KevinMD and Gary Schwitzer didn’t drink the CAT scan Kool Aide.  My advice?  When the press is serving up Kool Aide, hire a food taster.
Do I think there may a reasonable role for CAT scans in smokers?  I’m not holding my breath on this one. 

Sunday, October 31, 2010

Plagiarism and Medicine: Should We Care?

Recently, I wrote a post on plagiarism in medicine. I advocate a stringent code of ethics for our profession. Once our integrity becomes squishy, then the whole tapestry starts to unravel. We physicians are charged to search for and guard the truth.

In 1910, Sir William Osler wrote:
No human being is constituted to know the truth, the whole truth, and nothing but the truth; and even the best of men must be content with fragments, with partial glimpses, never the full fruition.
Of course, we physicians don’t always succeed in enlightening the truth, but we try. Every day, every one of us faces choices that test us. Some are easy. Most of us would not falsify billing submissions. Other choices are murkier. For example, do we coax a symptom out of a patient so that the procedure or visit becomes a covered benefit? Have we informed a patient whom we are recommending a colonoscopy about the radiologic alternatives? When a patient informs us that his primary care physician has referred him to a surgeon whom we do not hold in high regard, do we speak up? Some folks believe that dispensing medication samples to patients is improper because it encourages the use of expensive medications and raises drug prices for everyone.

I am not writing this because I am a paragon of ethical behavior. I have made some wrong choices in my career. I am also not suggesting that personal integrity is of greater worth for physicians than for others. However, although every individual and business should use honest weights and measures, personal integrity is a fundamental value of the medical profession. This is why I am so troubled about ethical lapses of pre-medical students, physicians-in-training, practicing physicians and academic researchers. Medical plagiarism targets the soul of the profession

There’s new twist on plagiarism, which makes the offense even more complicated. Which of the following scenarios do you find more troubling?

A college student deliberately enhances his research paper with someone else’s work and then submits the paper as his own. He hopes that his plagiarism will not be detected.

A college student appropriates information from various websites and ‘pastes’ liberally into his research paper without attribution. He would readily disclose his research technique as he does not recognize it as ethically problematic.
In my school days, when pterodactyls flew overhead, we all knew what plagiarism was. We didn’t need introductory college lectures to define it. When we ‘borrowed’ someone else’s work without attribution, we knew it was wrong. These days, kids, and even many grown-ups, don’t even know what plagiarism is, or when they are committing it. They have diluted the definition to such an extreme, that only a verbatim extraction of whole paragraphs from the holy bible would be considered plagiarism.

Consider two points from a recent New York Times article.

  • 40% of surveyed undergraduates admit to have plagiarized on written work
  • Only 29% of students believe that copying from web constitutes serious cheating
Many cheaters today do not even regard the offense as an impropriety. Somehow, they believe that the internet and other sources are public domain information reservoirs to be ‘cut & pasted’ and presented as one’s own work. A student caught cheating in my day would be punished. Today’s offenders are likely to deny that any ethical breach has occurred. Counseling these individuals is much more difficult task. We all know the first step of a 12-step program.

Medicine, along with the rest of society, has suffered some ethical erosion. If premedical students, for example, have a relaxed ethical attitude, what kind of medical students will they become? Can we expect that these students, who plagiarize in college, would undergo an ethical metamorphosis when they become grant-seeking academic researchers or practicing physicians? What kind of role models will these researchers and academic faculty be for younger physicians and investigators?

Plagiarists, idea thieves, have chosen personal gain over the truth. If the plagiarist seeks to enter the medical profession, what is our response? Do we close the gate or escort him inside?

I don’t believe that an isolated episode of plagiarism should permanently disqualify someone from becoming a physician, or remaining one. I do think, however, that this is a serious offense that merits a designation of impaired. The offender would need to admit the failing and submit to a process of reeducation and rehabilitation, similar to what is required for other afflictions. The most critical time to address any ethical lapse would be during the undergraduate years and during medical school, with the hope that early detection could change the game.

I’m interested in the readers’ views, particularly those who disagree with me. If you like this post, feel free to ‘cut & paste’ it into your own blog, under your own name, of course.

Sunday, October 24, 2010

ABIM Board Recertification Exam: Threat Level Green

Two Thursdays ago, I took the American Board of Internal Medicine (ABIM) recertification examination in gastroenterology (GI).   Whistleblower readers have already digested some of my musings on this event.  The good news is that there was no penalty for incorrect answers.  The bad news is that I submitted many incorrect answers.  Every one of these standardized tests that we all take becomes a mind game, where the examinee (us) tries to penetrate the psyche of the test makers (them).  We’ve all been there.   We torture ourselves between what we think is the right answer, and what we think that the questioners think is the right answer.   Sometimes, I thought that the ‘correct’ answer on the list is out of date, which confused me.  Or, what I felt was the truly correct answer, wasn’t included in the answer choices.  For example, I am a very conservative practitioner, who often advises observation, rather than tossing patients into the diagnostic arena.  In a few of the exam’s clinical management questions, I would have chosen ‘wait and see’, but on the test I was forced to scope, scan or operate. 
I didn’t invest even one nanosecond to prepare, which I think was the proper strategy.  I’ll find out in a few months. This is clearly a test that one cannot study for.
Many of the questions were reasonable.  Physicians’ define reasonable as an easy question that we know the answer to.  Unfair questions are all the rest.  Many questions do not relate to typical GI community practice, or they ask the examinee to resurrect an arcane medical fact, that was last known to us during the heady memorization days of medical school. 
Years ago, I submitted sample GI questions to the ABIM, at their request, to be considered in the internal medicine board certification exam.  This wasn’t an easy task, and I recall it took considerable effort to create just a few questions.  Here are some of the hurdles.  Is the question’s content reasonable for an internist?  Should the question test medical knowledge or judgment?  Is the clinical narrative realistic?  Is sufficient information included to lead the examinee to the correct answer?  Should I insert an irrelevant piece of data to distract the test taker, as occurs in the real world?  Has the question been sanitized of ambiguity so that examinee doesn’t develop bulging neck veins and a paroxysmal surge in blood pressure?
Is an exam question reasonable if you could find the answer by consulting a reference, as we do in everyday practice?  Of course, we do not need conventional text books or journals  any longer, now that we have 24/7 access to the world’s most authoritative medical resource – Wikipedia.  I think that internet use should be permitted during the exam to replicate actual medical practice.   Do physicians have to know the right answer immediately or simply know how to find it?
I think that creating exam questions is a useful exercise for medical students and residents, and even for practicing physicians.   Try it yourself.  Devise a few board questions and show them to colleagues. Be prepared for some critical reactions.  It’s not as easy as it looks.
However, many medical standardized exam questions are downright silly, and are of marginal clinical relevance.  On every one of these tests that I’ve ever taken, there are always a slew of patient vignettes that are literally foreign to American physicians.  Patients on these exams do a lot more foreign travel than my real patients do.
Here’s a sample question, which is solely the product of my imagination.  I will never divulge, even under hypnosis or interrogation, any of the copyrighted materials on the GI board exam.  I do not want the ABIM enforcers to snatch me in the middle of the night and escort me on a perp walk, cuffed and shackled, while reporters blind me as their flash cameras detonate.  

A patient returns home from Southeast Asia and develops a series of wacky symptoms. Chartreuse colored fluids are being ejected from various bodily orifices. He has a rash in the right nostril (see Figure A) and noticed some tingling in the ring fingers of both hands. For the last week, he has been speaking in rhyme and has developed a craving for guacamole. There is stridor present, which is quite ‘inspirational’. (Click Audio) Labs are notable for the abnormal trace element levels listed below.

Which of the following diseases that you’ve never heard of is the likely diagnosis?
The most impressive aspect of the experience was the security.  When I arrived, I had to show 2 forms of identification.  The testing administrator didn’t simply glance at them, he studied them.  I had my palm vein pattern recorded and my photograph taken.  I was advised that I would be monitored by video and audio devices.  I wondered if an examinee read questions softly aloud to himself, and was caught on audio, that a trap door might snap open underneath him.  Poof, another physician prematurely retiring! Every time I entered the sacred exam room, I had to empty my pockets and roll up my sleeves.   You could not enter or leave the room without a photo ID check and a palm vein scan.  When I returned for the final session after lunch, the proctor nabbed me trying to sneak my wristwatch into the exam room, which I forgot to remove.   “It was an accident,” I protested.  Was my medical career over?  Fortunately, this major ethical lapse did not constitute ‘irregular behavior’.  I’m sure after this incident, that I never left her site. 
Of course, I agreed to the Pledge of Honesty, and was given a list of admonitions afterwards that promised to send me to the gulag if I gave any test info away.
I am not here to criticize these security personnel, but to praise them.  I felt a lot more secure there than I do at the airport.   In fact, the Homeland Security Advisory System assigned a Low threat level in my testing center.   There were no free peanuts, but there was peace of mind.

Sunday, October 17, 2010

Advanced Cardiac Life Support and Tort Reform

Photo Credit

Two days from this writing, I will go mano a mano with a computer screen.   This will be my second gastroenterology (GI) board recertification.   Last week I suggested that the 490 minutes of unfettered fun might not be money well spent.  A reader could infer my view that the $1200 fee has more to do with securing the finances of the American Board of Internal Medicine than it does to enhance my knowledge of GI.   Perhaps, I was hyperventilating about the cost.  When I calculate the GI board CPM (cost per minute), I determine that the exam only costs $2.45 per minute   In other words, a full minute of quality board testing time costs about the same as a slice of pizza.  Clearly, the test is a bargain, and I retract any prior Whistleblower whisperings that contradict this. 
Yesterday, I took another exam, this one to recertify me as a qualified Advanced Cardiac Life Support (ACLS) practitioner.  An excellent paramedic instructed me and my 2 GI partners on new developments in basic life support, medication strategies to resuscitate the moribund, airway management and proper use of a defibrillator. 
Since my internship and GI fellowship,  I have never  had to administer life support.  This is fortunate for me, and for the patients, since I am unqualified to perform ACLS, despite my certification, which I am required to have..
You recall the 3 important initial steps of basic  life support.   These lifesaving ABCs are
  • Airway
  • Breathing
  • Circulation
I have my own 3 step emergency plan that I am always ready to implement.  They are
  • 9
  • 1
  • 1
Practicing physicians are simply not skilled advanced  resuscitators. If an individual collapsed, many physicians nearby would hope that paramedics would arrive before the doctor would have do any doctoring.   Indeed, many physicians are reluctant to identify themselves as doctors in emergency situations.   I’m not suggesting that any of us would stand aside if there was a person in dire need of urgent medical care.   However, if there are 20 physicians in a theater, and a frantic call is issued for a physician, some doctors might hesitate hoping that there is an ER doctor or a cardiologist who will step up.
The public wrongly believes that a medical degree includes lifelong lifesaving skills.   If someone drops while she shops, she might fare better if there is a boy scout nearby, instead of an allergist, dermatologist, psychiatrist, family doctor or even a gastroenterologist.
Jewish law mandates that an individual intervenes to save someone’s life.  The Talmud teaches, "...if  one sees his friend drowning in a river, or if he sees a wild animal atacking him, or bandits coming to attack him, that is he is obligated to save [his friend."   This concept is not part of American jurisprudence.   It is legal to stand idly by when someone needs to be rescued, even if such a choice would be morally reprehensible.   While there is no law requiring that we act to save someone, there are laws in all 50 states and the District of Columbia that try to encourage us to do the right thing.
We are all familiar with the Good Samaritan legal doctrine.  These laws provide immunity to folks who provide good faith emergency care to people who are at risk of death.  If a man suffers cardiac arrest and needs cardiopulmonary resuscitation, the Good Samaritan law protects the rescuer from being sued if the individual dies or survives with a devastating result.   We do not want fear of a lawsuit to restrain an individual from stepping in to save someone’s life.  It would seem difficult to argue against this concept, but nothing would surprise me in the irrational and unfair medical liability arena. 
In my medical practice and yours, if an adverse event develops, despite good faith and proper medical care, there is no Good Samaritan shield to protect me.   To paraphrase an oft quoted line from the New Testament, the truth may not set me free, at least not right away.
I think that the medical liability system needs to be defibrillated, wiped clean to allow society’s moral pacemaker to generate a new rhythm.    I’m ready to charge the paddles.  Are you?

Sunday, October 10, 2010

Board Recertification in Gastroenterology: More Fun than Colonoscopy

Photo Credit

This coming Thursday, I will have the joy and pleasure of taking the gastroenterology (GI) board recertification exam.   There will be many entertaining elements to the experience, as other board certified physicians already know.  Although there will be many fun delights, some will clearly be more amusing than others.
Which of the following features of the GI board examination will be most fun?  While more than one answer may be correct, choose the best answer.
(1)    A 490 minute all day exam is a thrill, by definition
(2)    Losing a day of income
(3)    Paying the American  Board of Internal Medicine (ABIM) $1200
(4)    Pleasing my partners who will cover my practice
(5)    Having my palm vein recognition scan to verify my identity every time I reenter the room
During this exam, each giddy examinee will be provided with a computer station.  I am nostalgic already for the proctor of yore announcing, ‘pencils down!’, as there will be no pencils permitted in the examination room.  In fact, many items are forbidden in the sancta sanctorum, the examination chamber. For example, portable phones, wallets and watches are classified as contraband by the ABIM Security Police.  While I understand that my phone could be a secret repository of important facts on the life cycle of the hookworm, a likely exam topic on a parasite that no American gastroenterologist ever sees, what’s the fear about wearing a timepiece?   Are they worried that my watch might be an upgraded version of Maxwell Smart’s shoe phone, allowing me to quietly ‘phone a friend’ whom is poised to Google my urgent request?   
At the present time, the ABIM is still permitting test takers to take the exam fully clothed, although this policy is under review.   Security professionals are concerned that examinees might have secret wires and antennae woven into their underclothing, which could transmit stealth information on hemorrhoids and flatulence –key board topics – to the GI board certified wannabee.   Perhaps, the ABIM intel pros fear that a ‘wristwatch’ might actually be a monitor where such improper information could be displayed.  This would explain the wristwatch prohibition.  The solution, of course, is to require that all examinees take their recertification exams naked.  While this appears to violate established social mores, this is outweighed by ABIM’s desire and obligation to secure the exam.  This should be acceptable to medical professionals who confront nakedness every day.  After all, we are doctors.  The proctor, however, who does not have a medical degree, would have to be blindfolded throughout the exam.
I now mention a specific ABIM board examination restriction in its own paragraph to set it apart.  I, MDWhistleblower, solemnly affirm that the following sentence is true and is paraphrased from the ABIM web site.  Examinees are not permitted to bring suitcases in the exam room.  I wish I were funny enough to make stuff like this up.
Of course, we will be warned that any ‘irregular behavior’ will be reported to the authorities, which can result in severe professional sanctions.   We gastroenterologists know more about irregularity than any other physician, and we should have been consulted on this issue.   We would have suggested that any first offenders be subjected to a rigid sigmoidoscopy performed by a first year surgical resident.   I suspect this would serve as an adequate deterrent against temptation, and would guarantee very regular behavior.
Before the examination begins, I will have to agree to a Pledge of Honesty.  I’d like the ABIM to agree to a Pledge also.  Do they pledge that this examination, and the 5 required home study modules that preceded it, will make me a better gastroenterologist?    I have already opined on this issue.
Do any other physicians believe that board recertification is ‘irregular’.  If so, I propose a rigid response to the ABIM.

Sunday, October 3, 2010

The Myth of Electronic Medical Records

Painting of Paul's Damascus Road Conversion

Electronic Medical Records (EMR) promises to be the holy grail of modern medicine.   It aims to deliver us from the Smith Corona era into the digital age.   I’m a gastroenterologist who has already been practicing digitally for two decades.  I guess I am way ahead of my time

Is EMR progress?    Consider these two hypothetical  patient assessments.  The assessment is a critical section of the medical record where the physician shares his thinking on the patient’s condition.   The assessment answers the question, “What do you think is going on here and why?” 
The Old Fashioned, Archaic, Fossilized and Sclerotic Assessment
The quality and timing of the patient’s abdominal pain is strongly suggestive of mesenteric ischemia (lack of blood supply to the guts), as the pain consistently develops  45 minutes after meals.  The patient has numerous risk factors for this condition.   Peptic ulcer disease is unlikely as the patient has been on an effective anti-ulcer medicine for months.   The frequency of the pain is not typical for gallbladder disease or pancreatitis…
The New & Improved EMR Assessment
Abdominal pain, unspecified
Our office manager admonished me earlier this week because I was free typing the medical history section, rather than use ‘point and click’ ( P & C).  Apparently, if I free type and forego the template entirely, it stymies the coding process.  (For non-physicians, coding = getting paid.)  While EMR vendors are convinced that medical histories can be recorded using P & C technique, I’m a deep skeptic.  The medical history is a narrative, a record of a fluid, and sometimes meandering dialogue between patients and physicians.   The history probes in all directions.  It wanders.  It creates new passageways. The patient’s response to a question often opens up a new avenue of inquiry, a function that cannot be reproduced on a rigid template.   
Imagine how our personal conversations would be if we communicated using a P &C template.

Steve:  “Jim, it’s great seeing you?  It’s been a while.  How’s it going?”
Jim:  “Samantha’s having a rough time with chemo and I was just laid off.”
Steve: “Fantastic!  Are you free to golf this weekend?“

I do believe that EMR systems in time will fulfill their early promises.  They will incorporate excellent voice recognition software.  The myriad of EMR systems will be integrated so that a recent emergency room visit will automatically be transmitted to my patient’s EMR record.   Patients will have their medical histories, EKGs, medical images, etc., recorded on flash drives, which will load into any EMR system.  When this occurs, it will no longer be possible to be an EMR non-believer.
But, some of today’s EMR whistles are whistling in the dark.  For example, we physicians all nodded like bobble-head dolls when we were told that we could have access to patient’s records at home after hours.  This meant that when we received weekend phone calls from our partners’ patients, whom we did not know, we could access their medical record and give better medical advice.   Of course, this makes sense, but is it really true?
First, it’s tough for cyber neophytes like me to boot up the laptop when a patient calls while I am behind the wheel.   Secondly, I have been handling patient calls at all hours for 20 years, and I have somehow managed to handle the issues with few catastrophic consequences.  Indeed, all practicing physicians have developed this important skill set of triaging patients by phone.  Our role here is not to make a diagnosis; it is to decide if a patient needs an emergency room visit or can be seen electively in the office.   I’m not suggesting that reviewing record is not useful, only that the benefit of instant access may be exaggerated in certain circumstances. 
I’m sure that EMR 2.0 and its descendants will ultimately deliver.  So far, it hasn’t surpassed ink on paper in my practice, although it's only been a few weeks.  So far, as expected, EMR has not brought me closer to my patients.  To paraphrase a past U.S. president, it's a divider, not a uniter.

I realize that there are some physician EMR users who worship the new technology. There are indisputable advantages that they can and will bring to medical care.  Some EMR systems may be better than others.  However, this has not a downhill sleigh ride for many doctors and patients, at least not yet.  Interestingly, the majority of physicans are still content to use paper charts.  In the near term, they will transition to EMR, not so much because of a Damascus Road conversion, but because payers will require it.

I admit that with each passing week, it is getting smoother for us.  But, it has taken an enormous investment of T & T (training & tweaking) time, which is ongoing.  And, we haven't yet incorporated our endoscopy practice into the system.   At the start, it may take longer to document a colonoscopy than to do one.
For me, blogging is the EMR antidote.  It’s open terrain.   There are no moats or fences.    It’s unpredictable and spontaneous.    It’s emotional and creative.   It has a point, but not a single click.