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Showing posts from 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 exa

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!

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 Admin

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 f

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&

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 cance

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-deportati

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 d

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 patien

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 controversia

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

Triceratops 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 d

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 h

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 nume

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 Sep

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 altern

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 m

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 phras

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 th

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.  Ho

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 o

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

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 patie