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.

Sunday, July 3, 2011

Why This Lawyer Won't Sue Me

I spent the entire last weekend with an attorney, not a desirable circumstance for most physicians. However, I wasn’t being deposed or interrogated on cross examination. This was a rendezvous that we both sought with enthusiasm.

Lewis is my closest friend, a bond that was forged since we were eight years old. We are separated now only by geography, and we meet periodically because we both treasure the friendship. Earlier this year we rolled the dice in Vegas. Last weekend, we sweated in the sweltering heat of the Mile High City. Next stop? Back to Denver with a few youngins'!

Lewis is the managing partner in a prominent west coast law firm that specializes in tax evasion. (Or is it tax avoidance? Am I confusing my terms here, Lew?) He has been redrafted to this position because he has earned the respect of his colleagues. Clearly, both Lewis and I have ascended to the highest strata of our professions. Lewis is in charge of a large law firm that has global reach; he travels all over the world cultivating business and negotiating deals; and he navigates clients through complex and labyrinthine legal conundrums. I, an esteemed community gastroenterologist, perform daily rectal examinations and counsel patients on flatulence.

I am sure that readers will agree that our future professional prestige is already evident in this photo of us taken several decades ago.

Lewis and me a few years ago

Among the many ponderous issues that we discussed, were the current state of each other’s profession. I enlightened Lewis that electronic medical records (EMR) has not yet fulfilled its promise of ease of use and integration with other medical offices and institutions. I shared my disapproval of ‘point & click’ medicine, which is the default mode of many EMR systems. I also opined that EMR has created many viable avenues for medical malpractice attorneys to pursue. For example, is it now the community standard for physicians with EMR to search surrounding medical databases during an office visit to gather results of all prior laboratory and radiology records from area hospitals if it is technically possible to do so? If a patient sees me to discuss the heartbreak of hemorrhoids, am I negligent if I do not perform a wide data search and discover that an ultrasound of the liver done 2 years ago for other reasons showed a small lesion that in 3 months would become a serious clinical issue?  Am I now responsbible for every lab and x-ray result that is within cyber reach?  Sure EMR can save the doctor, but it can sink him also.

Lewis shared his views on the state of our economy, the current tax structure and the fairness and efficiency of our legal system. His colorful descriptions of these and other issues cannot be reproduced here verbatim as this is a family blog. Using softer language and paraphrasing, he did not exude optimism for America’s future.

He related some of his interesting legal matters, and I shared anecdotes from my gastroenterology practice. This created an interesting philosophical question. Consider the following 2 inquiries.

If a tree falls in the woods, and no one hears it, has noise occurred?

If a doctor mentions a patient and his diagnosis, and no one hears it, has HIPPA been violated?

Luckily, I always travel with my HCH, a HIPPA Compliant Helmet, a device that resembles a CPAP apparatus that sleep apnea patients wear at night. Once fitted with the device, any patient’s name I utter becomes encrypted and emerges from my mouth as a Disney character.

If I Say...                                You Will Hear...

Joe Bellamy                                     Goofy

Susan Sherman                                Dopey

Karen Carmichael                            Dumbo

My HIPPA helmet this past weekend was strapped in tightly, even during sleep in the event I somnambulated and started murmuring privileged patient information. Sure, Lewis is my best friend. But, he is also a lawyer and he might have been wearing a wire. After all, business is business. 

We actually discovered common elements in our jobs.

  • We can’t guarantee the outcome to those we counsel.
  • We are routinely blamed for adverse outcomes that are not our fault.
  • Both of our professions are screaming for reform, but politics won’t permit it to happen.
We didn’t solve all of the world’s problems, but many of the intractable issues we did discuss seemed like they could be solved if 10 reasonable folks around a table could hash it out without political interference.

Real friendship matters. A lawyer and a physician are an ideal combination, as odd as this sounds. Sometimes the relationship may need the skills of a negotiator, and other times it may need some healing. If you are really lucky, as we are, the friendship just coasts on naturally, powered by the strength of a bond that in a few years will reach a half century mark.

Lewis and me today