Sunday, December 25, 2011

Whistleblower Holiday Cheer 2011!

Jingle Bells, jingle bells,

Romney cracks a smile,

Oh what fun it is to watch

The Gingrich pompous style.

Bachman bleats, Cain retreats,

Huntsman tries to please.

Oh what fun it is to watch,

When Perry’s brain goes freeze!

Ron Paul’s weird, Very weird,

Santorum has no chance,

Oh what fun it is to watch

His Tea Party romance.

Who will win? Who will Spin?

Who won Debatorama?

The winner dancing in the streets

Is Barack Obama!

Wishing you Joy & Peace

Sunday, December 18, 2011

Colt McCoy's Concussion Fumbled by Team Physicians

The Cleveland Browns have been in the news this week, and not because of newfound success on the gridiron. While sports is not among my highest priorities, I have developed increasing interest over the years since professional sports is religion to so many here in Cleveland and in Ohio. Cleveland sports teams all enjoy great success, provided that success is not defined by victories. It’s not if you win or lose but how…

I watched the Cleveland Browns compete against the Pittsburgh Steelers two Thursdays ago. I cringed as I witnessed our young quarterback, Colt McCoy, take a blow to the head that could have landed the perpetrator a 10 year prison sentence had this act occurred on the street. I wasn’t worried that McCoy would have to miss the rest of the game. I feared that he might have to miss the rest of his life. Violence sells tickets.

If an activity requires a participant to don a helmet and a coat of armor, then clearly it is an unwise activity for a human to engage in.

McCoy was taken off the field and reentered the arena 2 plays later, after an exhaustive evaluation that was completed in about 100 seconds. Since everything in sports and medicine is now measured, we know that McCoy was sidelined for a total of 3 minutes and 50 seconds before his soggy head reentered the arena. Perhaps, emergency room physicians should consult the Browns’ medical staff to learn how they can expedite their medical evaluations in their emergency rooms. With a little training, a heart attack patient, for example, can be treated in 3 minutes or less.

McCoy’s father went public chastising the Browns for the decision and the process that led to his son Colt returning to the field. While the NFL is now investigating, the Browns maintain that proper procedures were followed.

As more facts dribble out, we learn that McCoy did not receive the standard medical evaluation that is required after a suspected concussion known as the SCAT2 (Standard Concussion Assessment Tool , version 2). Apparently, Browns’ medical personnel were attending to others and did not witness the helmet-to-helmet collision. Are these folks aware of the futuristic technology commonly known as instant replay?

If the only medical training you ever had was how to swallow aspirin or apply Band-Aids, it is likely you would know that a 4 minute time out is not a sufficient assessment period after a cannon ball blow to the skull. Initially, the Browns were vague on the extent of neurologic testing that was performed on the concussed quarterback. We now know that there was no evaluation.

As a physician who has been sued, I am sensitive to applying blame retroactively. I can understand based on the available facts why McCoy was sent back in. But this event shows that either the process is flawed or that proper procedures were not followed. This episode warrants investigation for the right reasons, not simply to apply the broad brush of blame to make some folks feel good.

Nevertheless, this is a particularly galling vignette for physicians like since we are trained and dedicated to practice high levels of patient advocacy. We advise our patients on what we believe to be in their best interests. Sometimes, we take heat for this. We may, for example, advise an individual that they should surrender their driver’s license. We may counsel a patient not to travel even though a family trip was planned months ago. We may warn a patient that his job is threatening his health.

Our advice should not be contaminated by external considerations. We would not, for example, clear a patient to return to work prematurely because this would serve the employer’s interest.

In professional sports, team physicians advocate for the team. Obviously, there is an enormous conflict between serving the team and serving the player. If McCoy’s primary care physician were consulted after the head thrashing incident, do you think he might have offered a second opinion? Let’s hope so.

Sunday, December 11, 2011

Colonic Hydrotherapy and Colon Cleansing; Time to Bend Over?

Garden Hoses in Assorted Colors

A few times each month, a patient asks me for my opinion on colonics. They ask me because I am a gastroenterologist, and I am supposed to know this stuff. After 2 decades of performing colonic intrusions, I should be well qualified to respond to these alimentary inquiries.

To those who are unfamiliar with the concept of colonic detoxification, I offer a brief rationale of the procedure. Those who have been lured into the Fraternal Association of Rare Toxins (acronym not provided) have been persuaded that stagnant stool within the colon is a source of toxins that seep into the body causing disease. According to the anti-toxin crowd, when stool overstays its colonic welcome, it can lead to chronic fatigue, lassitude, restlessness, irritability, mood disorders, skin rashes, arthritis, cardiac rhythm disturbances, seizures, allergies, dementia and the murky diagnosis of candidiasis, or yeast infection. This symptom list could apply to half of my medical practice. So far, I've never prescribed a colonic to any of these sufferers. Have I been medically negligent to withhold this treatment from them?  Could a plaintiff attorney accuse me for failure to cleanse?

This is a scary symptom list, which is only a partial listing of the maladies attributed to a slothful colon. Patients reading through these symptoms, might be inclined to use a garden hose for an unintended purpose. Amateurs, however, are strongly advised not to do try this at home. Leave it to the professionals, who are trained to separate you from your stool and you from your money. They succeed on both counts.

To assist you in your research efforts, be aware that there are various names for colonics.
  • Colonic cleansing
  • Colonic hydrotherapy
  • Colonic irrigation
  • High colonics
  • Wallet cleansing
Then names may change, but the mission doesn’t. The objective is to get the colon toxins out. The motto of the Society of Hydrotherapists Investigating Toxins (acronym not provided)  is, Don’t just die, detoxify!

If any readers at this point are tremulous over your toxins, let me reassure you.  There is no science that supports colonic cleansing and no responsible medical doctor will prescribe them.  Indeed, if a health professional does recommend that your colon gets hosed down, I'd look for a second opinion.  Obviously, stool is waste matter.  That's why your intestinal system reliably and regularly eliminates it from your body. There is no persuasive scientific evidence that dangerous 'toxins' in your stool leech into your body and cause disease in normal folks. Hydrocolonic power washing can't compete against millions of years of human evolution. 

But, colonic hydrotherapy is big business, and I'm aiming to get a piece of the action.When health care reform gets underway in a few years, and doctors are on salary working supervised by government bureaucrats, I’ll need a side job to make a living. The colon can again be my pathway to success, particularly as colonscopy becomes obsolete. I’ll need a niche as the colonics competition will be fierce, from out-of-work gastroenterologists who will be on the street corner with a sign that reads, Will Do Colonic for Food. However, it won’t be enough to offer routine colonics to gain a foothold in the marketplace. I will need to provide a Bionic Colonic, or perhaps a Supersonic Colonic to turn a profit. Of course, there will be family discounts and volume pricing. Kids under 12 will be half-price. Tuesdays will be Ladies Night. Pets? Endless possibilities.

A year ago, I was worried that health care reform legislation, if it became law, would erode my livelihood. More wiser now, I realize health care reform will be a fountain of opportunities for resourceful physicians. For this gastroenterologist, there’s light at the end of the tunnel.

Sunday, December 4, 2011

Pay-for-Performance Attacks Hospitals - Shake Down or Fair Play

This blog has tried to support the virtue of personal responsibility. If you smoke, don’t blame Joe Camel. If you surrender to Big Mac attacks, don’t go after Ronald McDonald. If you love donuts, and your girth is steadily expanding, is it really Krispy Kreme’s fault? And, if you suffer an adverse medical outcome, then…

Medicare aims to zoom in on hospitals, suffocating them with a variation of the absurd pay-for-performance charade that will soon torture practicing physicians. Of course, a little torture is okay, as our government contends, but pay-for-performance won’t increase medical quality, at least as it currently exists. It can be defended as a job creator as several new layers in the medical bureaucracy will be needed to collect and track medical data of questionable value.

Medical quality simply cannot be easily and reliably measured as one can do with a diamond, an athlete or a wine. Most professions resist being graded or claim that the grading scheme is a scheme. Teachers, for example, refute that testing kids is a fair means to measure their teaching performance. Conversely, any individual or profession who scores well on any quality review program will applaud the system’s worth and fairness. Shocking.

Under the government’s new program, hospitals could be financially responsible for the cost of medical care that a patient requires for up to 90 days after discharge. One can imagine why this provokes angst with hospital administrators. It’s easier to defend the government’s concept if a heart attack patient is discharged prematurely and is readmitted two days later with congestive heart failure. The case is harder to argue is a stroke patient falls at a rehab facility 2 months after discharge and needs to be hospitalized. There will be spirited arguments as to whether the post-discharge events were preventable by higher quality and better coordinated out-patient care. Paradoxically, it might influence hospitals to prolong discharges, which increases costs and the risks of various hospital adventures, including infections and C. difficile colitis.

Government lexicographers have concocted a new phrase, ‘Medicare spending per beneficiary’, which will be used to compare costs among hospitals caring for the same types of patients.

How much responsibility can fairly be assigned to hospitals for bad stuff that happens once patients are released? If a medical event occurs at the nursing home, for example, would this be the hospital’s fault or the nursing home’s? It will be fun to watch the two institutions, who both champion patient care, duke at out. Cash breeds competition.

One item is beyond dispute. It’s a lot easier to measure cost than medical quality. I fear that many of these quality initiatives are veiled attempts to save money, but are camouflaged as medical quality incentive programs.

The ironic flaw in all of this is the absence of any quality control over pay-for performance and its cousins who claim they can raise the medical quality bar. I wish there was a way that we could pay these guys depending upon their performance. The government would resist this as it would be a job killer when all of these newly hired bean-counting bureaucrats would lose their jobs.

Sunday, November 27, 2011

Fecal DNA for Colon Cancer Screening and Cleaner Sidewalks: Which Matters More?

It’s Saturday morning, and I’m in an undisclosed location drinking a fabulous cup of coffee while turning the pages of The New York Times, knowing that ink and newsprint will be vanishing too soon. Yes, I do have an iPad now, but I haven’t figured out how to blog on it. Any suggestions?

Buried in the first section of the paper is an article on stool, which in my view as a gastro specialist, should have merited front page placement. Yes, we all know the adage, ‘one’s man’s trash is another man’s treasure’, but stool - as in excrement - should be prized by everyone. Perhaps, as a gastroenterologist, I have a jaundiced view on this issue, which explains my dyspeptic reaction.

All Whistleblower posts have an accompanying image, and I wonder what visual would be appropriate here.  I opted against my first choice, and chose instead a photo of our beloved Labrador Retriever, Shoshie, of blessed memory.

The Times reported a new program to trace canine unscooped poop back to Spot’s owner. Several apartment complexes around the country are now participating. All dogs residing there will submit a DNA sample that will be forwarded to data base. Hopefully, the mailing containers will be secure. It is not clear if a fecal sample can be acquired without obtaining canine informed consent, documented with a paw print, but until the courts rule on this issue, doggie cheek swabbing will continue.

Here’s how it works. If a pedestrian steps in the wrong place, as in ‘glitch’, then a sample from the bottom of the soiled shoe can be mailed to the Turd Squad to determine if there is a DNA match in the data base. If a connection is made, then the pet’s owner will be properly shamed and sanctioned.

Of course, howls of protest will erupt from barking pet owners who will challenge the company’s scientific credentials, or will claim that they were set up by landlords who were seeking back rent. Hey, Dick Wolf, is there a new version of Law and Order Here? How ‘bout, Law and Order: Excremental Intent?

I love seeing gastroenterology making an important difference in people’s lives.

Fecal DNA, I anticipate, will be doing much more for us than keeping our sidewalks a little cleaner. This technology may be the force that transforms colonoscopy from its position as the premier instrument to investigate the colon and to prevent colon cancer into a museum piece. I suspect that that this transformation will occur sooner than we all think.

While the FDA (Food and Drug Administration) has not approved fecal DNA testing for colon cancer screening, professional societies including The American Cancer Society, the U.S. Multi-Society Task Force on Colon Cancer and The American College of Radiology all endorse stool DNA testing as a screening alternative.

In the coming years, there will be a parking lot rumble among competitors who will argue that their colon cancer screening is best. I think screening colonoscopy has some good years left, but this is not the future. Fecal DNA promises to be one mean screening machine.

Sunday, November 20, 2011

Lawyers and Medical Malpractice Reform: Tort Reform Allies for Doctors?

When lawyers talk, I listen. Two attorneys penned a piece on medical malpractice reform in the April 21st issue of The New England Journal of Medicine, the most prestigious medical journal on the planet. Here is an excerpt from their article, New Directions in Medical Liability Reform.

The best estimates are that only 2 to 3% of patients injured by negligence file claims, only about half of claimants recover money, and litigation is resolved discordantly with the merit of the claim (i.e., money is awarded in nonmeritorious cases or no money is awarded in meritorious cases) about a quarter of the time.

This is not self-serving drivel spewed forth by greedy, bitter doctors, but a view offered by attorneys, esteemed officers of the court. Apply the statistics in their quote to your profession. Would you be satisfied if your efforts were benefiting 2-3% of your customers or clients? Would this performance level give me bragging rights as a gastroenterologist? Perhaps, I should attach a new slogan to my business card.

Michael Kirsch, MD


Correct Diagnosis and Treatment in 2-3% of Cases

We would have to build a second waiting room to accommodate the crowds of new patients who would be jamming in to see me.

The current medical malpractice is beyond broken, and it is absurd to debate this. When even lawyers write under their own bylines that medical malpractice reform is needed, then it must be even worse than I thought. I assume that their bylines are true, but perhaps they used pseudonyms for their own protection.

In fairness, the authors did not find persuasive evidence that various medical malpractice reform proposals, some of which I have advocated on this blog, would accomplish the desired objectives of improving care and controlling costs. They examined various reforms including damage caps, pre-trial screening panels, certificate-of-merit requirements, joint-and-several-liability reform and statutes of limitation limits. They advocate continued study and experimentation to achieve meaningful medical malpractice reform.

As a physician, I understand the value of evidence. We should not adopt a medical malpractice reform measure that is shown be ineffective, even if doctors like me favor it. This assumes, of course, that the reform measure has been fairly tested. Debating tort reform proposals is a legitimate discussion and lawyers should be included in the conversations.

Defending the current system, however, is not legitimate. Even lawyers admit that the current system targets but a tiny fraction of patients who have been harmed by medical negligence. What relief do the other 97% of patients receive? In addition, the system targets too many innocent physicians, ultimately releasing most of them after dragging many of us on an agonizing journey. In my office, and probably in your doctor’s office also, litigation fear promotes defensive medicine, which harms patients and costs money.

I will now turn away from tort reform and turn to my morning pleasure, The New York Times. I read a hard copy with ink and newsprint, but I am sure that this anachronism will soon be extinct. I have a new suggestion for their motto, which appears in the top left corner on page 1 of every issue.

“2-3% of the News

That’s Fit to Print”

Sunday, November 13, 2011

Joe Paterno Fired: Proper Punishment or Political Correctness?

As a gastroenterologist, I know a few things about scoping. Indeed, every working today I am tunneling through either end of the alimentary canal. These exercises are literally and figuratively enlightening as I seek new information that will make patients’ lives better or keep them well.

Endoscopy is an example of prospective scoping, meaning the result of the scope is not yet known because the diagnostic study had not yet been done. This contrasts with the concept of retroscopy, which describes the concept of looking backwards at events that have already transpired and then making judgments on these events. In the vernacular, retroscopy is known as ‘Monday morning quarterbacking’.

While I am not officially credentialed in retroscopy, and received no training in this procedure during my gastroenterology training program, I am quite familiar with the technique. Retroscopy is one of the main tools wielded by medical malpractice plaintiff attorneys who sue physicians for alleged medical negligence. It is in easy task in medicine, and in life, to look backwards after a tragedy has occurred and to assign fault by demonstrating how the event could have been averted. Those of us who must operate in real time, however, do not have power of clairvoyance which would enable us to choose the path that leads to a blissful outcome. We have all read about police officers who are vilified after using excessive or even deadly force against an individual. While there are times that law enforcement have clearly erred, on other occasions I’m not so sure. I’m grateful that I don’t have to make a split second decision with a gun in my hand as I face someone whom I believe poses an immediate danger to me or to others. What if the officer were to hold his fire and the suspect would then shoot some innocent bystanders? During the inquiry that properly follows deadly force by law enforcement, a team of investigators may take weeks combing through every angle and aspect of the episode to determine if the officer was trigger happy. The officer may have had but a moment to make his decision.

We physicians face the same unfair process when years after an unfortunate medical outcome we are chastised for failing to prevent the disaster when we - through the retroscope - had ample opportunity to do so.

“Why didn’t you recommend surgery, doctor, which clearly would have saved the patient?”

Because at the time the medical and surgical team believed that the patient would not have survived surgery and that continued intensive medical treatment was appropriate.

“Why didn’t you prescribe the antibiotic that was appropriate for the infection?”

Because, the rare germ that was infecting the patient wasn’t identified until autopsy.

“Why did you discharge the patient 12 hours before he returned to the hospital with a massive heart attack?”

The patient was discharged after a routine hernia repair. He had no symptoms at discharge and was properly sent home.

I think that Joe Paterno has been victimized by the retroscopers. He was fired this past week for failure to have done more after he was notified in 2002 of an illegal and indecent act that was perpetrated by a former defense coordinator. He didn’t bury the information, but promptly informed the athletic director and a Penn State vice president of what he was told. True, he did not follow-up on the issue afterwards or notify law enforcement of what he knew.

Interestingly, the two Penn State individuals who have been charged with crimes will have their legal bills paid by the University, while Paterno, a cooperating witness, was fired. Sure this might be a contractual requirement, but does it sound fair?

As more facts emerge, we will learn that many had knowledge or suspicions of sexual abuse, but remained silent.  What standard will be applied to them?

Should Paterno have done more? Yes, and  Coach Paterno deeply regrets his inaction, as he has stated publicly. However, is firing him the proper and proportionate response in the context of a lustrous career that spanned decades? He has spent 62 years at Penn State including 46 seasons as the Nittany Lions’ head coach. He has been a role model for thousands and thousands of young athletes and students on his campus and throughout the country. He has a legendary reputation.  By any measure, this man has done much good over a long and brilliant career.

He committed no crime and did not engage in a cover up. He made a mistake. In my view, his abrupt and ignominious ouster was wrong. This affair could have been handled much more gracefully, preserving the coach’s dignity, while still demonstrating disapproval of Paterno’s stopping short 9 years ago.

I know that my view here is not popular, but I hope that readers will give it fair-minded consideration. 

Is this the best that Penn State could have done? I don’t need to pull out the retroscope here. I’m watching the game in real time. Penn State fumbled.

Sunday, November 6, 2011

Medical Malpractice Reform Losing Physician Support

With regard to physicians’ support for medical malpractice reform, the times they are a changin'. These iconic words of Bob Dylan, who has now reached the 8th decade of life, apply to the medical liability crisis that traditionally has been a unifying issue for physicians.

The New York Times reported that physicians in Maine are going soft on this issue, but I suspect this conversion is not limited to the Pine Tree State. Heretofore, it was assumed that physicians as a group loathed the medical malpractice system and demanded tort reform. The system, we argued, was unfair, arbitrary, and expensive. It missed most cases of true medical negligence. It lit the fuse that exploded the practice of defensive medicine. Rising premiums drove good doctors out of town or out of practice.

What happened? The medical malpractice system is as unfair as ever. Tort reform proposals are still regarded as experimental by the reigning Democrats in congress and in the White House. The reason that this issue has slipped in priority for physicians is because our jobs have changed. Private practice is drying up across the country for the same reasons that family owned hardware and appliance stores are vanishing. Look what has happened to independent bookstores? If you want to find one in your neighborhood, you may need to hire a private investigator. Private physician offices are being squeezed out by surrounding medical institutions that, using Ross Perot’s famous phrase uttered in the 1992 presidential campaign, have created a ‘giant sucking sound’ as it vacuums up patients from private doctors’ waiting rooms.

This is only half of the story. Sure, the medical behemoths that employ doctors have cut deeply into private physicians’ patient bases. But, increasingly, physicians are joining these enterprises willingly becoming employees of hospitals and large multispecialty clinics. Understandably, these physicians who are entering their careers do not want the lifestyles of their predecessors. They want time off and a decent family life. They want hospitalists to admit their office patients who need in-patient care. They don’t want to spend hours of uncompensated time each week on paperwork that doesn’t help patients or improve their medical skills. They don’t want the stress of making payroll, hustling for patients or engaging in the fun pastime of trying to convince insurance companies to pay them what they are owed. You get the idea here. They are shifting to a shift work culture, and I certainly understand why.

Can these doctors still get sued? They can, and they will. But, they are not paying their own medical malpractice premiums. Some of the larger medical institutions that employ them are self-insured. Since these physicians are not paying the bill – or any bills – they don’t have the same stake in the game that we private practitioners do. Medical malpractice reform is still on their radar screen, but the blips occur at a higher orbit. They are focused on other issues.

What this means that one of tort reform’s most unified and vocal constituencies will lose interest in the medical liability issue. The crop of physicians entering the profession in the next decade just won’t view medical malpractice reform as a religion. Of course, they will reel when they are unfairly sued, as we do, but it won’t be an issue that commands much of their attention in between lawsuits.

Folk music is prophetic.  Where have all the doctors gone?  Long time past seen. Will medical malpractice reform ever really happen or will it continue to be just blowin’ in the wind?

Sunday, October 30, 2011

Medical Device Approval vs F.D.A. Whose Side Are You On?

Last week, I attended a 2 day medical conference in Cleveland on obesity. It was a heavy seminar, which I would rate 8 on a (bathroom) scale of 1-10. Interestingly, the majority of the speakers appeared to have BMIs (body mass indices) within the normal range. Coincidence? I suspect discrimination against rotund academicians. I’m sure that if any attorneys were in attendance, that a proper legal response would have been promptly initiated. They would take the matter on a contingency fee basis, or in a more novel approach, fees could be linked to excess body weight so that each pound that was unfairly discriminated against would be fully and fairly compensated. I’ve been told that I think like a lawyer. Is this a compliment I should graciously accept or a slur that warrants a lawsuit for defamation?

The conference was excellent and I hope to incorporate what I have learned into my practice. My community gastroenterology practice is ever expanding, and I don’t mean my patient volume.

There were lectures on exercise, nutrition, commercial diets, bariatric surgery, medications and medical devices. There was a fascinating lecture given at the conference’s conclusion by a banker who works with venture capitalists. He lamented that the F.D.A. was a major impediment against product innovation and delivering products to market. Investors and companies pour millions of dollars into start-ups or toward medical device research and are frustrated by what they believe are unreasonable governmental obstacles or migrating goal posts. He stated that this was not simply his personal view, but was a widespread view across the industry. Some of the consequences of this policy include:

  • Suffocation of of many small device companies and entrepreneurs
  • Diminishing competition to foreign device companies
  • Loss of investor confidence resulting in scarcer funds to fuel research and development
  • Encourages corporations to pursue ‘safe’ projects where F.D.A. approval is achievable but medical benefit is marginal
  • Harms the public by preventing or delaying new medical treatments from reaching them
A senior Cleveland Clinic physician offered a spirited rebuttal of the banker’s view stating that the system, while imperfect, is fundamentally sound. He pointed out various examples where recent medical devices were found to be seriously flawed which have cost millions of dollars and patients’ lives. Failing metal on metal hip appliances is the most recent example of the risk of under regulation. Indeed, it sounds horrendous for patients to have to undergo repeat hip surgeries because their new metal hips will soon be out of joint.

Earlier this year the Institute of Medicine (IOM) advised the F.D.A. that the system for approving medical devices should be scrapped, as it was too lax. The F.D.A., who commissioned the study, didn’t accept the IOM’s recommendations. Perhaps, they believe the agency can reform itself from within, always a dicey prospect.

Of course, a proper balance needs to be established between protecting the public and stimulating vigorous innovation. It seems to me that we are out of balance. We must recognize that no system will be perfect and please all players in the game. While we all strive to protect the public, if we tolerate no risk, then there will be no new products, devices or medications coming to us. How much risk is reasonable? There is no single answer here as most of us would tolerate more risk depending upon the circumstances. We accept more risk as the stakes increase.

While industry and the government have different interests and agendas, ultimately they both hope to serve the public good. Failed devices harm patients and harm industry by eroding the public trust.

All of us accept risk in our daily lives. Should the federal highway speed limit be lowered to 35 miles per hour? Why not? Wouldn’t this save lives? Wouldn’t this be worth some added travel time for all of us?

The political aspects of the medical device approval controversy were discussed in a New York Times article earlier this week which is worth a perusal.

Do you want more civil liberty protections or do you favor more power for intelligence gathering? Do save wildlife and forests or promote development and job creation? Do you want more public safety or do you want more medical innovation? It’s vexing to navigate through these tortuous conflicts.

We are being presented with a version of Trick or Treat. Each side claims to offer the treat and disparages the other as a trickster. It’s not quite that simple, is it?

Whose side are you on?

Sunday, October 23, 2011

Could Herman Cain Have Survived Obamacare? 9-9-9 Man With A Plan Speaks Out

Photo Credit

Herman Cain gleefully shouts to adoring crowds that he now has a target on his back. Amazingly, this non-pol has vaulted to the front of the back, leapfrogging over career politicians who have been running for president and other political offices for years. Can Cain go the distance? Does he have the right stuff? With a 'wink' toward Genesis, is Cain ‘able’?

He is derided over his 9-9-9 plan by folks who are scared that his bold and innovative reform proposal is attracting voters. They are more frightened that his plan may actually work. Critics point out or invent flaws in his proposal, trying to chip away at the edifice. Carping is a lot easier than constructing.

I’m not an economist and I have no idea if the 9-9-9 plan should be championed or stuffed into a pizza box and recycled. Increasingly, the public believes that whatever flaws and inadequacies 9-9-9 may have are preferable to the deficiencies and abuses of the current tax system.

Reform threatens the status quo whose agents will push back hard for all the wrong reasons.

A Whistleblower reader could use the above statement to challenge my numerous posted arguments against Obamacare, claiming that I am the hypocritical whiner who is clinging to the status quo and attacking medical reform.

This argument would have some merit if I accepted that Obamacare was truly reform, which I do not. Simply (mis)labeling the law as the Patient Protection and Affordable Care Act, doesn’t make it so. Over the years, I have been amused by the labels that legislators assign to the laws they sponsor. These names are often sanitized sheep’s wool covering up rotting carcasses.

Here are some other labels for Obama’s health care reform law that just missed the cut.
  • Phase 1 Government Takeover of Health Care Act
  • Medical Malpractice Attorneys Protection Act
  • Medical Private Practice Unaffordable Act
  • Medicaid Expansion Act
  • Pandering to Medicare Beneficiaries Act
  • Government Rationing of Health Care Act
  • Hassle Doctors Out of the Profession Act
  • The Democratic Party Protection Act
Of course, nothing is all good or all bad. There are elements of Obamacare that I do support. I do not think folks should be discriminated against for pre-existing medical conditions. I agree that everyone should have access to medical insurance coverage. I zealously support comparative effectiveness research, which I don’t think has a prayer to succeed against the medical industrial establishment. I support the objective of improving medical quality, but reject the pay-for-performance and related charades that will diminish quality and demoralize and punish doctors.

Herman Cain, like his GOP rivals, all promise to bury Obamacare if elected. Cain, a Stage IV colon cancer survivor believe that had Obamacare been the law of the land when he was ill, that he might have ascended prematurely to heaven.

If I had been under Obamacare, and a bureaucrat had been trying to tell me when I could get that CT scan, that would have delayed my treatment. I was able to get the treatment as fast as I could based upon my timetable, and not the government's timetable. That's what saved my life.

While Cain’s pronouncement may be hyperbole, patients should be concerned about the intended destination of today’s medical ‘reformers’. While the law is called the Patient Protection and Affordable Care Act, I think the law will strive for affordability at the expense of patient protection.

The government wants to shrink the pie and yet promises that we will all be satisfied. Which candidate today understands pies best?

This post is not a political endorsement. Herman Cain has not yet earned my support, but I’m glad he’s at the table. The ferocity of attacks against him convinces me that he has a valuable voice in the conversation. At the very least, it has forced the other candidates to defend their policies and positions. Competition breeds excellence. Let the games begin.

Sunday, October 16, 2011

Ten Questions to Ask Your Doctor?

The blog, Shots, posted a question primer to prepare patients for medical office visits with their doctors. A reaction to this appeared on Glass Hospital, where John Schumann offered his own wry version of the question list. My less wryer, and more drier response appears below.

While I agree with Shots that education is power, a closer look at the question list demonstrates that the intent to educate may obfuscate instead.

First, the post is entitled, Ten Questions to Ask Your Doctor, suggesting that patients arrive at their physician’s office armed with 10 inquiries spanning a spectrum of medical knowledge and philosophy including medical treatment strategy, physician qualifications, risks of treatment, medical treatment alternatives, choice of hospitals and even how to spell the names of their medications. (I guess Shots believes that spelling counts!)

Some of the questions sound reasonable, but could patients make sense out of the answers? For example, Shots suggests asking which hospital is best for my needs? Patients often are focused on the choice of hospital, when they should be more interested in which physicians will be caring for them. While the hospital matters, it’s much more important who will be performing your surgery, then where it will take place. Are patients equipped to evaluate hospital quality anyway? Is a good reputation or a shiny exterior a true surrogate for medical quality? Patients often have a negative view of a hospital based on an isolated anecdote, which they may not have even experienced first-hand.

Another suggested question is how many times have you done this procedure? Will this provide useful information for patients? I agree that for many medical procedures, a higher case volume means a lower risk of complications. But, will it enlighten a patient to know that the gastroenterologist has performed 2000 colonoscopies or 5000 or 10,000? Better questions, which can’t be quantitatively answered, would be how many times have you done this procedure well, or, how many of your procedures were truly medically necessary? I object to Shots’ version of the ‘how many’ question which simplistically reduces medically quality measurement to a check-off form, paying homage to the deities who gave life to the pay-for-performance beast. What really counts can’t be counted. Paradoxically, what can be counted, will count.

In addition, if you bring your doctor the 10 question list, be prepared for some frustration when your office visit ends and you’ve only covered the first 3 items on the list. There may not be time left for you to discuss the issue that brought you t see your doctor in the first place. It may take a few visits and a fair amount of dialogue for you to understand your physician’s philosophy and style of medical practice. This important information can’t be acquired by taking a multiple choice test or answering a series of questions.

The question list on the blog Shots is a guide that needs to be prioritized. You simply can’t cover them all in a single visit, and you shouldn’t have to. Experienced physicians know that patients often want to cover every last medical concern and we will often begin a visit with a question from our own ‘top ten list’. What are the 1 or 2 issues that we need to cover today?

Any questions?

Sunday, October 9, 2011

Health and Wellness Programs: Medicine or Marketing?

Shark Cartilage: Cancer Cure?

There’s a new term that has entered the medical lexicon. The word is wellness. Hospitals and medical offices are incorporating this term into their mission statements, corporate names, business cards, medical conferences and other marketing materials. The Cleveland Clinic Foundation has appointed a Chief Wellness Officer, an intriguing fluffy title that does not clearly denote this individual’s role and function. This is deliberate, as the word wellness is designed to communicate a ‘feel good’ emotion, not a specific medical service.

Just a click or two on Google will lead you into the wellness universe. Here’s a sampling.

  • Institute of Sleep and Wellness
  • Wellness Institute of America
  • Naturopathic Wellness
  • National Wellness Institute
  • Physicians Health and Wellness Center
  • Physicians Wellness Group
There’s even a sponsored ad on Google where one can search for physicians, presumably trained in the medical specialty of wellness. I was dismayed that my name didn’t appear in a wellness search of the Cleveland, Ohio region. Does this mean that I don’t offer my patients health and wellness?

Where is all of this wellness coming from?

It’s coming from marketing departments who understand the public mood. While conventional physicians view complimentary medicine warily, the public can’t swallow it fast enough. Patients want a softening of the medical profession and are willing to accept new genres of care based on promises, testimonials and faith. I admit that much of what my colleagues and I prescribe and recommend is based on scant medical evidence. I don’t have satisfying treatments for irritable bowel syndrome or chronic abdominal pain. I understand why such patients look beyond me and my colleagues for healing and relief. They are spending billions of dollars on herbs, colonic hydrotherapy, Reiki, massotherapy, holistic medicine, naturopathy, aromatherapy, biomagnetism, guided imagery, medication and homeopathy.

 Hospital and medical marketers may not know how to cure disease, but they sure can count. The vast majority of Americans have pursued alternative medicine for one reason or another. The medical establishment has expanded its healing mission to gain access to this huge and growing market. Conventional hospitals, where cardiac catheterizations and colonoscopies are performed, now offer a variety of wellness programming to extend their branding into the surrounding communities.

I think that we are risking a wellness overdose, and there is no antidote. My concern is that it confuses the public between ways to improve their lifestyles and state of mind and actual medical care and treatment. I concede that many alternative medical treatments make folks feel better, but I’m not sure they cure disease. There’s a danger in medicine when faith overtakes reason. An extreme example is when cancer patients were spending precious time and resources for shark cartilage or other high cost alternatives that have no scientific basis. These opportunities exploit desperate people who have no way out. They shouldn’t have to spend money to pray for a miracle. They can do that for free, and they should.

I know there is spirited belief and support for unconventional medicine to complement traditional medicine’s failings. If they want to turn skeptics like me into believers, then they’ll have to pursue a more conventional approach. Test your treatments in high quality clinical trials. If scientific studies determine that these treatments, or any therapies, offer no benefit, then abandon them rather than assail them as flawed and biased studies.

I’m in favor of any intervention that makes people feel good, provided it is safe and doesn’t exploit folks. Just because the word medicine is in the label, doesn’t make it so.

Sunday, October 2, 2011

Secret Shoppers in Doctors' Offices: Placebo Medicine for Physicians

Physicians are still debating whether prescribing placebos is ethical. Dissenters argue that this is dishonest and would erode trust between patients and their physicians. If the practice were to gain acceptance, then physicians’ credibility would be diminished. Patients would wonder whether the medicines their doctors are recommending are evidenced-based or fraudulent.

Patients can now push their own snake oil right back onto their physicians. I learned that the ‘secret shopper’ mechanism for quality assessment has been introduced into the medical profession. I first read about this in the March/April 2010 issue of the Journal of Medical Practice Management, a periodical that I suspect is not widely read by physicians.

Folks are hired as pretend patients and are dispatched to doctors’ offices and hospitals to document their findings. Their mission is to assess office staff, appointment issues and the waiting room experience. I wonder if soon they will add encore performances and will subject themselves to Pap smears and rectal examinations to assess doctors’ clinic skills and techniques directly.

Surprisingly, the American Medical Association’s Council on Ethical and Judicial Affairs endorsed the practice, although many physicians objected.

I agree that these pseudopatients could improve office quality by highlighting flaws that have not been recognized or remedied. Yet, I cannot support the stealth tactics of this quality control method. On its face, it is dishonest. It also costs medical practices and institutions time and money attending to people who are masquerading as actual patients. If the secret shopper strategy did gain traction in medical quality assessment, could it be used as an investigative tool by malpractice attorneys? Finally, the concept is wholly unprofessional using a technique that is generally used in large big box retail establishments and restaurants. It is demeaning that physicians are already being evaluated on Angie’s List and the Zagat survey, as if we are automobiles or toaster ovens.

The federal government has now indicated that it will initiate its own secret shopper program to gauge how difficult it is for patients to gain access into primary care physicians' offices.  Big Goverment becomes Big Brother.  Hours after this stealth plan was boldy announced, it was rescinded in a Big Retreat.

Let's make a deal.  Don’t make an appointment to see me unless you truly are seeking medical care. In return, I’ll never prescribe you a sugar pill. This will strengthen the trust between us, the foundation of a successful doctor-patient relationship.

Sunday, September 25, 2011

Better Bedside Manners? What's It's Worth To You?

How much are good bedside manners worth? Would you double your copay if you could be guaranteed an extra measure of TLC from your physician? Can we put price on a physician’s warm smile, an understanding nod or a reassuring hand on your shoulder? Do patients have to contract with a concierge medical practice to receive this treatment?

I agree that our bedside manners with patients need some rejuvenation. It’s not fair, however, to isolate this issue out of context. Physicians today are facing crunching pressures from various sources that we cannot always compartmentalize when we are facing our patients – even though we should. Most folks believe that the bedside manners of the prior generation of physicians were superior to ours. Were our predecessors simply more compassionate and caring human beings than we are? I don’t think so. I think the medical profession was a different beast then. I hypothesize that if these wizened physicians entered the profession today, that they would behave differently.

Context is so critical when examining any issue. Many physicians find today’s patients to be demanding and entitled. Again, before pronouncing a verdict here, there are reasons and explanations behind this that need to be aired. Patients and physicians are both different today because the culture and nature of the profession has changed. How would Marcus Welby behave if he weren’t making house calls with a black bag 40 years ago, but were now an employed physician in a large clinic who was sued every few years and whose medical ‘quality’ was monitored by bureaucrats who determined his reimbursement?

Again, I’m not excusing deficient bedside manners, but the issue has nuance and complexity.

A Chicago couple, Matthew and Carolyn Bucksbaum, believe that bedside manners are worth a lot. These philanthropists are donating $42 million to the University of Chicago which will create an institute under their names which will be devoted to teaching medical students good bedside manners. The hope is to ingrain values of compassion and empathy deeply enough into medical students that they will not be contaminated when they enter the medical arena later. The training would function like a suit of armor to protect young physicians from bedside manner decay and attack.

This is a fantastic initiative and I hope that other donors and medical institutions emulate the Chicago program. While medical schools do teach bedside manners and the importance of the doctor-patient relationship, it was undervalued, at least in my day. Younger physician readers can comment if times have changed.

Can you really teach compassion or do you have to be born with it? A Chicago couple has wagered in a big way that it’s nurture, not nature.

Sunday, September 18, 2011

Minute Clinics Threaten Doctors: Who Wins?

All of us have been to fast food establishments. We go there because we are in a hurry and it’s cheap. We love the convenience. We expect that the quality of the cuisine will be several rungs lower than fine dining.

We now have a fast medicine option available to us. Across the country, there are over 1000 ‘minute-clinics’ that are being set up in pharmacies, supermarkets and other retail store chains. These clinics are staffed by nurse practitioners who have prescribing authority, under the loose oversight of a physician who is likely off sight. These nurses will see patients with simple medical issues and will adhere to strict guidelines so they will not treat beyond their medical knowledge. For example, if a man comes in clutching his chest and gasping, the nurse will know not to just give him some Rolaids and wish him well. At least, that’s the plan.

Primary care physicians are concerned over the metastases of ‘minute-clinics’ nationwide. Of course, they argue from a patient safety standpoint, but there are powerful parochial issues worrying physicians. They are losing business. They have a point that patients should be rightly concerned about medical errors and missed diagnoses at these medical care drive-ins. These nurses, even with their advanced training, are not doctors. It is also true serious or even life threatening conditions can masquerade as innocent medical complaints and might not be recognized by a nurse who treats colds and ankle sprains.

The Annals of Internal Medicine, a prestigious medical journal, reported on the quality of these retail clinics and concluded that the quality of care for ear infections, sore throats and urinary tract infections in fast-medicine outlets was similar to that in physicians’ offices, but at lower cost. While this is ammo for fast-med aficionados, it doesn’t address a more important point. I’ll concede that if I take my kid with an ear infection to a Wal-Mart clinic or the pediatrician, then the outcome will be similar. (Many experienced Moms would also know what to do.) The tricky part is when the symptom is murky and the range of medical possibilities is broad. If my kid were having stomach pain, for example, I want a physician to decide if this is simple constipation, intestinal gas or acute appendicitis that needs urgent surgery.

These clinics are proliferating because the market demands them. The fundamental cause is the inadequate number of primary care physicians in this country. This shortage will become more acute when Obamacare extends coverage to tens of millions of uninsured. Massachusetts discovered this a few years ago when they provided coverage to the uninsured, but didn’t have enough primary care physicians to care for them. These clinics are also providing a service that physicians have been unable or unwilling to match. They offer evening and weekend hours at low prices. Patients come at their convenience and are seen without waiting.

Pharmacies and big box stores benefit from minute clinics. They bring shoppers into the store who are likely to purchase other items after their scraped knee is bandaged. And if a prescription is needed, guess where it gets filled? From a patient’s point of view, this experience sure beats an emergency room adventure.

Are these clinics a good idea? It doesn’t matter because they’re coming and they can’t be stopped. They fill a legitimate need that the medical profession cannot address and the public demands. Market forces created the opportunity and will monitor its success.

Will they survive? Remind me, how long have McDonalds, Burger King and all the rest been around?

Sunday, September 4, 2011

Overtreatment Alert! Antibiotics Fuel Medical Overutilization

A good friend of mine and Whistleblower reader contracted the sniffles and received a prescription for antibiotics at a local urgent care center. Nothing newsworthy here. So far this quotidian event sounds like a 'dog bites man' story. Had antibiotics been denied, this would have been 'man bites dog', as this denial would be a radical departure of standard medical practice, particularly in the urgent care universe.

No doubt, my friend was not assigned the dismissive diagnosis of 'the sniffles', but was likely given a more ominous diagnosis of 'acute upper respiratory infection', a term that sounds so serious that he might have feared that a 911 call had already been made.

Why are antibiotics prescribed so casually and so frequently? Choose from the following answers. There may be more than one correct response.

  • Antibiotics are the appropriate 'shock & awe' response to sniffle syndromes.
  • Patients demand antibiotics and offer evidence of necessity that their prior physician always prescribed them for the exact same symptoms.
  • Prescribing antibiotics is a sure method for increasing patient satisfaction.
  • Antibiotics are extremely safe and only rarely cause adverse reactions.
  • Patients fear that a delay in antibiotics could bring them to the brink of an infectious calamity.
  • Drug reps and direct-to-consumer advertising create a climate to prescribe medications including antibiotics.
  • It takes a physician 10 seconds to zap an antibiotic prescription to the pharmacy, but could take 10 or 15 minutes to explain why they're not indicated.
  • Antibiotic drug samples in physicians' offices encourage written prescriptions for patients.
  • Since physicians can't reliably distinguish viral infections from bacterial attacks, it's safer to prescribe antibiotics just to be sure that a bacterial infection isn't left untreated.
I'm sure that readers could add many other reasons that contribute to the antibiotic avalanche that is burying us, and I hope you will comment below. Infectious disease specialists and primary care physicians know that the majority of infections seen in outpatient visits are viruses - common colds - which do not respond to antibiotics; yet they are often prescribed for these illnesses. Changing this practice won't be easy and will take time. Look how long the public resisted buckling up in the car and using bicycle helmets, which are now universally accepted practices.

Antibiotic overutilization has real consequences.
  • It costs money.
  • It fosters a climate of medical overutilization.
  • Antibiotics can cause severe side-effects including C, difficile (C. diff) infections, which can be fatal.
  • It leads to the proliferation of resistant bacteria - superbugs - which won't respond to any available antibiotic. Care to be infected with one of these germs?
The Chief Complaint in medicine refers to the patient's summary statement explaining the reason for the medical visit. Typical Chief Complaints include:
  • Fever and cough
  • Chest pain
  • Abdominal Pain
  • Trouble breathing
These days, many patients have created their own version of the Chief Complaint (CC). Instead of describing their symptoms, they are now directing the treatment. See below.

Traditional CC: "I have a sore throat and a cough."

New & Improved CC: "I need an antibiotic."

Medical overutilization is my Chief Complaint.

Sunday, August 28, 2011

Should Patients Join the Pay-for-Performance Circus?

There was an extremely popular game show where several times each episode the emcee would shout out, "Survey Said!". Of course, this was just a game, not real life.  Now, several times each week I am asked to respond to surveys.  They pop up uninvited on the internet and are often veiled advertisements for products and services. They are on the back of receipts from coffee houses and doughnut shops.  Is it worth 10 minutes of my time clicking through the doughnut survey for either a free chocolate frosted doughnut or the chance to be entered into the grand prize drawing months later?  Hotels I stay at routinely follow-up with e-mail surveys for my feedback.  I suspect most folks delete these instantly, which skews the customer base to those who do respond. (Remember, disatisfied folks are often more motivated to give feedback than the rest of us are.) How often do we call a restaurant, a retail store, a bank or even a doctor's office to offer hosannas about great service?

Medicare recently released fascinating patient-survey data that raises interesting issues. In over 120 hospitals, patients rated the hospitals very highly, despite high death rates for heart disease and pneumonia. So, who do we believe here, the patients or the death rates?  I wonder if the patients' survey results were more optimistic since only the live ones were available to complete them.

Surveys are now serious bu$ine$$.  Reimbursement for hospitals and physicians will be influenced in either direction by patient satisfaction results.  But, are patients equipped to measure medical quality?  The discrepancy between the Medicare patient survey results and actual medical outcomes suggest that they are not the right tools for this task.  How can we expect ordinary folks to understand and rate medical quality when experts are confounded by the same mission?

Surely, there are important aspects of the medical experience that patients can evaluate.

  • On-time performance
  • Cleanliness of the facilities
  • Courtesy of the staff
  • Compassion and bedside manners
  • Responsiveness to billing issues
  • Ease of making appointments
  • Timely communications
  • Ease of reaching a living, breathing human being for a question or concern
But, while the above items are significant, are they true measurements of medical quality in the conventional sense?  Is the definition of medical quality being broadened simply to encompass measurable events?

Patients are being recruited under the Big Top, aka as the Pay-for-Performance Circus.  But, should patient surveys really count?  Or, do they count simply because their results are so easy to count?  Despite the dissenting arguments against P4P advanced on the Whistleblower, a must-read blog for health care thought leaders across the country, patient surveys will be folded into the expanding hydra of P4P programs. These programs won't measure true medical quality, at least in their current forms.  But, what a performance they will be.  The curtain will rise as the Secretary of Health and Human Services approaches the podium and shouts out, Survey Said!  What a Family Feud this will be.

Sunday, August 21, 2011

Tort Reform for Medical Malpractice System Another Study Needed?

Medical malpractice reform is in the news again. Of course, for the medical profession, the medical malpractice system is the wound that simply will not heal. For the plaintiffs bar, in contrast, the medical liability system is the gift that keeps on giving. I have argued that the current system fails on four important fronts.
  • Efficiency
  • Cost
  • Fairness
  • Quality Improvement
I admit readily that my profession has not been as diligent as it should be in holding ourselves accountable. We have not been forthright in admitting our medical errors, although can you blame us under the current medical liability construct? There is merit to the argument that tort reform is championed by medical malpractice insurance companies who have an economic agenda in this issue.

I recognize that certain malpractice reform measures, such as caps on non-economic damages, means that some individuals who have suffered severe injuries as a result of medical negligence, would not be adequately compensated. Nevertheless, I support caps because I am convinced it would serve the greater good, even though I would feel differently if I were one of the plaintiffs whose deserved compensation would be curtailed.

Despite the above admissions, the current system is a dysfunctional mess that fails in its mission to provide justice and fairness to the participants. More than physicians' arguments for reform, plaintiffs lawyers' pleass for maintaining the current system is permeated with economic self-interest. In my view, theirs is a weak brief that is transparent with regard to its true motives.

Here are some inarguable weaknesses of the current system.

  • The vast majority of patients harmed by medical negligence are not captured in the current system.
  • Non-partisan analyses confirm what we physicians know instinctively: litigation fear costs billions of dollars in defensive medicine, medical tests ordered to protect us, not our patients.
  • The majority of physicians targeted are ultimately released at some point in the process.
  • By stimulating defensive medicine, the current medical liability system diminishes medical quality, and does not serve as a deterrent against negligent care. Paradoxically, arguing that defensive medicine is negligent could be a potent niche for plaintiff attorneys.
The New England Journal of Medicine (NEJM) recently released a study after analyzing data from a medical malpractice insurance company involving over 40.000 physicians. Here are some highlights.

  • Every surgeon will face a medical malpractice lawsuit at some point in their careers. Is this a good lure to recruit talent into the surgical specialty?
  • About 7.5% of physicians face a medical malpractice lawsuit every year. 'Hey, I haven’t been hit for a few years. Is my number coming up soon?'
  • About 80% of claims against physicians are dropped. Would physicians be satisfied if a medical treatment were effective in 20% of patients?
  • Nearly 20% of neurosurgeons and cardiac surgeons are sued every year. Would you perform well at your job under a 20% yearly threat of being sued?
So, the NEJM has sprinkled some more data on a mountain of evidence that the current medical liability system is broken.  Did we really need another study?   Let's study if patients who are suffering heart attacks or severe pneumonias fare better if they are hospitalized rather than left at home.  Who can divine the outcome of this hypothesis?  After all, since this issue has never been published, who could predict the outcome?  Yes, of course, I am being deliberately absurd.

Some issues are self-evident and don't require a study to determine the obvious conclusion.  Yet, when it comes to medical malpractice reform, the current administration and Democratic legislators reassure us that they are serious about tort reform and want to 'study the issue' further. We hear the euphemism 'pilot program', which means quicksand.  Tort reform is moribund and has been assigned a DNR (Do Not Rescuscitate) status. Defensive medicine, in contrast, is alive and well. 

Sunday, August 14, 2011

Greedy Insurance Company Backs Down: The Little Guy Wins!

A few months back, while we were on vacation in Washington, D.C., my 17-year-old son Noah sustained an injury at 1:00 a.m. I was asleep, but this is usually a few hours earlier than he typically retires. In our hotel room’s bathroom, he dropped a glass and then managed to step in the wrong place. A sharp shard sliced through the soft skin between his great and second toes. Blood was spurting wildly and he woke me up with a shout. He was spooked.

We gastroenterologists are experienced at stanching bleeding, although I was uncertain how to do so without some kind of scope in my hand. I reflected on my ACLS training, which is a comprehensive 2 hour course that my partners and I take every 2 years. In between those sessions, I neither think about nor practice any advanced life saving procedures. It doesn’t seem rational that a community gastroenterologist should be schooled in temporary pacemakers, when most of us haven’t interpreted an EKG in decades.

I still remember the fundamentals of life support, the famed A, B, Cs, standing for airway, breathing and circulation. I decided to apply this to the hemorrhage at hand.

Airway: the windpipe was open and functioning

Breathing: the kid was breathing

Circulation: BINGO!

After going through this brief but critical checklist, I now knew where to focus. No need to intubate him. No need to call the front desk to rush a defibrillator to the room. No need for chest compressions, at least not yet. I considered tightening a tourniquet around his waist to clamp the aorta, but opted instead to apply direct pressure to the wound. Luckily, this high class hotel was equipped with just the medical apparatus I needed - a wash cloth. Once the bleeding slowed and I was able to visualize the wound, I realized that this was no Scotch tape fix. It was time for a field trip to the ER.

The hotel front desk advised me where to take him and 20 minutes later we were in Sibley Memorial Hospital. The care was excellent and the sutures were applied expertly by Gregory Cope, M.D. Two hours after our arrival, we were back in the hotel room. I decided not to rouse the kids at 9 a.m. for our intended trip to Ford’s theater, a site that has been deferred for a future trip.

Nothing is certain but death, taxes and emergency medical care bills. I reviewed the explanation of benefits form I received, which are never easy for me to unravel, even though I am somewhat of an insider of the medical profession. One of the 2 charges that I am responsible amounts to $391.50. I phoned my insurance company, always an opportunity for stress management, and reached a living breathing human being. Of course, I was first greeted by a mechanical voice who assured me that my call was important to them. Melanie, the insurance company customer service representative (Any reader agree with me that the phrase customer service is a euphemism?) explained that I had selected an out-of-service facility and was charged accordingly. After some research, she determined that there were in-network hospitals in the Washington, D.C. region. See what I mean about stress management?

“Melanie, let’s forget for a moment that I am a doctor and that you are an insurance company tool. It’s two o’clock in the morning. I am 500 miles away from home. My son’s foot is spewing blood. While you might regard me as irresponsible, I never contemplated whether the hospital was on the formulary. Should I have researched this issue then? How would I have done this at that hour? It’s challenging enough to reach a living insurance company soul during ordinary business hours. I wonder what my son would have thought if I told him we had to wait for authorization before we could leave the hotel. I’m sure this would have elevated his opinion of me as a doctor and a father.”
Melanie checked with a superior who agreed that under these circumstances they would reprocess the bill as an in-network charge. Victory! How much will I save? Probably, only a few bucks, but some victories are not measured in dollars. I ‘stuck it to the man’.

I have learned an important lesson from this experience. The next time I’m traveling with kids, I’m bringing paper cups.

Sunday, August 7, 2011

Is Cost-Effective Medicine on Life Support?

The concept of cost-effectiveness in medicine is elastic. One’s view on this issue depends upon who is paying the cost. Of course, this is true in all spheres of life. When you’re in a fine restaurant, you order differently when the meal will be charged to someone else. Under these circumstances, the foie gras appetizer and the jumbo shrimp cocktail are no longer luxuries, but are considered as essential amino acids that are necessary to maintain life.

In the marketplace, except in the medical universe, goods and services are priced according to what the market will bear. If an item is priced too high, then the seller will have fewer sales and a bloated inventory. Consumers will not pay absurd prices for common items, regardless of supernatural claims of quality.

  • Would you pay $100 for an ice cream sundae that boasted it was the best in the world?
  • Would you pay $1000 for a tennis racket that promised performance beyond your ability?
  • Would you pay $500 for a box of paper clips that never lose their tension?
Of course, you wouldn’t because none of this stuff is worth it, even if the quality claims are true. If any readers disagree, then send me a private email so I can enter into a business arrangement with you.

We lose sight of this obvious truth in medicine. It is not enough for a treatment to be effective. The benefit must be worth the cost. I realize that a cost-benefit analysis is interpreted differently by sick people and their families. I am sure this would be true for me and my own family. If my child needed a bone marrow transplant, I would devote my entire being to making this happen, regardless of long odds against success and a six figure price tag. In this hypothetical, I am no longer a smug blogger, but I am a terrified parent.

There will always be arguments about where to draw the line. Some treatments, such as routine vaccinations and proven preventive medical screening tests should be under the line. Other therapies that have minimal clinical benefit and astronomical costs should remain in high orbit and out of reach. All the stuff in between will be the grist for comparative effectiveness research, if it ever gets airborne.

A few months back, The New York Times reported on 2 new drugs, approved by the FDA for cancer treatment. Provenge, a new drug for prostate cancer extends life by 4 months at a cost of $93,000. Impressed? Wait, there’s more. Yervoy, a treatment for melanoma also extends life by 4 months at a cost of $120,000.

Are these two treatments under the line or over the line? In my view, as a spectator and not a sufferer of either disease, I think they should both be directly in the line of fire.

What’s your view?

Sunday, July 31, 2011

Will Wireless Capusle Endoscopy Replace Colonoscopy?

Most of born several decades ago, recall the futuristic book Fantastic Voyage by Isaac Asimov, where a miniaturized crew traveled through a human body to cure a scientist who has a blot clot lodged in his brain. Ironically, miniaturized medical care is now upon us while books are at risk of becoming obsolete.

I hope that gastroenterologists won’t become obsolete, at least until my last kid graduates from college.

I perform an amazing diagnostic procedure called wireless capsule endoscopy (WCE), when patients swallow a camera. Once swallowed, this miniaturized camera takes its own fantastic voyage through the alimentary canal. The test is used primarily to identify sources of internal bleeding within the 20 feet of small intestine, which are beyond the reach of gastroenterologists’ conventional scopes. I have performed over 200 of these examinations, and I am still awestruck when I watch a ‘movie’ of someone’s guts. While most examinations do not reveal significant findings, I have seen dramatic lesions that were bleeding before my eyes. WCE can crack a cold medical case wide open.

Here’s a typical view of the small bowel as seen by the cruising camera.

Up to now, cameras are used only diagnostically, but this will change. In other words, at present, the camera can only visualize. Prototypes are being developed that can equip cameras to take biopsies of lesions and to stop bleeding that is encountered on their journey. Physicians will be able to guide cameras in real time to perform diagnostic and therapeutic tasks. Once perfected, a physician on the west coast could be directing a camera that is voyaging inside a Manhattanite. (Aren't most movie directors on the west coast?) Amazing stuff. Of course, this technology may also be used by other medical specialties to search out and destroy diseases in their organs of interest. It will certainly have applications beyond the medical arena.

The capsule endoscopy folks have been trying to use their technology as an alternative to colonoscopy. This is a tough sell to patients who must endure a camera prep that is more vigorous than the routine torture that we gastroenterologists require prior to a colonoscopy. In addition, since the camera is only diagnostic, if a polyp is encountered, the patient would then enjoy the delight of a future colonoscopy to remove it. The latest advance in this area is a self-propelled camera that is inserted into the rectum and then guided by remote control by a physician.

When I read about the self-propelled capsule, I realized that I have committed a grievous parental miscalculation. I have tried to restrict and discourage our kids from playing video games, which I was certain wasted time and destroyed neurons. How wrong I was. These were the precise skills that would have permitted them to become medical pioneers. I have closed off many professional options for them from my misguided zeal to encourage them to pursue silly activities, such as reading.

How will gastroenterologists react if a ‘camera colonoscopy’ becomes ready for prime time? Perhaps, a future generation of colon cameras will be able to remove or destroy polyps and other lesions? Will we willingly surrender our colonoscopes to serve the greater good? We might do what many of us do in our bedrooms and our living rooms. We may fight with other medical specialists, or even technicians, as to who gets to hold the remote control.

Sunday, July 24, 2011

Pharmacy Benefit Managers vs Physicians: Let the Games Begin!

As a gastroenterologist, I treat hundreds of patients with heartburn. You already know the names of the medicines I prescribe, since they are advertised day and night on television and appear regularly in print newspapers. Pharmaceutical representatives for each one of these drugs come to our office each claiming some unique clinical advantage of their products over the competitors. They have a tough job since the medicines are all excellent, are priced similarly and are safe. On some days we will have 2 or 3 reps visiting us, each one proffering a medical study or two that supports their product. They show us graphs where their drug is superior to the others regarding an event of questionable clinical import. Their goal is to show that the graph line of their drug is going up, while those of their competitors are going down.

Physicians, like me, who do give these folks some time, have mastered the art of the slow head nod as the drug’s virtues are being related. In the past, the relationships they cultivated with us translated directly into prescriptions being written. Not so today, when our prescribing pens are controlled by insurance company formulary requirements. Those drugs that are not on the coveted list not just swimming upstream, they’re trying to scale a waterfall.

Drug companies know a lot more about us than we know about them. They have detailed prescriber information about what we are prescribing to our patients. Though I assume they don’t have specific patient identities, they purchase date enabling them to know how much Nexium, for example, I am prescribing. This information is used by the companies to motivate their reps. “Kirsch is prescribing Nexium to only 20% of his reflux patients. We need him at 30% by the end of the year.” Drugs reps, who are hired for their extroverted personalities and communication skills, become tongue twisted or even mute if this issue is raised with them.

One of physicians’ most exasperating waste of time is handling calls from pharmacies that the heartburn drug we prescribed isn’t the ‘preferred medicine’. There is no way that a busy medical practice can keep track of the drug coverage preferences for every insurance, company, particularly since these lists change regularly. When the pharmacy calls us, we have to review the record and then change to the new drug, if this is medically acceptable. This takes an enormous amount of time, clogs up our phone lines and doesn’t seem to improve any patient’s health. The real fun starts when we try to convince a pharmacy benefit manager (PBM) to authorize a medicine that is not on their magic list. The phone calls and paperwork are designed to discourage all but the most dogged doctors from pursuing the request. Doctors who enter this arena must relish the thrill of combat if they are to have any chance to prevail. Of course, the PBMs have the leverage, but skilled and seasoned medical professional can pierce their armor to achieve a Pyrrhic victory.

On those occasions when I triumph over the PBMs, I bask in the glow of victory. But, no victory is total. At the end of these setbacks and skirmishes, guess who needs the Nexium most?

Sunday, July 17, 2011

An iPhone App for Medical Checklists?

Not quite, but my iPhone inadvertently made a strong case for medical checklists.

This past weekend, I was once again in Denver. Colorado is a great destination for those who love natural beauty and outdoor adventure. My own personal adventure involved a fierce competition between me and water. Which machismo activity was I engaged in?

  • Level 5 white water rafting
  • Slalom water skiing
  • Cliff diving
  • Hang gliding with water landing
  • Sitting poolside with my iPad
If you are agonizing over the above choices, then you don’t know me.

I put the iPad down and crept into the pool slowly. Why do folks in the pool always beckon others in claiming the water temperature approaches hot tub levels, when it’s freezing? I’ve never been one to dive right in. I enter at a glacial pace. I dipped my toe in and in 10 short minutes, the water and I became as one. Then, the shock struck me with cold fury. Had Zeus pierced me with a lightning bolt, it would have been a mere pinprick in comparison. At that moment, I am standing in the pool with the water level at my navel. The iPad was resting safely on a nearby lounge chair. The iPhone, however, was in my pocket, an electronic submersible being bathed in chlorine.

While it took me 10 minutes to enter the pool, it took me 10 nanoseconds to exit it. The iPhone was dead. There were no breath sounds or pulse. I scanned the area for an AED (automated external defibrillator), not for the fibrillating phone, but for its terrified owner. ‘Get some rice’, my friend exhorted. I had heard of this fantasy where dead phones were resuscitated by lifesaving, hydrophilic rice. I sprinted to the hotel restaurant and received a large container of raw rice. I plunged the iPhone into the abyss and prayed for a miracle.

How could I be so careless? Humans make mistakes and I am a typical Homo sapiens. Who hasn’t locked their car keys inside their car, placed a food item in the fridge that needed to be frozen or left the umbrella in the car at the wrong time? Yes, to err is human, but drowning your iPhone seems downright inhuman. Indeed, if there were an eighth deadly sin…

Could this catastrophe have been avoided? What if I always performed a ritual prior to entering a pool, a lake or an ocean? What if I checked my bathing suit pockets every time before my toe hit the water? Had I done so, I would have discovered the iPhone before it became iDead. In other words, if I had a swimming checklist, my phone would still be alive today. If only I had considered this ‘app’ beforehand.

Medical checklists are red hot these days. These are procedures that doctors and nurses are encouraged or required to follow without exception to prevent human errors. The medical community has belatedly adopted this concept from the airline industry, where pilots proceed through an ordered checklist every time before take-off. Deviating from the ritual invites disaster, even though checklist adherence can become a mechanical process that can lose its meaning. (How closely do we listen to the flight attendants as they yawn through their safety presentations at the beginning of flights?) Checklists are being adopted in operating rooms throughout the country to reduce errors such as wrong sight surgeries and other preventable events.

Just this week, I read of two medical horrors that could have been prevented had checklists been followed.

  • The prestigious UPMC in Pittsburgh has shut down their living kidney donor transplant program when several folks missed that a donor was positive for hepatitis C. Yes, this tainted kidney was transplanted into an unsuspecting recipient. Whoops!
  • A Florida veteran is suing for a mere $30 million claiming he contracted hepatitis C from a colonoscopy performed at a VA hospital 2 years ago. It is well known that many cases of hepatitis C and other infections transmitted endoscopically occurred when standard scope cleaning procedures were breached.
My iPhone has been replaced costing me the $169 deductible on my replacement insurance and $16 for the screen protector, which probably costs Apple 3 or 4 cents each.


My advice? When you’re ready to dive in from the deep end, or you are poised to begin a colonoscopy, think of the sage advice from the Christmas standard, Santa Claus is Coming to Town. Are you making a (check)list and checking it twice?

Sunday, July 10, 2011

Health Care Reform and Obamacare: Lessons from the Last Century

Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity…The poor have more sickness, but they get less medical care. People who live in rural areas do not get the same amount or quality of medical attention as those who live in our cities.

The above quote wasn’t taken from an Obama administration policy proposal. These words are from a 1945 speech by President Harry Truman. It is astonishing that over 60 years later, the health care crisis is not only still with us, but is slowly smothering us. How many years of oxygen do we have left until health care in America is entirely asphyxiated? Each year, the challenges deepen and multiply, which pushes necessary solutions and reform further out of reach. The financial costs of simply maintaining the current system are sailing beyond the stratosphere. The ‘reform’ strategies in my adult lifetime have been to promise, procrastinate and pray, methods which provide politicians with short term gains at our long term expense.

As I write this, Democrats and Republicans are arguing on reforms to preserve and protect Medicare, even though the contours of the solution are well known to all. Politics is a poison pill.

Last year, about 17% of the GDP was devoted to health care, compared with about 15% in 2003. It is projected that 20% of GDP will be spent on health care in 2017. Medical economists agree that the current rising medical costs are unsustainable. The present government will be under enormous pressure to reduce costs of healthcare. Do we believe that costs can be cut while maintaining, or even improving medical quality? Will budget slashers swing their axes so wildly to drive down costs that medical quality will be crippled as collateral damage? Will the country be satisfied with medical mediocrity as a side-effect of cost control?

Operating on the health care system requires major surgery. The fear is that the government will declare that the operation was a success, even though the patient died. President Obama has stated repeatedly that health care reform is one of his highest priorities. While he didn’t create the mess, once his Patient Protection and Affordable Care Act was passed, he now owns it. Although I oppose Obamacare, and have explained my views throughout this blog, I congratulate the president for taking on this radioactive issue. This was a promise kept. Nevertheless, I hope that many of its damaging provisions will be repealed.

Will Obamacare ultimately sink from its own ponderous weight? If it does, or is watered down, the president may be tempted to start spreading blame around. President Truman, who worried about health care in America before President Obama was born, can offer our new president some advice on leadership. Remember his famous homespun maxim the buck stops here? Let’s hope President Obama remembers it also.