Sunday, January 30, 2011

President's State of the Union Address Targets Frivolous Lawsuits: Was I Dreaming?

We watched the president’s State of the Union address recently with the kids, to try and inculcate them with civic interest and responsibility. He is an inspiring and skilled speaker whose words seem to transcend partisanship and divisiveness. Nothing like an electoral ‘shellacking’ to push a politician into a Kumbaya mode. I thought the speech was long on ideals but sidestepped the pain and sacrifice it would take to reach the objectives the president outlined. I was waiting to hear the president’s plans regarding Medicare and Social Security, and I’m still waiting. The president took such a high road, that it was in the stratosphere, beyond real life.

Here’s what he said: the end of the decade, America will once again have the highest proportion of college graduates in the world.

Here’s what he didn’t say: save Social Security we are cutting benefits and raising the age when seniors can collect.

I’m not a journalist or a speechwriter, but my understanding is that the reverse pyramid system is used, meaning you start off with the important stuff and proceed toward the trivial. This is why The New York Times piece on the speech did not open with a comment on the president’s tie.

The following three subjects were included in the President’s speech. Place them in the order of importance.

The War in Afghanistan

The Peace in Iraq

Medical Malpractice Reform

Has the president experienced a Damascus Road conversion on the medical malpractice situation.? Not only did he acknowledge that frivolous lawsuits are real and are not simply physicians’ phantasmagoria, but he addressed the issue before mentioning Iraq and Afghanistan. Am I reading too much into this? Here’s what he said.

Still, I'm willing to look at other ideas to bring down costs, including one that Republicans suggested last year: medical malpractice reform to rein in frivolous lawsuits.

Does the president really get it, or is he the wily political pragmatist who now views life through the prism of 2012? I suspect the latter because if medical malpractice reform were truly important to the president, then he would have insisted it be included in the Patient Protection and Affordable Care Act, known to many as Obamacare. Time will tell if this plan is affordable and protects our health, as suggested by the law’s name.  Put me in the deeply skeptical category.

Yes, the president is a facile orator. The State of His Rhetoric is strong. The State of the Union, however…

Sunday, January 23, 2011

Why Medical Ethics Should Matter to Patients

Medical ethics has properly gained a foothold in the public square. There is a national conversation about euthanasia, stem cell research, fertilization and embryo implantation techniques, end-of-life care, prenatal diagnosis of serious diseases, defining death to facilitate organ donation, cloning and financial conflicts of interest. Nearly every day, we read (or click) on a headline highlighting one of these or similar ethical controversies. These great issues hover over us.

We physicians face ethical dilemmas every day in the mundane world of our medical practices. They won’t appear in your newspapers or pop up on your smart phones, but they are real and they are important. Here is a sampling from the everyday ethical smorgasbord that your doctor faces. How would you act under the following scenarios?

  • A physician has one appointment slot remaining on his schedule. Two patients have called requesting this same day appointment. The first patient who called has no insurance and owes the practice money. The second patient has medical insurance coverage. Neither patient is seriously ill. Who should get the appointment?
  • Two hours before a doctor is to see a patient, her husband calls to relate private information that he fears the patient will not share with the physician. Should the physician disclose this conversation to the patient? What is the risk if she discovers at a later time that a confidential conversation occurred?
  • A patient has been non-compliant with medical care. He has missed appointments and does not take his medication reliably. The physician is contacted by a local emergency room after the patient arrives there for a medical evaluation. Can the doctor ethically decline to treat this patient who has repeatedly rejected the physician’s advice?
  • Many physicians dispense medication samples to their patients. Is this practice ethical in that it raises drug prices for everyone since drug companies must fund these giveaways?
  • An attorney contacts a physician to testify against a fellow doctor who is accused of committing medical malpractice. The physician and the accused doctor both work in a small community hospital. The facts suggest that a medically negligent act has occurred. Is the physician ethically obligated to testify against his colleague?
  • A cardiologist decides not to accept smokers in his practice as he views this behavior as a direct attack on his medical treatment and strategy. All smokers in his practice are notified that if they do not quit within 6 months that they will need to select another physician. The cardiologist states he will actively counsel and treat all smokers on the available options for nicotine addiction. Can this physician ethically dismiss smokers from his practice who can’t or won’t quit?
  • A patient asks a doctor to fill out a temporarily disability form for back pain present for 2 weeks prior to the office visit. During this time, the patient did not seek any medical care. Is it ethical for the doctor to sign off on this request?
While none of the examples above will make the front page of your morning newspapers, they are newsworthy. They are under the radar, but need to be exposed. While the public square is crowed with the monumental ethical controversies of the day, we need to reserve a small corner there for everyday ethics.  Ethics in the office should not be a private matter.

Sunday, January 16, 2011

Electronic Medical Records Attack Hospitals

Whistleblower readers know of my criticisms of the electronic medical record (EMR) juggernaut that is oozing over the medical landscape. Ultimately, this technology will make medical care better and easier to practice. All systems will be integrated, so that a physician will have instant access to his patients’ medical data from other physicians’ offices, emergency rooms and hospitals. In addition, data input in the physician’s office will use reliable voice activated technology, so that some antiquated physician behaviors, such as eye contact, can still occur. Clearly, EMR is in transition. I place it on the 40 yard line, a long way from a touch down or field goal position.

A colleague related a distressing meeting he had at the community hospital he works at. This hospital, like nearly every hospital in Cleveland, is owned by one of the two towering medical behemoths. I’m not a businessman, but I have learned that when something owns you, it’s generally better for the owner than the ownee. This meeting was about the hospital’s upcoming EMR policy. Sometimes, these hospital meetings are ostensibly to seek physician input, but the true purpose is to inform the medical staff about decisions that have already been made. In the coming months, this hospital will adopt a computerized ordering system for all patients. In theory, this would be a welcome advance. It would create a digital and permanent record of all physician orders that could be accessed by all medical personnel involved in the patients’ care. It would solve the perennial problem of inscrutable physician handwriting, including mine.

One advantage that computerized ordering aficionados claim is that physicians’ orders can now be standardized for various medical conditions, such as stroke, congestive heart failure and diabetes. Of course, patients are unique and may not neatly fit into packaged computerized ordering templates. Will deviating from these standard order sheets by easy, or will we need a 14-year old beside us to help us over the cyber hurdles? Most of us have been issuing medical orders on paper for decades, without loss of life or limb. When I write an order with a pen for a potassium supplement, for example, I have not found the task to be onerous. Will the computerized system be another example of solving problems that I didn’t know that I had?

One of the physicians at the hospital meeting asked if the verbal order policy would remain. The response suggested that verbal orders would no longer be permitted. The physicians wondered how they would give admitting or other orders at 2 a.m. Would they have to boot up a computer at that time? What if a nurse calls for an urgent blood transfusion order when the physician is in his car? Does this enlightened verbal order ‘reform’ sound like it originated from folks who understand doctors?

I have to hope that the speaker was misinformed, as this aspect of the policy is simply too dumb to survive, at least I hope so.

I am not a Luddite who opposes EMR on ideological grounds. I believe, and have written, that once perfected, it will accomplish its mission. My quarrel is with those who already claim that the goal line has been reached, or is in sight. I also believe that many of these systems were designed by folks who don’t practice medicine or understand physicians’ needs. What’s good for billers and coders may not help physicians in exam rooms with living, breathing patients.

I am sure that most physicians who are retiring now do not regret that they will miss the steep vertical climb from paper to electronic medical practice. Personally, I am glad to be part of it, although I wish that ‘point & click’ medicine was more about medicine than about pointing and clicking.

Perhaps, this approach can be extended to blogging. Right now, it takes me a while to pound out these posts. If I could use a packaged medical ranting blogging template instead, then I could post a Whistleblower twice daily. Point & click blogging. Hmm. I can see the goal line.

Sunday, January 9, 2011

Death Panels Resurrected? Medicare Pays for End-of-Life Consultation

I’m blogging again while aboard an airplane. Continental demonstrated an effective strategy for bestowing a small measure of comfort onto its beleaguered passengers. The flight was on a one hour delay. Of course, time is an elastic concept to the airline industry. One hour can morph and expand into several hours. The most frustrating aspect for passengers is that we cannot rely upon the latest update to be a firm commitment. It is a modern day recreation of the Sisyphus myth, recalling the king who spends eternity pushing a boulder up a mountain, but never reaching the summit.

Are the death panels back? You remember this distortion from the political right who claimed that coverage for discussions of end-of-life care would soon lead to pulling the plug on granny? This provision was excised from the president’s health care plan, but has been resurrected by executive regulation at the end of 2010. The president has demonstrated that if you can’t get it by legislation, then grab it by regulation. Now, Medicare will reimburse physicians to advise patients on various end-of-life medical care options.

I support this policy. Of course, the time to discuss end-of-life issues is before the end of life. Without such discussions, patients and families do not make optimal and rational medical decisions. Understandably, during these times, they are not thinking clearly and are influenced by guilt, false hopes, pressure from friends and other family members and confusion about what is truly in the ill person’s best interest. Families may focus on trivial clinical events, which will not affect the outcome. I know this because I’ve been there. “Look, I think that his toe moved!” This process is made more agonizing since we physicians are rarely certain of anything, and medical miracles have occurred.

With advanced planning and discussion, folks can decide on the boundaries of their medical care and treatment. My primary reason for supporting this policy is on the medical merits. It will save patients from invasive, toxic and futile care that won’t add much time or meaning to their lives. Of course, it will also save a fortune in health care dollars, but this is not my primary objective.

Let the record show that I do not reflexively carry water for the political right, as I have been accused. I recently received the following comment from an op-ed piece published in our Cleveland newspaper. I offer excerpts of the kind and gentle comment below, for your amusement.

Did a Google serach (sic) for Michael Kirsch, M.D. -I suppose he is the second in the list (Michael Kirsch, MD Gastroenterologist in Cleveland, OH).
He has his own blog called "MD Whistleblower" where ALL he does is trash Obama and "Obamacare".
You are right. I can't believe the [Cleveland newspaper] would even publish articles by someone like this. He's got the credibility of Glenn Beck.
The title of his latest blog tells it all...
Sunday, December 26, 2010 - Obamacare Unconstitutional!
The second anyone refers to The Affordable Care Act of 2010 as "Obamacare" in an article you know what you're about to hear. Republican spin. He wastes no time - puts it right in the title. It might attract "his people" but it should be a turnoff to anyone else reading who has a mind of their own. I don't even bother reading such garbage.
More proof that he's another Rand Paul "less government in my life" libertarian nutjob (even when it comes to certification of doctors)...
SUNDAY, APRIL 18, 2010 - Does Board Certification Really Matter?
... and a believer of faith healing...
Sunday, September 19, 2010 - The Healing Power of Prayer: Faith vs Reason?
And he's got various other typical wingnut rants on everything from tort reform to EIGHTEEN different blogs ranting about the evils of healthcare reform.
NICE JOB - Keep your readers "informed" by the "professionals". Professional wingnut teabaggers that is. LOL!
Well, not everyone is a Whistleblower fan. But, sometimes the labels we assign to folks are wrong. Very few of us can be neatly categorized as liberal or conservative. Personally, I regard myself as a political moderate, although my views on Obamacare have given some the impression that I must be a Sarah Palin devotee. Do I think that Sarah Palin has been grossly underestimated? ‘You betcha!’ (Insert ‘wink’ here.) Do I think she has a political future? She will be a potent force, but she will never be a candidate for high office, in my view.

No, I don't regard the president's regulation permitting end-of-life discussion to be a 'Death Panel'. I'd call it a Life Panel.

Addendum:  The president performs a backflip on this issue!

Sunday, January 2, 2011

Are You at Risk for Alzheimer's Disease?

The medical profession’s ability to diagnose far exceeds its ability to effectively treat the conditions discovered. Consider arthritis, Parkinson’s disease, irritable bowel syndrome, strokes, emphysema and many cancers.

When a physician orders a diagnostic test, ideally it should be to answer a specific question, rather than a buckshot approach. A chest x-ray is not ordered because a patient has a cough. It should be done because the test has a reasonable chance of yielding information that would change the physician’s advice. If the doctor was going to prescribe an antibiotic anyway, then why order the chest x-ray? Physicians and patients should ask before a test is performed if the information is likely to change the medical management. In other words, is a test being ordered because physicians want to know or because we really need to know the results?

Does every patient with a heart murmur, for example, need an echocardiogram, even though this test would be easy to justify to patients and to insurance companies?

If the test won’t change anything, then it costs dollars and makes no sense. Spine x-rays for acute back strains are an example of a radiologic reflex.

While some tests yield too little information, others provide too much knowledge. I remember as a medical student discussing if healthy patients at risk for Huntington’s Chorea, a progressive and lethal neurologic condition, should be tested to determine if they will develop the disease. Recently, The New York Times reported on a similar ethical controversy regarding testing to determine a person’s risk for developing Alzheimer’s disease, another progressive and incurable condition. Should we make efforts to identify patients with risk, or even certainly, of developing terrible diseases, which have no effective treatments? Would you want to arise each morning knowing that progressive dementia is in your future? Each time you would misplace your keys, or had trouble finding a word, you would wonder if this was the leading edge of the impending meltdown. To me, this knowledge would result in a profound reduction in quality of life, and would also affect relationships with family and others. One could imagine diagnostic panels being run on young couples who are contemplating marriage, a new twist on pre-nuptial agreements. Could life and disability insurance carriers demand access to these results?

Is there a reasonable rebuttal to this view? Of course, folks are entitled to know their genetic predispositions, if they are properly counseled beforehand. These folks, knowing of a dim future, could modify their current priorities so they could enjoy a more satisfying life. These individuals may choose not to wait until retirement to take that trip around the world.

We must also keep in mind that medical tests are not always right. A ‘positive’ Alzheimer’s test result might be dead wrong. Or, the individual might develop a very mild form of the disease. Genetics is a complex and murky universe.

Medical tests that provide too little information are wasteful and unnecessary. Those that provide too much information can be dangerous and destructive. If the plague of Alzheimer’s is in my future, I don’t want to know it now. Sure knowledge is power, but sometimes sweet ignorance is bliss.