Sunday, December 30, 2012

Why Doctors Should Write

Sharpening a quill.

I am a physician who writes and I think that more of my colleagues should do so. Not because, we are such skilled wordsmiths or understand plot and characterization. We don’t. But, we confront the human condition every day. We see pain and struggle and fear and rebirth. We have much to share.

Beyond my own profession, I think everyone should write, because everyone has something important to say and to share.

To paraphrase an old Pete Seeger song, where has all the writing gone? Long time past seen. I long for longhand. I plead for paper. I pine for a pen.

Sadly, there has been steady erosion in the craft of writing, which I attribute to the ’new & improved’ forms of communication that have supplanted the written word. In addition, folks don’t simply regard writing as a worthy pursuit. Writing today means tweeting, emailing, texting and various other keyboard or voice activated techniques. This progress, like many other technological advances, has exacted a cost that may be difficult to measure, but is real and it matters. Today’s communications are either robotic directives, such as ‘board meeting cancelled’, or ‘you’r e fired’, or are coded messages that require cryptographers to decipher, such as TTYL and C U L8R!

Writing is intimate. It’s real and it’s raw. It angers and soothes.

I am so struck when I read letters written by ordinary folks in the 18th and 19th centuries, many without any formal education, who write with such grace and poignancy. Yes, they were somewhat flowery, but they conveyed warmth and feelings that can never be transmitted on Twitter. That they were written in longhand, only adds to their authenticity and intimacy.

Today, on those rare occasions when I receive a signed note in longhand, it is a singular experience. I picture the writer at his desk, pen in hand, composing a personal message just for me. The writer might be delighting in the scene that will follow, when I am holding the envelope and imagining its contents. After I open the letter, I hold it in my hands and absorb its words. Afterwards, I can stash it in a drawer to join with other companions that I have received in the past. Unlike the ethereal iCloud, the desk drawer is a real, live treasure chest that I can see and touch.

Master writers from the past created their opuses in long hand and in ink. How did they do it and get it right? Today, this would be an unfathomable task. Today, students and the rest of us write and research in a very different way, cutting and pasting our way to the final draft. I recall as a high school student learning that Hemingway would tell his wife that when he was staring out the window, he was working.

I love words and respect those who use them well. When I am writing, I often wrestle to find the precise word. Is the right word stubborn or tenacious? Bossy or assertive? Timid or reserved?

While we physicians confront an enormous dose of life experiences every day, every one of us has something worth writing about. I’m sure that on any given day, we could send someone a note of love, a letter of apology, a prayer for healing or a description of an experience that moved us.

Why don’t we do this? IMHO, I think I know why.

Sunday, December 23, 2012

Whistleblower Holiday Cheer 2012!

Jingle Frost
Romney Lost
Obamacare is here
Brought to us by the Dems
With promises and fear.

Fiscal Cliff
Might be teriff!
Sailing through the air
Watching Boehner and the Pres
Pretending that they care.

Susan Rice
Playing Nice
Charging in reverse
Kissing up to GOP
Who now say she is worse.

Taxes Rise
Before your eyes
While the masses cheer
Will Medicare go on the block?
Let’s punt this 'til next year!

Obama plan
Kick the can
And claim that it's progress.
Who's to blame? You know his name.
George Bush has caused this mess!

Wishing You Joy and Peace!

Sunday, December 16, 2012

Should Drug Reps be Mute on Off Label Drug Use?

Am I an apologist for the pharmaceutical companies?  I don’t think so, but others may disagree based on some sympathetic Whistleblower posts that have appeared in this blog.  It is without question that the drug companies have been demonized and portrayed as rapacious gangs of greed who seek profit over all.  Haven’t you come across the pejorative term, Big Pharma?  Linguistical note:  The adjective ‘Big’ means evil. Consider:

Big Oil
Big Government
Big Tobacco

Get the point?

 Big Elephant!

I’m not suggesting that the pharm guys and gals are all Eagle Scouts.  These companies operate to make money, just like car companies, the cosmetic industry, the airlines, banks and financial institutions, hospitals, manufacturers, the hospitality industry and retailers throughout the land. 

Here’s a bold Whistleblower pronouncement.

There is nothing evil about making money.

Of course, I want our drugs to be safe and effective.  We need the Food and Drug Administration (FDA) to provide oversight to protect the public interest.  I acknowledge that the industry needs external review and enforcement powers to keep the industry responsible and accountable.   There’s a reason that professional football games need referees.  Somehow, I don’t think that the honor system on the gridiron would be sufficient.  Players cannot police themselves.

But some of the constraints that drug companies face constitute unnecessary harassment that does not protect the public interest.   Pharmaceutical representatives, or drug reps, are prohibited from discussing ‘off label’ use of their drugs with physicians.  (Off label refers to a medicine being used for a purpose not officially approved by the FDA.) I’ve always felt that this edict was silly and stifled communication between physicians and reps.   Yes, some drug reps have aggressively marketed their products for off label use. GlaxoSmithKline and Johnson & Johnson paid handsomely for committing this offense. 

But, there is a clear difference between misleading promotion and honest communication.  If I question a drug rep about off label indications of a drug, a straightforward response  harms no one.  In fact, it may give me new knowledge that I could use to help a living and breathing patient.  Relax, patients.  I am well aware that pharm reps are sales folks and are not my primary resource for pharmaceutical education.  But good reps have deep knowledge of a very narrow medical issue – their products – and often know stuff that I don’t.   They may, for example, know of side effects of their medicines that are not widely known.

Keep in mind that most of the medicines that we physicians prescribe are off label, which is entirely proper and is acceptable to the FDA.  At present, the only folks in the country who can't discuss off label use of drugs with me are the reps.  

Recently, a federal appeals court set aside the conviction of a drug rep concluding that his marketing a drug for off label use was permissible under the freedom of speech doctrine. This ruling only applies to the region under the jurisdiction of the Second Circuit, but this will not be the last legal word on this issue.   More details appear in the New York Times piece that reported the decision.
Where should the line be set here?  I’m not sure, but I think the current FDA boundary is overly restrictive.   We need a dose of leniency and a tincture of common sense from Big FDA.

Sunday, December 9, 2012

USPSTF Pushes Back on Hepatitis C Virus Mass Screening.

I spend a lot of my time reading, thinking and writing about politics and medicine.  I love the debate.  Three of the five Kirsch progeny engaged in serious school debate programs, and I believe that they received years of training at our dinner table.  I certainly learned a lot from them – and still do – and I hope they picked up a few worthy lessons along the way.

Some time ago, an associate admonished me to avoid dialogue concerning religion or politics, two of my staple conversation themes.  This advice seemed misplaced as I’ve never had an argument in my life discussing a controversial issue.  Indeed, I seek out these opportunities. I don't want the other individual to change the subject; I want this person to change my mind.

Controversy erupted recently when Hepatitis C enthusiasts pushed back against the U.S Preventive Services Task Force (USPSTF) draft recommendation regarding testing folks for hepatitis C virus (HCV). More turbulence is sure to follow. The Center for Disease Control and Prevention (CDC) had previously issued their guideline advising that all individuals born during 1945-1965 be tested once for HCV.  That would include the Whistleblower who has no risk factors associated with HCV infection. I have not been tested and have no intention of doing so.

Electron Micrograph of HCV

I’ve already posted a vigorous rant explaining why I feel that patients with HCV are overtreated.  As I indicated there, the Food and Drug Administration has approved two new medicines, boceprevir (Victrelis) and telaprevir (Incivek) which have significantly increased treatment efficacy.  HCV patients who opt for treatment are prescribed one of these two medicines along with two others to complete a three drug HCV cocktail.  These are very serious medicines with potential serious toxicities.

I applaud this medical advance and hope that research in the near term will increase efficacy, reduce toxicity and simplify the treatment. 

HCV experts and many physicians advocate treatment to eliminate the virus so that the hepatitis infection will not progress to cirrhosis and liver cancer.  Liver failure from HCV infection is a major cause of liver transplantation.
Indeed, if you were a HCV patient and your doctor advised treatment “to prevent liver failure, cirrhosis or liver cancer”, I suspect you would be inclined to accept the recommendation.  I don't think, however, that many patients are given the fair and balanced context when they are considering how to proceed.  Only an informed patient can provide informed consent. 

Consider the following before pulling the treatment trigger.  
  • The vast majority of HCV patients have no symptoms and have had the disease for decades.
  • Only 10-20% of HCV patients will develop cirrhosis, many of whom will function well.
  • The treatment is toxic and extremely expensive.
  • We have no reliable method to determine which HCV patient is destined for future complications.
  • HCV patients who ‘respond’ to treatment may have lived a normal life without treatment.
Is there a role for treatment in this disease?  Of course, but I suspect that once again, medical practitioners are casting too wide a treatment net ensnaring many folks who should be left alone.

The USPSTF just issued their draft HCV guidelines that were considerably narrower than those of the CDC.  The task force recommends HCV screening only for those who are at high risk of the disease, such as those who used intravenous needles or received blood transfusions prior to 1992.  Unlike the CDC, no mandatory screening of folks born during 1945-1965 is advised.  The task force pointed out the absence of proof that widespread screening for HCV would reduce liver disease and mortality.

When the final guideline emerges, there will be criticism.  Some of it may be based on the medical merits, which is fair game. Other criticism will try to game the system.  There’s a huge and growing HCV testing and treatment industry and gazillions of dollars at stake.  Certain stakeholders will advocate policies that endorse widespread screening for HCV.  Will this be only for medical reasons?  Our track record on this issue isn't encouraging.  Beware of conflicts of interests buried under feigned arguments to protect patients. There are 4 million Americans with HCV.  Treatment with the new 3 drug regimen can cost in excess of $50,000 per patient.   Do the math.  

50,000 x 4,000,000 =

We shouldn't retreat from discussing whether treating HCV makes sense.  After all, it's not religion or politics. 

Sunday, December 2, 2012

Mammograms Overdiagnose Breast Cancer - Let the Games Begin!

Breast news is booming.  Mammography is in the news again. We have legions of breast lobbyists that have agendas that are far beyond the true medical value of mammography.  Even legislators have entered the mammographic arena in a clumsy effort to show their pro-women bona fides.  Politicians should not practice medicine.  It’s absurd that they try to do so when they can’t even perform their own jobs competently.

In 2010, the government overturned its own panel the United States Preventive Services Task Force (USPSTF), in response to an outcry from politicians and mammo-cheerleaders. The USPSTF is not anti-mammogram, and neither am I. I’m pro medical evidence. Mammogram enthusiasts often champion positions that are beyond the science.  Beyond the Kool Aid drinkers, there are billions of dollars at stake here.  Medical evidence is massaged by companies who manufacture conventional and emerging imaging breast techniques and by radiologists who interpret the studies.  If you're a player in the Mammogram Industrial Complex, and a major study threatens your livelihood, predict the reaction.  Here are some sample press releases.
  • The study is irreparably flawed
  • The study is a right wing conspiracy
  • The job killing study will shift more jobs overseas
  • The male study investigators want mammography to fail so they can divert research money to prevent prostate cancer
Let me preempt the argument that I am holier than thou with respect to my implication that radiologists may be tainted by a conflict of interest.
  • Gastroenterologists perform too many colonoscopies
  • Colonoscopy is a clumsy tool for colon cancer prevention
  • Colonoscopy advocates primarily rely on polyp removal as evidence of its worth, which is a surrogate marker of uncertain value.
Hopefully, the above statements will support my credibility.
The truth is that mammography, even in its most optimistic light, isn’t the lifesaver that the public believes.  Indeed, some experts opine that women who undergo mammography do not enjoy a mortality advantage, although they may suffer fewer breast cancer fatalities and complications.  While this is a worthy outcome, it is clearly a limited benefit. 
The November 22,2012 New England Journal of Medicine article strongly suggested that millions of women have been overdiagnosed with breast cancer, meaning identifying cancers that would not have progressed or would have been detected later without posing more danger to these women. 
Advances in breast cancer treatment may exaggerate the benefits of mammographic detection.  In other words, a breast cancer survivor might wrongly credit the mammogram as her savior rather than the treatment.
Overdiagnosis of cancer should be regarded a disease itself.  These women undergo unnecessary surgeries, chemotherapy and radiation, which can have profound and lifelong effects on them and their families. It is also costing us a fortune. It is not a fair and balanced approach to showcase women who have been saved without acknowledging the harm that mammography causes  Shockingly, the American College of Radiology issued a statement calling the study ‘deeply flawed an misleading’.  Any conflict of interest here?
It is easy to deepen our cynicism when those who support or attack a view have a personal interest that coincides with their position. 
The medical and political establishments do not reverse course easily.  We have known for years that prostatespecific antigen (PSA) is deeply flawed and harmful. Look how long it took to disarm its advocates, many of whom were urologists who believed in PSA with religious zeal.  Every one of them honestly believed that this test had saved men’s lives.  I do not dispute this contention.  How many men, however, were gravely harmed by treatment of prostate cancer that would have never threatened them?  Isn’t this worthy of some consideration?
Patients need to know the medical evidence that supports our medical advice.  When there isn’t evidence, or the evidence is conflicting, we physicians need to disclose this, and patients should interrogate us directly on these issues.  I welcome this dialogue in my office.
The public has an exaggerated view of the benefits of mammography. For instance, I suspect that most ordinary folks believe that mammography prevents breast cancer, which is completely false and was never its intent. 
The vexing issue for patients is whom can they trust to offer them candid and unvarnished advice?  I believe in truth. It’s not enough in medicine to believe that something is true because we want it to be or because it serves our own interest. 
Have any women Whistleblower readers been counseled about the hazards of mammography by their physicians?  If not, then was your decision to proceed truly informed?  Aren’t your breasts worth knowing the whole story?

Sunday, November 25, 2012

Accutane Users Win Huge Verdict Against Roche. Who's the Winner?

I was engaged in one of my pleasures, sitting in a coffee shop leafing through medical journals. Usually, I am perusing newspapers. I spend many hours each week combing through various newspapers and routinely forward items of interest to folks of interest. No newspapers today. I have a few gastroenterology journals to look through. My professional reading habits have evolved over my career. I am more interested in reading about medical ethics, health care policy and the art of medicine than in studying hard science or clinical research, which used to be my required reading years ago.

I read an essay entitled, Irritable Bowel Syndrome (IBS) Patients’ Willingness to Take Risks with Medications published in the June 2012 issue of the American Journal of Gastroenterology. The article stated that IBS patients would accept a small chance of death if there were an overwhelming likelihood of cure. This caught my attention. Of course, IBS can be a debilitating illness. But, it is not cancer and poses no threat to life. Nevertheless, patients who are desperate for succor, would accept a small risk of a premature journey to the hereafter. While many physician would not be comfortable with these odds, if patients make an informed judgment, then it is their call to make.

Patients need to know the material risks of a medicine or treatment in order to provide informed consent. For example, many successful medical malpractice lawsuits prevail because the plaintiff claims that the physician ‘failed to warn’ of a known complication. The plaintiff alleges that if he been properly warned of a potential rare complication, then he would have rejected the risky and reckless treatment. These cases often suspend disbelief. Do we believe that a patient with a serious medical condition would have declined a treatment if informed about a 1 or 2% chance of a dangerous complication? Give me a break.

In New Jersey, a cauldron for medical malpractice litigation, a jury awarded damages of $18 million to two plaintiffs who developed colitis after taking the drug Accutane. They claim that the company, Roche, failed to warn about this complication. There remain over 7000 cases of alleged Accutane induced colitis that are pending.  Roche has paid out nearly $80 million in verdicts and denies that their medication causes this complication. I wonder how much medical research could have been funded with this incomprehensible amount of cash.

I am a gastroenterologist who has never seen a case of colitis linked to Accutane. I am not certain that this complication truly exists, even though a jury of ordinary folks accepts this, particularly when an ailing person is seeking ‘justice’ from a rich and heartless pharmaceutical company. The first I ever learned of a supposed connection between Accutane and colitis was when I read about a medical malpractice case in a newspaper years ago.

Does this drug truly cause colitis? Who knows? Is the company responsible for not warning about a complication that it doesn’t believe exists? Do we believe that a patient with disfiguring acne (Accutane was prescribed for severe acne, not typical teenage blemishes.) would decline a highly effective medicine because there might be an extremely small risk of developing severe colitis? I would suggest that these patients, like suffering IBS patients, would accept considerable risk in return for considerable relief.

In 2009, Roche took Accutane off the market after enduring tens of millions of dollars in verdicts. Who emerges victorious here? Choose the best answer.

  • The public
  • The medical profession
  • Roche
  • Trial Lawyers
Would trial lawyers abandon a case if there was a 1% chance they would lose?

Sunday, November 18, 2012

Romney is a Loser - Is This a Fair and Balanced Judgment?

Romney lost.  This update is for those who have just awakened from a deep coma.  I voted for him which will not surprise even the occasional reader of this blog.  While he was an imperfect candidate, I believe that a businessman whose successes have straddled the public and private worlds may have provided a pathway forward out of the abyss.  Sure, I recognize that campaigning is quite different from governing.  Had Romney prevailed then he would have been opposed by an obstructionist Senate that would have stiff-armed him in the way that I expect the House to do to the president.
The loser always faces a merciless post mortem where pundits and pontificators point out the series of fatal errors that the candidate committed. 

“He dissed the Latinos.”
“He didn’t reach out to women.”
“He tacked too far to the right in order to gain the nomination.”
“He made a $10,000 bet with Rick ‘Brain-Freeze’ Perry on national TV.”
“He introduced us to the concept of ‘self-deportation’.”
“He was clumsy abroad.”
“He was clumsy here.”
“He was too soft on Bengazi during the debates.”
“He was too hard on the 47%.”
“He returned too late to the center.”

Of course, all of these criticisms are legitimate.   I’ll add my own criticism to the list.  No candidate seeking high office should ever have any member of his family engage in dressage, an activity that was entirely foreign to me and most of the hoi polloi prior to the campaign.  Let the Googling begin.

Where were these conservative carpers during the campaign?  Not only were they mute on criticism, but many of them were enthusiastic cheerleaders.  Now, they are spinning like pin wheels as if they knew all along how the Romneyites were faltering and destined for a stinging loss. 

Had Romney prevailed he would be heralded as a political genius and the conservative naysayers would all be competing to reap credit for a victory that each one would claim to be responsible for. 
This is not fair and balanced.  Of course, had the president lost, we would be witnessing the same process.  Leftists and moderates would emerge screeching their hollow claims of ‘I told you so’. 

Why exactly does this post-election drivel belong on a medical commentary blog?   You mean it isn’t obvious to my erudite readership? There’s an analogy between the recent dissection of the Romney loss and the practice of medicine. Consider this scenario.
  • An adverse event occurs in medicine despite the best efforts of the physician.
  • The doctor is blamed for the event.
  • Various experts emerge who point out in retrospect the physician’s obvious failures that seemed acceptable at the time.

Sometimes, patients get better in spite of our efforts.  When this occurs, we may be unfairly lionized as heavenly healers.  On other occasions, patients suffer despite our best efforts.  When this occurs we may be unfairly blamed for the result.

Should our judgment of a doctor, or anyone, depend upon the outcome or the path that led there?  How do you vote on this question?

Sunday, November 11, 2012

Electronic Medical Records Holds Doctors Hostage

Which of the following events is most traumatic for a practicing physician?
  • Your staff doesn’t show up because the roads are flooded, but the waiting room is full of patients.
  • Medicare notifies you that coding discrepancies will result in an audit of 2 years of Medicare records.
  • You receive an offer of employment by a corporate medical institution who will bury your practice if you do not sign.
  • Your key expert witness defending you in your upcoming medical malpractice case is incarcerated.
  • Your office electronic medical records (EMR) system suffers a cardiac arrest.
Tough choices, I know. Our office lost complete access to EMR for 3 days, and it wasn’t pretty. I don’t grasp the technical (doubletalk) explanation for the temporary EMR coma, but we were reminded of how dependent we are on technology. Our IT gurus were working tirelessly, but their adversary was wily and formidable. Finally, they prevailed, but I wouldn’t regard this as a clean win for us. We were hobbling for 3 days. The fried server has been rebuilt and now has reinforcements to insulate against another crippling assault.

Ink and paper never crash.

Luckily, our brains were still functioning adequately during these 72 hours. We hadn’t yet lost the ability to obtain a medical history without pointing & clicking. Somehow, we managed to obtain a review of systems without trolling and scrolling across our laptop monitors. Ancient physician techniques, such as maintaining eye contact and offering nods of understanding to patients, were effortlessly recalled, like riding a bicycle. I even prepared a few paper prescriptions, once I was able to locate a yellowed and tattered prescription pad. I hope the pharmacies will accept these medical anachronisms.

The tough reality is that during these 3 days we had no records available for the patients we saw. We compensated when we could, with faxes and phone reports, but this is no substitute for a complete medical record. Patients arrived to review test results that we couldn’t access. In some cases, I had faxed biopsy reports available, but not the accompanying endoscopy operative reports that were hiding in the EMR black hole. Patients were understanding of our dilemma, since many had faced their own computer rages. But, many of them did not receive a full measure of medical services from us. I asked some to return to see me for another visit, once the EMR was resuscitated, as I feared I may have overlooked some important issue during the 3 days of Stone Age medicine.

Karl Marx

To paraphrase, the most famous phrase uttered by the individual pictured above, technology is the opium of the people. We love technology. We demand it. We upgrade it. And, we are hooked on it. Like any addiction, when the fix isn’t there for us, withdrawal is painful.

I’m thinking of opening the first chapter of Techno-Addicts Anonymous. Of course, the first step of recovery is the toughest. “My name is Whistleblower and I am a…”

Sunday, November 4, 2012

Does Doctor to Doctor Communication Protect Patients?

One of the gripes that patients have about the medical profession is that we physicians don’t communicate sufficiently about our patients. In my view, this criticism is spot on. Patients we see in the office often have several physicians participating in their care. The level of communication among us is variable. While electronic medical records (EMR) has the potential to facilitate communication between physicians’ offices and hospitals, the promise has not yet been realized. The physicians in our community, for example, all have different EMR systems which simply can’t talk to each other. We can access hospital data banks from our office, but this is cumbersome and burns up time. Ideally, there should be a universal system, an Esperanto approach where all of us utilize the same EMR language.

On the day I wrote this post, I participated in a direct conversation with the treating physician at the hospital bedside which vexed me. This scenario would seem to be ideal from the patient’s perspective. At the bedside were the attending physician, the gastroenterologist (the Whistleblower) and the anesthesiologist who were conferring about the next appropriate diagnostic step in a patient who had experienced upper gastrointestinal (UGI) bleeding.

I was asked to evaluate this patient with UGI bleeding and to arrange an expeditious endoscopy to examine the esophagus and stomach region in order to identify a bleeding source. Hours prior to seeing the patient, I scheduled the procedure that I knew would be needed, a short cut that every gastroenterologist will do in order to be efficient. As the patient had other medical conditions, I requested that the sedation be administered by an anesthesiologist, rather than by me, to provide greater safety to the patient.

I arrived and became acquainted with the medical particulars. I agreed with the diagnosis of UGI bleeding and also that an endoscopy was the next logical step in this patient’s care. These observations are not sufficient, however, to proceed with the examination. There are other criteria that must be considered.

  • Does the procedure need to be done now?
  • Do the risks justify performing the procedure?
  • Has the patient provided informed consent for the procedure?
After I arrived on the scene, the anesthesiologist approached me and advised me that the anesthesia risks were extraordinarily high. He was concerned that performing the case could have a disastrous outcome. My reaction to his frank assessment? Thank you! The decision then fell to me to decide on whether to proceed. For me, this was an easy call. The patient did not need an endoscopy at that moment to save his life, the only reason that would justify subjecting him to the prohibitive risks of the procedure. Before discussing this decision with the family, who were awaiting an endoscopy, I summoned the attending hospitalist to relate to him our revised plan. In my view, when an anesthesiologist and the gastroenterologist advise an attending doctor that it would be unsafe to proceed with a planned procedure, the response should be, ‘thank you’! But, it wasn’t. This physician wanted the test and seemed irritated that the set diagnostic plans had been set aside. He wanted a diagnosis, and we declined to proceed after concluding that the risks exceeded the benefits. I was as comfortable with this medical decision as I have been with any other decision I had made in my career. On other cases, when a consultant advises me against a planned course of action for safety reasons, I am so grateful that a patient has been spared from danger.

We got to the right answer here, but had to set aside an unforeseen obstacle to get there. Communication means listening to another point of view and being able to change your mind. As a doctor, when it’s my finger is on the trigger, I call the shots.  I this case, a doctor misfired.

Sunday, October 28, 2012

Breast Cancer Screening of Dense Breasts - Dr. Government Prescribes Bad Medicine

This blog is about freedom and personal responsibility.  I have opined that cigarette smokers should not be permitted to transfer total responsibility for the consequences of their choices to the tobacco companies, even if this industry has committed legal and ethical improprieties.  I do not support the politically correct beverage ban in New York City, sure to spread elsewhere, where the government decides the content and dimensions of beverages that the public desires to purchase.  With regard to Obamacare, don’t get me started or I’ll never get to the intended subject of this post.

First, let me refute a point in advance that is sure to be leveled against me by the pro-breast crowd.   I am zealously pro-breast and want all breasts foreign and domestic to remain free of disease. I am against breast cancer and support the goal of striving for early detection of this disease and medical research to prevent it.  Indeed, I am against all cancer and boldly express this controversial view in print for all to see.

Breasts and politics have been intertwined for years.  Many medical advocacy groups admire and envy the huge amount of research money that is garnered for breast cancer research.  Some argue that breast cancer, while worthy, receives a disproportionate share of research dollars at the expense of other crippling and deadly diseases. 

There is no clearer example of the contamination of breast cancer with political interference than Mammogate, when the federal government cowardly rejected the sound and impartial recommendations of its own expert panel for political reasons.

Now, a new scene in the government's Breast Fest has appeared where our elected legislators play doctor.  States are passing laws that require medical facilities to inform patients who have undergone mammograms if they have dense breast tissue and that they should discuss with their physicians if additional testing is necessary. More details are found in the New York Times report on this issue.

I will defer expressing a medical view if women with dense breasts are adequately protected by conventional mammography. If medical professionals, unelected but presumably trained in actual medicine, believe that ultrasound exams or M.R.I. scans are necessary to illuminate dense breast tissue, then brace yourself for an avalanche of unnecessary scans which will generate anxiety, cost a few zillion dollars and identify false positive lesions which are entirely innocent and lead to a breast biopsy bonanza.  This cascade will be fueled also by the medical malpractice system, the raptor present in every mammography suite that is ready to sink talons into its prey.  Am I exaggerating here?  Ask any radiologist why he has stopped reading mammograms.  The guys that still do are scared stiff. These breast images are not sharp iPad images with futuristic resolution.  Instead, they look like grainy collages where it can be agonizing for a doctor to decide if a small smudge is nothing or everything.  Understandably, in today's litigious climate, radiologists join OperationOVERCALL, rather than risk the opportunity to serve as a defendant years later.  

The government are not physicians and should not legislate medical advice.  It’s hard enough for actual doctors to sort through conflicting and controversial medical data and evidence to determine what is best for our patients.  We struggle with this every day.  Will the clumsy axe of government be a helpful player in this effort?   Do we want folks who are beholden to lobbyists and are political animals by definition to force physicians to practice in certain way?

Why stop at breasts?

Pass laws that will require physicians to
  • Obtain a CXR if a patient has a cough and a fever
  • Tell every patient who has a negative cardiac stress test that the patient can drop dead of a heart attack within a week and that a cardiac catheterization should be considered
  • advise patients who are scheduled for surgery to obtain a second opinion in case surgery is silly
  • advise patients to pursue the probiotic promise of a panacea.  
Sure, there's dense breast tissue out there.  But, not nearly as dense as the government.  I suppose we should trust them with our lives and our health judging by the sterling performance they demonstrate as legislators.  Congress' approval rating is now soaring at 21%.  

Sunday, October 21, 2012

Weight Loss and Exercise Fail to Prevent Heart Attacks and Strokes? A Skeptic Scoffs

Photo Credit

A theme woven throughout the Whistleblower blog is skepticism.  I endorse and rely upon this in my medical practice and in my life. I admit that there were times that I argued a point that was not truly my own at the dinner table simply to stimulate the minds of my progeny.  As the kids are not readers of this blog, I trust that actual readers will be protective of this knowledge that if released could sow a storm of familial strife.

I am reluctant to incorporate new medical breakthroughs into my practice until enough time has passed to convince me that these medicines or treatments are truly safe and effective.  Often, the test of time exposes the vulnerabilities and hazards of new remedies for old maladies.  This is to be expected.  Once a new medicine is released into the marketplace, its true risks may not be known until thousands of patients have taken it.  On other occasions, new science retires old treatments.  When I was a younger physician during the Pleistocene Epoch when I used to take my pet triceratops out for a walk, we gave nearly all women hormone replacement as a guard against the heartbreak of bone breaking osteoporosis.  Now, a physician who would make such a recommendation would be labeled as a medical fossil from the Jurassic Period, and would be labeled as a medical dinosaur and would be encouraged to limit his practice to administering influenza vaccines.

In medicine, and beyond, don’t believe stuff that sounds as if it should be true.  This is one of the dangers of the surrogate marker, a medical research sleight of hand that tries to substitute an outcome of limiting meaning for another that the researcher wants to be true.    

Of course, it’s a fact that there is excess obesity in the United States and in many other countries.   Weight loss has become a national crusade that has even entered corporate America who increasingly incorporate weight loss and fitness into their wellness programs.   It is also a fact that obesity is associated with many medical conditions such as heart disease, arthritis, strokes and cancer.  Many folks, however, confuse a medical association from actual causality.  For example, exercising in a gym may be associated with better health, but these workouts may not be the cause of the desirable outcome.  Gym freaks may be healthier because of their diet or lifestyle.  They may have access to higher quality medical care.  So the headline, Gym Users Have Fewer Heart Attacks, is rather misleading.

It is taken as fact that weight loss, which is associated with many diseases, will reduce the risk of these diseases, but is this really true?   I know that even posing this question constitutes medical heresy, a charge that has been leveled against me from time to time.   The New York Times reported that a study of weight loss was stopped two years ahead of schedule because an aggressive program of diet and exercise did not reduce heart attacks, strokes or cardiac mortality even though the study group lost 5% of their weight, a significant amount.

Those who are biased over the true medical value of weight loss will criticize the study.  Medical skeptics, however, will gloat about it on their blogs.  

Sunday, October 14, 2012

Fighting Obesity in America: Has Weight Loss Gone Too Far?

One cannot escape the issue of rising obesity rates in the United States. A current statistic predicts that by the year 2030, 42% of us will be obese. The ramifications of this ponderous eventuality could indeed weigh down and sink the nation. Some of the consequences include:
  • Zillions of health care dollars spent treating obesity directly.
  • Gazillions of health care dollars treating medical consequences of obesity.
  • Loss of economic productivity from a bloated workforce.
  • Diminished economic activity from corpulent citizens who limit travel and recreational activities.
  • Loss of quality of life for those who have expanded far beyond their desired BMI.
  • Phasing out of Whoppers and Big Macs, two national gastronomical treasures.
Of course, the percentage of us who are deemed to be obese depends upon how we define the condition. Look what the medical experts have done with blood cholesterol levels, with the assistance of Big Pharma. As the threshold for a normal cholesterol value has steadily been lowered, more and more of us will be diagnosed with hypercholesterolemia. If the trend continues, the entire nation will be diseased and we will be urged to ‘statinize’ ourselves.

What harms one person saves another. Even natural disasters create jobs and keep entire industries profitable. Similarly, the movement against obesity threatens many livelihoods. Here are a few folks whose incomes would suffer if the nation slims down.

  • Magic weight loss supplements that promise to melt pounds off.
  • Big & Tall clothing stores.
  • Funeral homes. Fewer deaths per year will bury many of these businesses.
  • The medical profession. How would physicians and hospitals make a living? There’s no money in preventive medicine.
  • Tailors and seamstresses who won’t have to let our pants out each year.
  • Gastric bypass centers that would have to market their services to overweight pets.
  • Weight loss programs that view the obese as worth their weight in gold.
  • Big Pharma who will suffer huges losses as there will be fewer diabetics and hypertensives to treat.
  • Medical device companies who manufacture cardiac catheterization equipment.
  • The exploding sleep apnea medical industry will be gasping for breath.
  •  Splenda and Sweet & Low companies. Slender folks won’t be scared to ingest real sugar.
  • Kentucky Fried Chicken and other ‘finger lickin’ good’ delicacies.
Obesity has been demonized and has created industries to combat it and ostensibly to improve the nation’s health. Crusades have arisen, spearheaded by the First Lady to protect kids from the heartbreak of heft. Dietary police will be roving the countryside targeting establishments that are pushing poisons on us, including doughnuts, chicken wings, funnel cakes, movie popcorn and Haagen Dazs ice cream, which creates the best vanilla ice cream in the world.

But before we create a national movement to stamp out corpulence in our lifetime, consider the economic consequences. (Why do you think that cigarettes are still legal?) Many folks depend upon our excessive poundage to feed their families and run their businesses. Weight loss is a job killer. To those who aim to destroy America one pound at a time, where’s the outrage?

Sunday, October 7, 2012

Medical Ethics: Why I Wouldn’t Write a Prescription

Medical ethics is woven into the Whistleblower blog. I have presented vignettes exposing ethical controversies in the medical profession. I have pointed out scenarios when patients test the steeliness of our ethical scaffolding. I have admitted when my own ethics can be fairly challenged. Indeed, this blog does not take a ‘holier than thou’ posture, though at times I have been accused of this. I have directed as much criticism at myself as I do elsewhere.

Recently, I received a request to assist someone whom I was told was in dire need of a physician’s assistance. While I am a physician who has taken an oath to heal and comfort, in this case I turned away from a person in need. I present the anecdote not because it will stimulate a discussion of the competing ethical angles of the case. Indeed, the case has no angles and no reader will challenge my decision. I present it as an example of an outrageous and improper request that was made to a doctor. Indeed, while I have received numerous improper requests from patients over the past two decades, which I routinely declined, this request was the ‘mother of all ethical outrages’.

Valtrex Structural Formula

A woman whom I know called me with a medical request. She is not my patient. Her niece, also not my patient, was desperate to receive a prescription for Valtrex, a medication she needed for oral herpes. Her own physician would not refill the prescription. The niece did not want to see another doctor for a prescription, as this would create a paper trail that her husband, who opens the mail at home, might discover. The niece was frightened that her husband would discover this infection, and worried that this would result in a marital strain. The woman who phoned me asked if I would call in a prescription for Valtrex under her name, although the pills would be transferred to her niece.

This case poses no ethical quandary for any physician.

The woman who called me is a wonderful and caring person. I wanted to offer some counsel beyond a rebuke of her request, and I did so.

I am interested in what advice readers would have offered, as well as potential explanations for the niece’s anxiety. Once a discussion has hopefully developed, I will share the advice I rendered, and will look forward to readers’ response to it. I always welcome criticism because I am holier than no one.

Sunday, September 30, 2012

Institute of Medicine Issues Report on Waste in Medicine - Why Whistleblower Readers Should Care?

It was recently discovered that Fareed Zakaria committed plagiarism in an essay he wrote for Time Magazine on gun control.  He confessed and apologized.  I think he could have been fired for this as plagiarism, aka theft, is a cardinal offense for a journalist and a news magazine where trust is a central pillar.  This was not a matter of an indiscretion in his private life or an offense that doesn’t threaten his profession’s central mission. This was dishonesty in a job that should demand honesty in every syllable.  Zakaria is a Harvard graduate and a Yale trustee.  How would these institutions have ruled on a student who admitted committing plagiarism?  CNN and Time ‘suspended’ him.  Was Zakaria too big to fail?

I’ve devoted several posts in this blog to professional integrity and personal ethics.  Medical plagiarism is a serious ethical wound in the medical world and all of us must hold our academic colleagues, medical students and practicing physicians accountable.

In September 2012, the Institute of Medicine (IOM) issued a report that delivered a bold and unexpected message – our health care system is wasting money!  Who knew?  I have to assume that this 18-member panel has plagiarized the Whistleblower as so many posts here are devoted to this issue long before their report was published.  I’ll leave it to readers to decide if I should seek judicial redress on this unethical appropriation.  This is an opportunity for an ordinary reader to become a Whistleblower.

Whistleblower Readers are Watching!

This panel after a year and a half of study concluded that we’re incinerating a ton of money. Lest you accuse me of hyperbole, $750 billion are being vaporized annually, nearly a third of every dollar spent.  How would your personal or professional balance sheet appear if you wasted 30 cents of every dollar?  No business or home can remain solvent under that scenario, and neither can the health care system.
Why are there no checks on this system?  Here are a several reasons why unnecessary care is practiced.
  • Fee-for-service medicine where physicians like me are reimbursed in an a la carte manner.
  • Defensive medicine where physicians like me order unnecessary tests to reduce legal risk.
  • Pressure from patients who desire more testing and treatment believing that more medicine is better medicine.
  • Patients who pursue expensive care of questionable value that they don’t have to pay for.
  • Physicians who practice non-evidenced based medicine.
  • Rising administrative costs.
  • Fraud.
Feel free to add to the list.  Climbing out the hole will be like scaling a glass skyscraper.  Every reform measure angers and threatens a powerful player in the medical arena.  I support initiatives like comparative effectiveness research and the more recent Choose Wisely program, which represent the first steps of what will be a very long odyssey. 

If any blogger has their eye on this post with an aim of posting it as his own, caution.  Whistleblower readers will be watching.

Sunday, September 23, 2012

Are Organic Foods Healthier?

In American society, packaging trumps contents. Look at both the Democratic and the Republican presidential nominating conventions we all just endured. In the old days, these conventions had a purpose – to select nominees. Now, they are scripted, grandiose infomercials that insult our intelligence more than they inform us. They are coronations. I heard great oratory, decent rhetoric and pabulum. The spectacles wasted tons of money that could have been devoted to charity or some other worthy cause. As marketing and political folks understand well, packaging sells products. Think of this the next time you are choosing a bottle of shampoo off the shelf. Are you really buying the sleek bottle? Are you voting for the sleeker and more likable candidate?

Except for Mitt Romney, it seemed that every other speaker was raised in a log cabin. Lincoln would have no advantage if he were running today.

There’s plenty of packaging and fluff in the medical universe also. Complementary and alternative medicine, in my view, lures us with a seductive ‘package’ that often overpromises on what it can deliver. Don’t misunderstand me here. I am not dissing C & A medicine categorically or suggesting that it is not worthy of study. I maintain that any medical treatment that we contemplate for our patients should be based on science and not faith. Admittedly, in many clinical circumstances, we physicians must make a judgment before science has ruled on the issue. Yes, there is artistry in medicine.

I dine out often with close friends who believe that organic foods are more healthful. I’m skeptical of this and many other health claims made with regard to stuff that we eat. Is irradiated milk really dangerous even though this label sounds like we should be hearing scary music when we open the carton? Remember the phrase ‘farm fresh eggs’ which are no better than competing chicken eggs even though the label conjures up feelings of health and wellness? And probiotics? This requires its own blog post to sort out what we know from what we believe.

I’ll admit that the organic food label suggests a higher quality product, but this is not evidence. Just because we think, or other folks want us to think, that something is better for us, doesn’t make it so. Hebrew National hotdogs had a brilliant ad campaign years ago when they told viewers that their company ‘answered to a higher authority’ suggesting that their kosher product had a divine imprimatur. I’m not certain, however, that these porkless franks were truly food for the gods.

The respected journal the Annals of Internal Medicine recently published a study concluding that organic foods were not more healthful than ‘inorganic’ alternatives. There were some differences found with regard to antibiotic-resistant germs and pesticide exposure, but this does not mean that these products are safer for consumers.

Organic food is big business and it’s getting bigger. Tens of billions of dollars are spent on them each year by Americans who believe that these foods are higher quality. There is one indisputable difference that distinguished organic stuff from the rest of the stale and moldy stuff that I eat regularly. It sure costs more. Maybe the higher cost is part of the packaging to convince us that it’s really better. Remember the hair color product that used the phrase ‘it costs a little more, but it’s worth it’ to convince us that a higher price implied higher quality?

So, whom should I vote for this November? I’ll likely be voting against the president, although neither candidate inspires me. However, when it comes to packaging, the president is far ahead. Barack Obama is presented as the organic candidate. Romney is white bread.

Sunday, September 16, 2012

Medical Complications and Medical Negligence: What's the Difference?

The day before this writing, a patient who was minutes away from his colonoscopy, asked me how many colonoscopies I had performed. Before I could answer, he quickly followed-up asking if any of my patients developed perforation of the colon after the procedure.

I satisfied his initial inquiry when I informed him that I have intruded into at least 20,000 colons in the past 2 decades. With regard to his second and more ‘penetrating’ question, I told him, yes, there have been a few perforations. I continued the dialogue in order to place the issue in context for him and his wife so he wouldn’t be spooked before his procedure. We didn’t want a panicked patient leaping off the gurney and high-tailing through our waiting room in a flapping opened-back gown to the parking lot. Fortunately, our discussion accomplished its purpose and his procedure proceeded calmly and uneventfully.

Sure, complications matter, but numbers can deceive. Our most highly experienced physicians have likely had more complications than other medical colleagues, although their complication rate may be very low. For example, a known complication of heart surgery is the dreaded complication of a stroke. A heart surgeon, who has operated on thousands of patients, may have had 25 stroke complications. A younger surgeon, however, may have only have had 3 or 4 stroke complications in his briefer career. Which surgeon would you choose?

In addition, a doctor’s higher complication rate may reflect that he accepts more risky and challenging patients that other physicians have rejected.

Perforation of the colon after a colonoscopy is a terrible event, mostly for the patient and the family, but also for the physician. While it is rare, it is inevitable. If your gastroenterologist has never had one, he likely has very limited experience. If this is the case, don’t jump off the gurney. Recognize, however, that a perfect record doesn’t mean medical perfection.

Keep in mind that complications are blameless events. They are not negligent. If you prescribe penicillin to a patient who denies allergies, and a severe rash develops, then a complication has occurred. The physician is not culpable. However, if the patient had a known penicillin allergy, and the physician neglected to inquire about medication allergies, then the same rash is not a complication, but is the result of medical negligence. The distinction between complications and negligence is not appreciated by most lay individuals and many plaintiff attorneys.

Physicians will be increasingly tracked on various ‘quality’ measurements that will be accessible to the public. While knowledge is power, incomplete and deceptive knowledge can mislead and confuse. When you are reviewing the quality statistics on your doctor, be skeptical that this data is a true measurement of medical quality.  In medicine, what really counts can't be easily counted.  Conversely, what's easy to measure rarely measures up. 

While poking a hole in the colon is thankfully a rare event, pay-for-performance and other medical quality initiatives have more holes than Swiss cheese. These are not complications.  It's negligence.

Sunday, September 9, 2012

How to Take a Medical History: A D-Day Approach

One of the joys of being a physician is learning the patients' histories. A joy, you say? Isn't taking the history simply part of the doctoring routine? You've all been there.

When did the pain start?
What made it worse?
Did it move around or stay in one place?

I agree that inquiries like these are not intrinsically joyful, but this is not my meaning here. I refer to history here in the conventional sense. I am interested in who the patients are as people, what they did and what they saw.

It is amazing how many seemingly ordinary folks have extraordinary tales and vignettes that they are quite willing to share, if they are asked.  I have a sense that they are a reservoir of wisdom that we must actively draw from, as they may not volunteer their advice.

I recall a science teacher whose prior occupation was serving as a commander of a nuclear submarine. Even years later, his secrets remained tightly held, despite my gentle entreaties. He was, to borrow a phrase, a tomb of confidentiality. Perhaps, the sedation I would be administering prior to a future colonic violation might loosen his tongue. Oh, the secrets I've extracted in the endoscopy suite!  Relax, patients. What's uttered in the endoscopy suite, stays in the endoscopy suite, our own version of the Vegas Rules.

Another patient, now elderly participated in a historical event that changed the world. He took a leisurely boat ride across the English Channel on June 6, 1944 reaching the shores of Normandy. I've been to beaches many times in my life, but his experience was quite different. I was mesmerized as he recalled the fear that he and his men suffered as their craft approached the French shoreline. He told me of a chilling order that he never had to carry out. If any soldier refused to leave the craft, he was to shoot him. When I was an 18-year-old, I was a comfortable pre-med student. When he was the same age, he walked through the valley of the shadow of death and, unlike the psalmist, he did fear evil.

Another patient, now a nonagenarian, was a scrawny 17-year-old kid who awoke up one morning to hear bombs bursting in air. This quiet and modest man, several decades ago, was stationed in Pearl Harbor on the date that lived in infamy. I was tingling.

Just a few weeks back, an old man came to see me wearing one of the veteran baseball- style caps that many aging vets wear. For me, these caps are a reliable sign that there will be more to talk about than just heartburn and hemorrhoids. "Where we're you stationed," I asked. "Iwo Jima," he answered. You know what's coming now, readers. This man witnessed the marines raising the flag on Mount Suribachi in, perhaps, the most iconic image ever captured in American military history.

Over the years, I have related these treasured vignettes to the kids, who rightly wondered if I actually performed any medical work in the office. For the years that we home schooled the 2 boys, my patients' experiences became part of their curriculum whenever possible. On more than one occasion, these gracious individuals met with us so that we could hear history directly from the folks who made it happen.

Seasoned physicians may not know the answers.  But, they know what questions to ask.  When your doctor is taking your history, is he asking the right questions?  Am I?

Sunday, September 2, 2012

Medical Device Approval Process Under Fire

All parents have heard their kids complain that but for 1 or 2 percentage points, they would have achieved a higher grade.

“This is so unfair! My average is 89.9999 and he is still giving me a B+!”

Every kid should receive an A, of course, since psychologists are now professing that every kid is a prodigy in some new measure of intelligence. Academic intelligence, the conventional and obsolescent notion, has been sidelined to make room for other types of smarts, such as musical intelligence, existential intelligence, interpersonal intelligence, spatial intelligence and many others.

I agree that there’s a lot more to being smart than conquering number theory and linear algebra, but I wonder whether this effort to broaden the definition of intelligence is simply so more parents can have smart kids. Personally, I think that the conventional definition of intelligence is too rigid and we should be open to where rigorous research leads.

Fortunately for me, I did not discover that there is a category of navigational intelligence, which would have cost me at least 40 revised IQ points.

In my day, a grade of 94% was a solid A, and we strived to reach this threshold. Were our teachers too lenient? Should a grade of A required that at least 99% of our answers were correct? Where do we draw the lines to separate excellence from acceptable? Who makes the decision?

Last year, a public fight erupted over an Institute of Medicine (IOM) report that had not even been issued that argued for tougher rules for medical device companies. The report had been commissioned by the FDA and was in response to several recalls of medical devices that had malfunctioned and harmed patients. Advocates of medical device companies cried foul claiming that the 12-member panel was biased. Look for a lot more of this strategy when comparative effectiveness research (CER) goes forward. If a CER panel’s conclusion is against your interest, then attack the panel. Lawyers have mastered this technique generations ago. If the facts are on your side, attack the law. If the law is on your side…

IOM Report Targets Medical Device Industry

Is the IOM on target or is the aggressive pushback from the industry legitimate?  I do know that is an easy task to make medical device companies and pharmaceutical companies appear callous, avaricious and indifferent to human suffering, when this may be entirely false. Can you say ‘demonization’?

Of course, we want medical devices and pharmaceuticals to be safe and effective. We expect that artificial hips, pacemakers, defibrillators and stents will perform superbly. Safety and testing policies should be made by experts independent from industry, but I believe that industry is an important voice at the table. Indeed, several constituencies should be represented, including the public. If we strive to eliminate every real and potential conflict of interest, then we will lose many voices of medical experience from the real world.

I'm not suggesting that reform in the device approval process is unnecessary. But, there are truths that must be acknowledged.

  • No medical device or drug is 100% safe or effective.
  • A percentage of medical devices will fail which may result in injury, reoperation or death.
  • A failed medical device is not tantamount to corporate misconduct
What percentage of medical devices should perform as intended? 90%? 95% 98%?

How much testing and clinical trials should medical devices be required to undergo before they can enter the market? If the device is similar to an existing device, or is an existing device that is applying for a new use, should the testing process be the same as for a new product?

A grade of 98% sounds like an A+ to most of us, but this may not be sufficient in the medical device universe. Would we be content on an airplane knowing that we have a 98% chance of landing safely?

If we all agree that the medical device industry needs tougher standards so that their safety and effectiveness levels approach 100%, then we will need to accept higher medical costs and a reduction in innovation. Will this trade off serve the greater good?

I’m sure if the federal highway speed limit were lowered to 50 miles per hour that lives would be saved. No one is hollering for this reform. What should the medical device speed limit be?

Sunday, August 26, 2012

Improving Patient Satisfaction: Lessons from 18,000 Feet

First Customer Service Representative?

Your call is important to us.  Please listen carefully because our options have changed.

Reader query: During your current or any prior lifetime, has any phone menu option ever changed?

I have more than once experienced an option not offered on the robotic phone menu option choices - a dead phone line after a 30 minute wait.

Have you tried this customer plea as I have?  Could you pretty-please jot down my cell phone number in the event that we are disconnected?  Here are some of the responses one might expect from such in insolent request.

• Are you joking?
• I would but I think it's illegal.
• Sorry, our phone bank only receives incoming calls.
• No, but if you prefer, I can transfer your call to our grievance hotline. Just click on option #17.
• Uproarious laughter from the entire phone bank who heard my request on speaker.

As I write this, I am at 18,000 feet in a propeller plane that I trust will land safely in Cleveland.  Hopefully, the air traffic controllers are all awake and alert. I'm flying in from Canada where my mom and I observed how indifferent the airline and customs personnel were to the plights of the passengers.  Regrettably, this level of  'customer service' isn't restricted to our neighbor to the north.  Air travel isn't much fun these days for anyone anywhere.

I'm sure the airline folks are as hassled as we travelers are.  Would you want to face angry and frustrated passengers each day when you are powerless to remediate their complaints?  At times, the lines of happy travelers at the customer service desk in the airport for lucky folks who have missed flights or lost luggage reminds me of the lines I endured at Disney World.  This analogy is apt since both sets of lines lead to adventure!

Here are my observations as an airline customer.

• I do not feel that my business is appreciated.
• Reaching a living, breathing human being on the phone should only be attempted if a physician has cleared you for this activity. Cardiac patients need not apply.
• Flexibility to adapt to customers' needs or to changes in circumstances have been left out of the playbook.
• Fees charged to make even the most trivial change in ticket reservations are unconscionable.
• No obvious regard for the value of customers' time with regard to flight delays.
• Service on board?  Now we passengers can ask, 'are you joking?'
• Dissatisfied customers have no recourse.  In other spheres of the marketplace, if we are not treated well, we dump them and walk down the street to a competitor.

There are lessons here for the medical profession and for our patients.  Fortunately, patients and physicians enjoy much better partnerships than do airline industry have with its customers.  But, our relationships with patients have been challenged from many internal and external forces. How are we doing in with regard to patient satisfaction?   What do our patients say?  While there are many legitimate reasons why high levels of patient satisfaction are more diffiicult to achieve today, patients still deserve our best effort and outcome.  I am skeptical that pay-for-performance and similar efforts are the right tools to get this job done.  When your only tool is a hammer, than physicians start to look a lot like nails.  Haven't we been hammered enough?

While it is a generalization, I believe that private practice medicine - like any private business - has stronger incentives to provide high levels of patient satisfaction.  Employed physicians, the emerging dominant model for doctors, may not be as vested in catering to their customers, although I know there will be disagreement here.  For employed physicians, their sense of patient satisfaction may be feedback survey results from patients, which will be reviewed by their supervisors and placed in their personnel files.  Private practitioners, in contrast, may be more concerned with pleasing the patient directly than in pleasing the survey. This difference may appear subtle, but I believe it is substantive.  In the same way that teachers are criticized for teaching to the test, physicians who must answer to bean counters may be practicing medicine with an eye toward the survey.  This can lead to gaming the system. 

As I noted on a prior post, the airline industry has taught the medical profession important lessons on medical check lists.  I don't think, however, they have much to teach us about customer service.  If you disagree, give them a call for some pointers on how to soothe seething passengers.  Remember, your call is important to them.

Sunday, August 19, 2012

Unnecessary Antibiotics in Livestock: What's My Beef?

I’ve already written about the overuse of antibiotics in this country. This overutilization costs money and causes medical complications. It also is believed to be the cause of a new generation of superbugs, that can attack us with impunity as we may have no effective antibiotic to defend ourselves with.

As an aside, I remember when I first learned the meaning of the word impunity. Here’s the opening paragraph from the short story written by a nineteenth century master.

THE thousand injuries of Fortunato I had borne as I best could, but when he ventured upon insult, I vowed revenge. You, who so well know the nature of my soul, will not suppose, however, that I gave utterance to a threat. AT LENGTH I would be avenged; this was a point definitively settled -- but the very definitiveness with which it was resolved precluded the idea of risk. I must not only punish, but punish with impunity.

Without resorting to Google, can any readers name the work and the author?

Digression over. Antibiotic (ATB) overutilization is not just an issue that affects man; it affects beasts also. Farmers have been prescribing antibiotics to fowl and cattle for years to make their animals heartier. This issue falls under the jurisdiction of the Food and Drug Administration (FDA), who have imposed restrictions on ATB use in livestock over the years. There is tension between those who feel that ATB should be banned and those who favor a more permissive policy.

Surprisingly, more antibiotics are prescribed to animals than to humans in this country.

Farmers and veterinarians feel they should be free to prescribe ATBs to keep their animals in good health. Antagonists claim that ATBs should not be allowed simply to prevent infections that result from unsanitary conditions. Moreover, there is a widespread view that overutilization of ATBs in cattle creates superbugs that can threaten humans. Farmers counter that these fears are hyped.

These are real issues that need real science to separate facts from politically correct arguments.

(1) It’s true that ATB use in cattle and livestock have increased.

(2) It’s true that superbugs are on the rise.

(3) This does not mean that (1) has caused (2).

The FDA has tightened the rule requiring now that farmers will need veterinarians' prescriptions for antibiotics, a requirement that is expected to substantially decrease their use. 

I’m inclined to agree that both animals and humans receive more ATBs than they need. But, I wouldn’t want to create new mandates based on a hunch or even a logical belief. Before we adopt policies that affect industries, livelihoods and jobs, let’s ask ‘where’s the beef?’

Sunday, August 12, 2012

How Much Does A Colonoscopy Cost?

One would think that a physician who earns his living billing patients would be conversant with the prices of his services. Not this doctor. I am queried periodically by patients asking how much I charge for a colonoscopy. Of course, every physician recognizes that this question is not phrased properly. It doesn’t matter what we charge; it’s what an insurance company determines we will be paid. I might believe that your colonoscopy was worth a thousand bucks, but those who pay the bill have a different sense of its value. Many ordinary folks think that we doctors can simply raise our prices to enrich ourselves. Physicians cannot do this. The hardware store and the supermarket can raise prices in response to rising overhead and market forces, but we physicians cannot. While I realize that the public does not sympathize with physicians who are lumped in with the 1%, a pejorative term popularized by the Occupy movement.

The reality is that many private medical practices are struggling financially and have closed. Many of these practitioners have retired and others have become physician employees. Our practice in the Cleveland suburbs is feeling the squeeze and I cannot estimate how long we will remain viable. Personally, I believe that private medicine is being targeted by design, and when it becomes extinct, the public will lose an important health care resource. While I am not opining that private practice is the only model that can offer high quality medical care, I maintain that when the physician is also a business owner, that he has a strong incentive to satisfy his patients and his referring physicians. Employed physicians are given incentives, which are metrics that reward or punish them depending upon how the measure up on various ‘quality’ schema. Throughout this blog, I have railed against pay-for-performance and its cousins which claim to measure medical quality, but will fail in the mission. It’s like assessing the quality of a chef’s culinary creation by weighing the plate of food. Get the point?

Pay-for-Performance is in the lowest tier of the bottom 99% of quality control measurment. It was not designed to increase medical quality, but to control costs, which is a legitimate goal. At least have the guts to say so out loud.

I don’t have a clue what a colonoscopy costs. This is partially because I have never been interested in the business of medicine. However, colonoscopies are like airline tickets; no two passengers pay the same fare. Insurance companies have different rates. If we obtain biopsies or use a nurse anesthetist to administer the Michael Jackson juice before colonoscopic take-off, then there will be additional charges that cannot be firmly stated in advance.

When I do see what we are paid for a colonoscopy, it certainly doesn’t seem exorbitant considering the years of physician training and experience we have, the outstanding nursing care we provide, the immaculate and modern facility and equipment we use and our devotion to providing the highest quality service possible.

Who can put a price on an experience like this? Not us.

Sunday, August 5, 2012

The Plague of Unnecessary Antibiotics

With regard to antibiotics, physicians and the public have each been enablers of the other. Patients want them and we doctors supply them. There’s nothing evil about this arrangement. Antibiotics are one of medicine’s towering achievements and have saved millions of lives. Shouldn’t we prescribe them to patients who need them? Of course we should. But why do we prescribe them to patients who don’t?

Before you race to the comment section to accuse me of being a self-righteous preacher, realize that throughout this blog, I have confessed my own mistakes and shortcomings, and will continue to do so. (Yes, many commenters have enthusiastically assisted me in this effort.) So, when I throw a stone at the medical profession, I am also in the line of fire.

I have since the heady days of medical internship, been a conservative practitioner, preserving my soul even after completing training where medical overtreatment was worshiped. In medicine, less is so much more. I wish that more patients and more of us subscribed to the philosophy of medical parsimony.

Why would a physician prescribe an antibiotic (ATB) that is not needed?

First, there are times when the medical situation is murky, and the physician may be unsure if an ATB is truly needed. If there is concern about this patient, then the doctor may understandably prescribe the ATB, just in case the illness is a bacterial infection. (ATBs are effective against bacterial infections, but are not effective against more common viral infections including common colds.) Doctors often must make recommendations and decisions based on incomplete information. Wouldn’t it be nice if we knew with 100% certainty if a sick patient needed surgery, as many medical malpractice attorneys believe?

However, I am not referring to prescribing ATBs when the clinical situation is unclear. I refer to situations where they are clearly not indicated, and should not have been prescribed.

Over the years, I have seen numerous cases of ‘diverticulitis’, ‘sinusitis’, ‘touches of pneumonias’, upper respiratory infections, coughs, colds and various sore throats all treated with ATBs. Many of these patients received a 2nd course of ATBs when the condition persisted or recurred. In many of them, these drugs were simply not needed. Don’t think that ATBs were mere placebos. Unlike true placebos, ATB have real medical risks and can cause harm.

Of course, it’s possible that my medical judgment is flawed and that these patients truly needed ATBs, and it was lucky these folks had sharper physicians who recognized this. However, ask any doctor – including yours – if the ATB trigger is pulled too quickly. If the doctor says no, then get a second opinion.

So, why does this happen?

  • Patients demand it, convinced that they need it. This belief is strengthened if prior physicians have provided them with ATB ‘Kool Aide’ for the same viral symptoms.
  • Patients who are told only to rest and drink fluids may not believe they received sufficient medical care. “He did nothing for me. Who needed this appointment? For this I took off work?”
  • It may take 15 minutes to convince a patient that ATB are not needed, and only 10 seconds to prescribe one. Additionally, some patients can’t be convinced by any argument.
  • Physicians want to keep their patients satisfied. This will become more relevant when patient satisfaction reporting will be tied to physician reimbursement. Won’t that be ironic if lower quality care that patients approve of will reward doctors?
  • Physicians may falsely believe that prescribing an ATB reduces their legal vulnerability, arguing that the ATB is evidence of active treatment against the condition. For some reason, physicians don’t fear being sued if an unnecessary ATB causes a medical complication or a serious side-effect.
Overutilization of ATBs costs money and exposes patients to unnecessary risks. I’m also philosophically hostile to any treatment or medical test that is not needed. Additionally, medical experts have warned us for a few decades that the tsunami of ATBs that are prescribed so casually is breeding out superbugs that resist our available ATBs. It is tragic when a patient is severely ill from a true bacterial infection, and the necessary ATBs won’t work because the germ overpowers it.

So, the next time you have the sniffles and you’re in your doctor’s office, make sure you demand the right treatment. And, if you leave without a prescription, don’t feel that the doctor did nothing for you. He may have done quite a lot for you. And, that's nothing to sneeze at.