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?