Sunday, April 29, 2012

How Many Tests Do Doctors Need to Make a Diagnosis?

History matters. I didn’t realize this as a kid, but I sure do now. I endured 2 years of U.S. history in high school, as New Jersey state law required. Can you say, soporific?

Only years later, as an adult, did I realize that history is a potent intoxicant that lured me into a deep addiction. Along with my Dad and brother, we sojourned many times across the country to many of our nation’s historical treasures. Most of these were civil war sites, which we properly regarded as hallowed ground.

Through happenstance nearly 2 decades ago, I learned of an aging physician in Saginaw, Michigan, Dr. Richard Mudd. I read that he had spent nearly his entire life trying to clear the name of his grandfather, Dr. Samuel Mudd, who was convicted as a participant in the conspiracy to assassinate Abraham Lincoln. My Dad and I drove up to Dr. Mudd’s home and listened to him tell his stories in in his parlor. The memory of this wonderful afternoon is vivid and indelible. This man, just 2 generations removed from the civil war, led me straight back to Lincoln.

As a physician, I also believe that history matters deeply, but it has been devalued. The medical history, the narrative that physicians elicit from our patient, remains the cornerstone of high quality medical care. Experienced physicians know, even if we often deviate from this practice, that a thorough medical history is the most significant and relevant data that will be available to us. Too often, short circuiting occurs, such as the hypotheticals listed below.
  • A patient with chest pain is summarily referred for a cardiac stress test
  • A patient with abdominal pain is whisked off for an ultrasound of the gallbladder (GB)
  • A patient with a headache is sent for an MRI of the head
I’m not suggesting that these diagnostic tests may not be the proper responses to the listed patient complaints. But, they may be premature or unnecessary. Medical tests are often ordered mechanically in a reflexive mode rather than after reflective moments. Medical tests are not tools for obtaining a medical history. In contrast, it’s the history that determines which test, if any, is necessary to narrow the diagnostic possibilities. Patients have a hard time grasping this concept and have come to believe that lots of medical tests, particularly imaging studies, define high quality care. This is not their fault. Who taught them these lessons?

Using chest pain as an example, in many cases, a thorough history can lead to the diagnosis. While many diseases can be sly and masquerade as other conditions, experienced physicians can usually obtain solid evidence that chest pain is cardiac, pulmonary, gastrointestinal or muscular simply by listening to the patient’s story. A medical test should be ordered to answer a specific and significant question that remains after the medical history and a physical examination. (While the physical examination has real value, in general, it does not approach the worth of the medical history.) For example, we do not order an ultrasound of the gallbladder because a patient has a stomach ache. We do so because the history is suggestive of gallbladder pain, and the ultrasound will confirm the specific diagnosis under consideration. Here’s why this is so important. If an ultrasound of the GB is ordered casually on a patient with stomach pain, and gallstones are discovered, then it may be falsely assumed that an explanation for the pain has been found. This patient may be referred to a surgeon for a ‘curative’ cholecystectomy, or removal of the gall bladder. What should have happened at the initial visit was a careful medical history, which may have excluded the gallbladder as the culprit. Most gallstones found these days are innocent bystanders, and not a cause of symptoms.

Israeli researchers showed how powerful physicians’ basic clinical skills and acumen were in making a correct diagnosis, without scans and other imaging studies. It’s nice when a study confirms our gut instincts.

If a medical test is ordered, ask what specific question it is designed to answer. Is it a fishing expedition? Will it decide between 3 competing diagnoses? How will the test result change the care? If the results won’t change anything, then should the test be done?

Medical history counts in a big way, even if the pay-for-performance schemes can’t measure it. Will physicians still be taking old fashioned medical histories four score and seven years from now?

Sunday, April 22, 2012

Frivolous Medical Malpractice Lawsuits Targeted by Medical Justice

Whistleblower readers know my views on the perverse and dysfunctional medical liability system. I have read numerous plaintiff lawyers’ blogs, and those of other tort reform opponents, to better understand the issue from other perspective. As a physician, I bring bias to the issue, as do all the players in the game. After 20 years of thought, and some legal brushfires, I am persuaded that the medical profession has the better argument. I also do not believe that we physicians are as strident and ideological as the other side is, but perhaps this is simply because this gastroenterologist has a jaundiced view of the issue. For example, most physicians readily admitted that our health care system, before Obama and the Democrats cured it, had serious deficiencies that demanded reform. In contrast, rarely do I hear or read plaintiffs’ attorneys remarking that the medical liability system needs some healing. What I read in their columns and postings is a spirited defense of the status quo. When a physician like me points out flaws in medicine, as I have done throughout this blog, this is an attempt to improve our profession and public health. Indeed, physicians on blogs and in medical journals write openly and often about where our profession is falling short. Reflection and self-criticism are ingrained in the culture of the medical profession. If a plaintiff’s lawyer were to publicly advocate medical malpractice reform, then I suspect he would be shunned for his blasphemous utterance, or banished to the gulag for some re-education.

In my tort reform meanderings through the blogosphere, I stumbled upon Medical Justice (MJ), a company that is devoted to protecting physicians against the abuses of the medical liability regime. This organization aims to:

  • Prevent frivolous litigation from being filed against a member physician
  • Attack internet defamation of physicians’ reputations
  • Hold medical ‘expert’ witnesses accountable
I was intrigued and reached out to them to learn more about their enterprise. When a member physician is unfairly sued, MJ gets into the other side’s face to alert them that their national organization is squarely behind the doctor. This puts the plaintiff and the opposing medical experts on notice that their actions will be scrutinized and held accountable. There is a yearly charge for membership, which depends upon the amount of protective service the practitioner desires.

Some of MJ’s services require the physician and the patient to sign certain agreements, which I think would be problematic for doctors to implement. While I understand why a physician would desire a signed agreement that would protect his interest, I am less certain why a patient would do so. In addition, such a discussion might erode the doctor-patient relationship.

Thus far, they have over 2000 physician members and are in a strong growth phase. I think their fees are reasonable, a fraction of what I pay each year for my medical malpractice insurance. If even one lawsuit is prevented, it would be worth a decade or two of MJ membership charges. I wish them well and encourage Whistleblower readers to visit their site and their very fine blog.

In fairness, I should disclose my relationship with this organization. Admit it; you already think I’m an MJ shill, right? You suspect that I have a ‘pay for click’ arrangement with them. I must get a kickback for every Whistleblower reader who signs up. Here is the arrangement I have with them, which I disclose publicly.

I am not an MJ physician member and they pay me nothing. They didn’t ask for this blog post and the only reward they might offer me is gratitude for having done so. Keep reading because I now must confess a potentially corrupt act as my conscience is torturing me. I did have lunch with their Cleveland rep months ago who rejected my offer to grab the tab and paid for my meal, which cost about 10 bucks. Readers must now weigh and decide if my integrity can be compromised for a free meal.

MJ added me to their blogroll for the usual reasons; they liked my Whistleblower tort reform content. I am plugging them for free because they are the only folks I’ve discovered who want to put a few arrows in our quiver so our unfair fight will be a little less unfair.

I expect that MJ’s services will grow and become more refined as the company matures. If they are successful, then medical malpractice carriers might be willing to subsidize physicians’ membership costs.

With so many out there stabbing us in the back, it’s refreshing to have an organization that’s watching our back.

Sunday, April 15, 2012

The Art of Medicine: A Pursuit of the Truth

I read this morning in our local newspaper that Tennessee is soon expected to have a law that would permit public school teachers to offer views on climate change and evolution that are counter to orthodox doctrine on these subjects.

No, I don’t think that creationism is science and it should not be disguised as such. Climate change, however, is more nuanced. While it is inarguable that temperatures have been rising, it is not certain and to what extent human activities are responsible for this. Clearly, this issue has been contaminated by politically correct warriors and those who have an agenda against fossil fuel use. Science, like all scholarship, should be a pursuit of the truth.

Just because something sounds true and logical, doesn’t make it so. In addition, repeating an opinion like a mantra isn’t sufficient to confer legitimacy on the view. Many sidestep around these inconvenient truths.

In medicine also, much is presented as true, which is either false or unproven. Consider how many established medical practices have no science to buttress them. Consider the following examples and decide if you agree that each is a good idea that makes sense and that you would support.

  • Patients should have regular physical examinations as an integral part of preventive medicine.
  • Patients should undergo a CAT scan of the chest and abdomen at age 50 in order to detect any silent lesions that may be present, before they have an opportunity to grow and threaten the patient.
  • Medical care is superior in large medical centers because physicians there have access to the best minds and technology.
  • If you have fever and a cough, it’s best to begin antibiotics early before pneumonia can develop.
  • Everyone should restrict their salt intake.
  • Probiotics facilitate good digestion and should be part of a healthful diet.
  • Placing stents in narrowed arteries helps patients live longer by allowing for increased blood flow.
  • Cardiologists are more skilled at managing high blood pressure than general internists because of additional training and experience.
  • A back x-ray is important to evaluate new back pain to exclude a fracture or other serious condition.
  • Everyone should receive medication to lower their cholesterol levels, even if the levels are ‘normal’, as this will reduce risks of developing heart disease.
  • Alternative and complementary medicine is safe and effective and should be incorporated into mainstream medical practice.
  • Colonoscopy is a fun and exciting event that everyone should enjoy often.
  • Medical bloggers who spew forth sarcasm need to be chastised and reined in.
So, let’s not label the backwoods Tennessee folks as backwards too quickly. Medicine and climate change have common elements. Both are suffused with politics.. Proponents of both make spirited claims without scientific basis, and attack principled dissenters as outlying heretics. Count me as one of them. Someone has to blow the whistle here.

I have something in common with climate change, formerly known as global warming, myself. When I read some of this politically correct pablum, my own temperature starts rising.

Sunday, April 8, 2012

The Supreme Court and Obamacare. And the Winner is...

I write now from the nation’s capital, one of my favorite destinations. For one who dwells on history and politics, this is the place to be and to return to. During these few days, I took a kid to Ford’s Theater and then to Mount Vernon. Today, I hope to amble throughout the National Mall where I will stand in awe before the great monuments that remind us of what we all need to be reminded of. We will see the monument to Martin Luther King, Jr., which has been in the news because objections have been raised to the inscription carved into the monument. Words matter.

The Korean War Veterans Memorial, one of the most moving memorials I've ever seen, is introduced by stark words of enormous power and meaning:  Freedom is Not Free.

Many Washington, D.C. license tags are adorned with the the words, Taxation Without Representation, a demonstration of citizen protest that is unthinkable in so many other world nations.

I recall years ago, when a protest developed when the Smithsonian Institution included a written description in an exhibit of the Enola Gay, the small airplane that dropped a heavy payload on Hiroshima on August 6, 1945. After vehement protests from American veterans and others, the words were withdrawn.

The United States Supreme Court heard and read many words a few weeks ago on the Patient Protection and Affordable Care Act, affectionately and derisively referred to as Obamacare. The Court heard extended arguments over a 3 day span, a marked departure from the brief period of time usually allotted for oral arguments.

After those 3 fascinating days, tens of thousands of words were spoken and written trying to divine where the justices stood on the issue. Would the individual mandate be struck down? Would parts of Obamacare be preserved? Would Justice Kennedy be the deciding vote? What judicial horse trading would be necessary for one side to secure 5 votes?

The critical question that emerged once again from these proceedings is why does Justice Thomas never ask any questions during oral arguments?  Where are his words?

As everything else that occurs in this town, there is always a political prism that folks peer through. I read one piece suggesting that Republicans win regardless of what the Court decides. If Obamacare is declared constitutionally invalid, then the president is weakened. If the Court upholds the law, then the Republicans can run hard against it in the upcoming election. I don’t agree with this analysis, but this is an example of the drivel that dribbles freely around here.

The truth is, of course, that no one has a clue what the Court will decide. Court watchers know that justices ask questions during oral arguments for many reasons, which may not reflect their views or predict a decision. Yet, predict and pontificate we must.  The president had to walk back from his own comments this week, when he opined that the Court should uphold the law, as if the judiciary were not a coequal branch of goverment.  Marbury vs Madison anyone?

I’ll make my own prediction here. Readers know that I am hostile to Obamacare. I predict that if the law is upheld, that more and more folks will agree with me as time goes on. Medical costs will continue to rise and medical quality will decline. The medical profession will be suffocated by toxic regulations, restrictions and oversight.

However, I don’t think that the Court should strike down the law just to please me or because the president’s health care law will fail. If you reject judicial activism, then you have do so consistently. It’s not the Court’s job to save a worthy program or to make policy. In my mind, they are charged to answer one question. Is it legal?

Last year, I took the kids to the Supreme Court, and we peered into the chamber where 9 citizens hold enormous power and responsibility. Engraved in the building’s fa├žade are the words, Equal Justice Under Law, an ideal we strive for, but don’t always achieve. Yet, there is no better system.

Thomas Jefferson spent some time in Washington, D.C. also.  He was a magician with words, an alchemist who could transform mere words into a harmonious symphony. He wrote to Thomas Paine, another man whose words wielded enormous influence; “Go on doing with your pen what in other times was done with the sword.” Words mattered then, and they still do.

Sunday, April 1, 2012

Whistleblower Releases Top Ten News Stories: Nation Shocked!

My research staff at Whistleblower, which is me, scours the news each week so that I may deliver to my tens of thousands of readers, or at least a few dozen including family, pithy profundities. Here are some news items that were leaked to us by high level sources whose identities we will zealously protect for as long as their monthly payments to us continue. Here’s our top ten list. Let the whistle blow!

Whistleblower Researcher

  • Obama admits he voted for George Bush in 2000.
  • Residency training regulations modified at NYC hospital. House staff is now required to work a full 7 days without sleep to maximize continuity of care and to reduce hand off errors.
  • American College of Radiology argues that CAT scanning is underused and that thousands of incidentalomas are being missed.
  • Pay-for-Performance model will now be applied to elected officials. Physicians will design the quality metrics.
  • Medicare will now cover the cost of any treatment that a patient believes is medically necessary. Medicare may appeal the decision, which will be decided by the patient’s family.
  • American Bar Association announces strong support for caps on non-economic damages. When asked if they now admit that the medical malpractice system was unfair, abusive and unjust, they responded, “yup”.
  • FDA requires that the consumer cost of every prescription drug not exceed $1 per dose. Pharmaceutical companies concerned over loss of R & D revenue were reassured. Their profits will explode, our government explained, as Canadians will turn south for cheap medicines.
  • Physicians can now receive fees for referring patients to medical colleagues just like lawyers now do with clients.
  • Gastroenterologists, cardiologists, ophthalmologists and dermatologists volunteer to transfer 25% of their income to family physicians and internists because fairness feels good.
  • Obama reassures the public about our stagnant economy. “I will do for our economy exactly what I did for health care.”
Fool me once, shame on me. Fool me twice…

Happy April Fool’s Day! Now, go pull a fast one on someone. If you’re not sure how to do this, and you need expert advice, call your senator or congressman. These fools are pros.