Sunday, December 29, 2013

Should HIPAA Compliance Guard All Protected Medical Information?

Everyone is familiar with the acronym HIPAA, which is the 1996 edict called the Health Insurance Portability and Accountability Act.  Isn’t that a smooth and melodious name?

These are rules & regs that are designed to protect your confidential protected medical information.  I support the mission.  I don’t think that your medical records should be deliberately or inadvertently shared with those who are not lawfully permitted to view them.
  •  Medical charts (remember when there were medical charts?) should not be left open on the counter.
  • A physician should not yell to front desk personnel within earshot of others to give the patient a psychiatric referral.
  • Elevators are not proper venues to have medical discussions about specific patients.
  • Medical information should not be disclosed to inquiring friends and family without permission.
I maintain that HIPAA has been OperationOVERKILL for many physicians and staff.  Keep in mind that doctors, at least in my generation, have been imbued with a culture of confidentiality.  For me, HIPAA has not changed my personal practices as I’ve always kept protected information private.  There are entire industries now whose function is to assure that billing software, electronic medical records (EMR) and various medical vendors are ‘HIPAA compliant’.  Of course, I recognize that the EMR era has unique privacy concerns that must be addressed.  Yes, privacy and protection are necessary, but HIPAA often extends further than it should and is often the grist for office eye-rolling banter.

HIPAA Enforcment Training Mission

But, as is often the case with bureaucratic mandates, common sense is left at the curb.  Clearly, there are circumstances where absolute compliance should be relaxed even if this is a technical violation.  Do we really want 100% HIPAA compliance?  Do we ever want 100% compliance in any sphere?  If we insist on a policy of zero tolerance of weapons in our schools, for example, do we support suspending a second grader who fashioned a gun out of a Pop-Tart?   Zero tolerance invariably leads to absurd situations.

A woman fell and was sent by her doctor to the emergency room so that ankle x-rays could be done.  Fortunately, there was no fracture.   Afterwards, the doctor’s staff called the hospital to have the relevant records faxed, but the request was denied.  The heavy hand of HIPAA was firmly raised.  They would need a signed release by the patient to authorize transfer of records to the very doctor who sent the patient to the emergency room in the first place.  The reason given was to be faithful to HIPAA.   The woman does not have a fax machine and had to hobble from her condo to the front desk for the signing and faxing ceremony.  Luckily, this forced ambulation did not further damage her ailing ankle.

Readers might be wondering how I am knowledgeable about an individual’s private medical information.  The patient is my mother.   I share the vignette even though I did not obtain her signed release authorizing me to disclose her protected medical information to my millions of readers.  I now live in fear that a middle-of-the-night knock on the door will be the HIPAA police.  If this blog and its author disappear, then you will know what happened. 

Sunday, December 22, 2013

Whistleblower Holiday Cheer 2013!

Jingle bells, Jingle bells,
Sebelius in her role,
Oh what fun it is to see
Her bringing us some coal.

Obamacare, If you dare,
The website has a glitch
Fox News ratings - out of sight!
While Dems are in the ditch.

Here a tweak, there a tweak,
Mad Obama fans,
When he said a hundred times
“You can keep your plan.”

Here’s a clue, From me to you
Just a little trick,
To help survive Obamacare
You’d better not get sick!

Wishing you Joy and Peace

Sunday, December 15, 2013

Physician Fee Schedule 2014 Uses Frequent Flier Model

Whistleblower readers know that I have spewed some vitriol toward the airline industry, where customer service goes to die.  Indeed, in a prior post I contrasted their routine harassment of frequent fliers with the individualized stroking that Apple customers routinely receive.   For sarcastic scriveners like me, the airlines are the gift that keeps on giving.  The target is so large that one can hit it from miles away with a blindfold on at night.

Fun, fun, fun...

Some, but now all, sources of customer angst include:
  • The convenience and rationality of the TSA process (“Out with those dentures, Granny!”)
  • The sumptuous meals served aboard. (“Exact change for the pretzels is appreciated.”)
  • The plush and spacious seats which easily accommodate those with BMIs < 18
  • On-time performance (Do we really know what time is?)
  • Truthfulness with regard to the occasional flight delay  (Pinocchio would nasally impale customers if he worked as a gate agent.)
  • The simplicity and predictability of ticket pricing (Do any 2 passengers pay the same fare?)
  • The reasonable cost of changing reservations (Why does it cost 100 bucks for a keystroke?)
  • The ease of reaching a living, breathing human being when calling the 1-800 number
  • Their priority of storing your carry-on stuff on board to avoid checking your bags.  (“You mean my shaving bag needs to be checked?”)
Earlier today, as I penned this post, I read that airlines are increasingly picking our pockets in search of ancillary revenue. 

Let’s define some terms.
Ancillary revenue:  noun phrase, gouged funds extracted from helpless customers

Usage: The mugger obtained ancillary revenue from his victim.

Ancillary service:  noun phrase, stuff that should be free that is now provided at surcharges to customers                        whom have no recourse

Usage:  The client was surprised that the handshake offered by the consultant at the                                                    first meeting was an ancillary service that was itemized on the billing invoice.  

Airline passengers are now charged for seats with an extra inch or two of legroom, designated aisle seats, special posh lounges where the honey roasted peanuts are always free, priority boarding so there will be overhead bin space available and a complex baggage fee schedule. I wonder that if circumstances resulted in oxygen masks (which I hope truly exist) springing out of their hiding places, that we wouldn’t need to swipe our credit cards before the life-saving gas would flow.  (Premium members are guaranteed 3 minutes of free oxygen and a clean mask.)

Imagine if the medical profession – or your job – was reimbursed in this fashion?
  • We will be happy to reschedule your appointment for $100
  • Sedation is included in the price of colonoscopy.  If you want a sterile needle…
  • Waiting room reading material is available for rent
  • Pay toilets
  • Elite waiting room for premium patients where a registered nurse will serve you a cocktail
  • Free waiting room chairs that can comfortably accommodate leprechauns.  Upgrade available.
  • Rewards program.  Each gastro procedure earns valuable points that can be used for a future colonoscopy, enema administration or rectal exam.  The points are not transferable, will expire in one year and face a labyrinth of restrictions that will ensure you’ll never cash in as promised.
I’ll bring up these ideas at our next medical  practice meeting.  Why should our small private practice leave money on the table?  Are you ready to reach for the ‘stomach distress’ bag now?

Sunday, December 8, 2013

Disaster Obamacare Rollout Rolling Over A Cliff

I can’t add much meaningful commentary to the Obamacare roll out disaster.  There has been a deserved tsunami of criticism and derision across the political spectrum.  Democrats are sprinting for the exits.  Many of them in their last campaign repeated the sound bite of 2013, “If you want to keep your doctor…”.  Of course, without the miracle of video tape, these obfuscators would simply deny their own words. 

The disaster rollout is a travesty on so many levels.   We should not forgive any institution that produces an abject failure after 3 years of preparation and nearly $600 million when they have been crowing for months about the October 1st start date.  It did start something, but not what the government wanted.   More incredible is that the government was told by experts prior to the launch that the website was not even half baked, and yet they rolled it out anyway.  Is there any reader who can explain this decision to me?   If we knew that a plane had mechanical defects, would we still board it?

Used by Obamacare Webmasters

The website is a sorry example of why many of us are so skeptical and cynical of expansive governmental liberalism.   This is not a partisan swipe, but a recognition and validation of those who prefer the ingenuity and expertise of private enterprise. Which institution do you admire more, the Bureau of Motor Vehicles or Fed Ex?

Beyond the website fiasco, millions of American have had their insurance plans cancelled who are then directed to the website which doesn’t work.  Would it be fair to fine these folks if they aren’t able to sign on to a health plan because of government incompetence?   Those who do receive divine intervention and penetrate the web site cannot divine if their doctors will be on the plans.  Additionally, many premier hospitals are declining to participate in the exchange plans, which will shut out many patients.  And, after the Obama ‘apology’, insurance companies who have been scrambling over for the past few years to comply with Obamacare mandates are now told, ‘never mind’.  

Cyber experts testified in congress that personal confidential data is not secure.  Another glitch?

A few weeks back the administration promised that by the end of November the website would be working for the vast majority of users.  The term vast majority was not defined.  Considering, the creative way that these Obamaphiles use words, perhaps, 25% of users will constitute a majority.  More recently, they are promising that 80% of Americans will glide through the website by month’s end.  Watch the Obama numbers plumbers massage the data to make sure that the 80% threshold is reached.  Somehow, lots of folks who will not be able get the website to work won’t be counted. 

Is 80% ‘success’ after years of preparation and gazillions of dollars a worthy goal?   Before we had Obamacare, 85% of Americans had health insurance.  I guess that insuring only 85% of American’s is a failure, but an 80% success rate for the website is a great victory. 
Would we be satisfied with an 80% success rate in other spheres of our lives?
  • A taxi driver reaches his destination 80% of the time.
  • A gastroenterologist properly cleans and disinfects his instruments 80% of the time.
  • A pharmacist dispenses the proper medicine 80% of the time.
  • Google Maps is accurate 80% of the time.
  • A dentist extracts the correct tooth 80% of the time.
  • Traffic signals operate correctly 80% of the time.
  • An ATM dispenses the correct amount of money 80% of the time.
  • A journalist is accurate 80% of the time.
  • An airplane lands safely…
I try to be informative, factually correct and even entertaining on every Whistleblower post.  Clearly, this super human standard is beyond reach.  From now on, I will strive to create worthy essays in the vast majority of my postings, a threshold that the government will soon be defining for us.   Can you say out loud in public that 51.5% is a vast majority with a straight face?  If you can, then you should be in government. 

Sunday, December 1, 2013

Thanksgiving, Pausing to Say Thanks...

To everything, there is a season, and a time to every purpose under heaven.

It’s time to pause and offer gratitude for the blessings that have been bestowed upon us.

Roman Goddess with Cornucopia
  • We are thankful that our insurance coverage has not yet been cancelled.
  • We are appreciative for websites that work as promised.
  • We are grateful when our personal approval rating is above 50%.
  • We acclaim the president for his interim deal with the Iranians, a government that supports Bashar Al Assad, funds Hezbollah and refers to Israel as a rabid dog.
  • We offer Hosannas to Democrats Dianne Feinstein, Harry Reid, Barbara Boxer, Joe Biden and Barack Obama who were all vehemently against dismantling the Senate’s filibuster rule until they were for it.

Diverging from sardonicism, I hope that all enjoyed a Thanksgiving holiday filled with mirth and laughter in the presence of loved ones.  To those who find themselves in one of life’s valleys, I hope that brighter days are ahead for you and sooner than you expect.  Find a piece of joy and seize it.

Warm wishes to all.

Sunday, November 24, 2013

Should Doctors Apologize to Patients?

I had thought that apologizing was a straightforward act, but I now realize that it is a nuanced art form.  We’ve all heard the ‘mistakes were made’ version, usually issued by politicians who attempt to insert a layer of passive voice insulation between themselves and their screw ups.  There is also the ever present conditional apology which by definition falls short of complete responsibility acceptance.  The template here is: “I’m sorry for my oversight which wouldn’t have happened if….”

The Gettysburg Address - Silly Remarks?

There have been several apologies in the news recently.  First President Obama offered a faux mea culpa with regard to his indisputable and repeated ‘misrepresentations’ on his broken promise that we could all keep our own doctors and health insurance plans.  Here’s what he said on November 7th.

“I am sorry that they are finding themselves in this situation based on assurance they got from me.”

Finding themselves?  Really?  I grade this as beyond lame on the apology scale.

CBS’s flagship and enduring news magazine 60 Minutes apologized for using a source on a Benghazi piece who was a liar.  “We were wrong to put him on the air,” said Lara Logan a few days prior to airing a formal apology.  The latter included: “It was a mistake to include him in our report.  For that, we are very sorry.”  While some have criticized this apology as inadequate, I am more lenient here.  They admitted they screwed up, apologized and didn’t blame anyone for their mess up.  Sure, they could have fallen harder on their sword or fired a few folks, but I think they crossed the minimum standard for contrition and acceptance of responsibility.  

Recently, a newspaper issued a retraction for comments published 150 years ago.  The Patriot-News, a Pennsylvania newspaper earlier this month issued a retraction for referring to Lincoln’s Gettysburg Address as ‘silly remarks’.   Their recent editorial included the statement: “The Patriot-News regrets the error.”   I congratulate them on reaching this belated, enlightened position.  They certainly cannot be accused of a rush to judgment.  Let’s look for other retractions from them for other errant opinions they published in the 19th century.

Martin Bashir, issued 2 minute on air apology on MSNBC for a diatribe against Sarah Palin that shattered the network's already low threshold for decency and fairness.  While the apology seemed genuine, most of us would have lost our jobs for similar behavior.

What should doctors do when we make a mistake?  Of course, from a moral perspective, there is no controversy .  We should  do what we expect others to do.  When we err, we should admit it and apologize for it.  Of course, some errors are trivial and do not require us to march into the confessional.  If a patient receives liquid diet when a soft diet was ordered, the world will continue to spin.  No foul here. But substantive errors must be disclosed. 

The dilemma for physicians is fear that admission of error, which is morally required, may be used as a cudgel if the physician is sued for medical malpractice, which is an unfair arena.  Personally, I believe that this concern that apologizing will increase legal risk  is exaggerated and that a genuinely contrite physician may reduce legal vulnerability by explaining candidly what went wrong.  It should be self-evident that an adverse event or a mistake is not tantamount to medical negligence, but so many misunderstand this.  Nevertheless, physicians should choose their words carefully when disclosing medical errors to patients and their families.

Many states have physician apology laws that state that expressions of regret are not admissible in  medical malpractice trials.   These laws are narrowly crafted.  If the physician’s statement goes beyond expressions of regret and empathy, it is admissible.

 Inadmissible:   “I’m very sorry that this complication occurred and that a second surgery will be necessary."

Very Admissible:  I’m sorry that I nicked the spleen and I had to remove it.”

So, how was this post?  Verbose? Self-serving?  Tedious?  Factual errors?  Arrogant?  If so, don’t blame me.  Sometimes, mistakes are made. 

Sunday, November 17, 2013

Medical Overtreatment: Why Doctors Like to Slay Dragons

Saint George slaying the dragon. Bernat Mortorell, 15th century

I’m sending a patient downtown to see a pancreatic expert.   He’s a young man who didn’t fully appreciate the health risks of a former alcohol addiction.  He’s been sober for well over a year, but alcohol toxicity can be unforgiving and permanent.   We don’t fully understand why some alcoholics develop cirrhosis and other complications while others seem to skate by without a scratch.  While I want folks who have the strength to conquer addictions to regain lost health and opportunities, many life choices lead to irreversible consequences.   Life is often an unfair mystery.  We witness this in medicine often.  Some smokers live well into their 80s, while others become tethered to oxygen tanks or contract cancer.   Trim athletes who eat seaweed salads seasoned with probiotics keel over while obese Whopper-swallowers wallow their way into old age. 

My guy has chronic pancreatitis, a known consequence of alcohol abuse.  Most of us don’t pay much attention to our pancreas, until it’s not performing well.  His is sick and is causing him pain.  He’s got a ball of fluid hanging off the tail of the pancreas, which shouldn’t be there and is not going way.  In fact, it has enlarged some as seen on his most recent CAT scan.
There are three things that doctors love to do.

Enter any orifice possible.  Why do you think that gastroenterologists, ENT (ear, nose and throat) , urologists, proctologists, gynecologists and pulmonologists are always smiling?

Stretch any narrowed tube in body.  If a cardiologist finds a narrowed coronary artery on a cardiac catheterization, the impulse to stretch it will be overpowering convinced that this has to be a good idea even if medical studies have refuted this. 

Drain Fluid.  Doctors like to do this because it’s cool and it always sounds right to patients and their families.   We welcome telling patients afterward that we’ve successfully shrunk their fluid collection by 50%.  Patients then become 50% relieved.  It sounds right that we should attack an abnormal fluid collection and that eliminating it is the ideal objective. 

Here are the unasked questions?

Does the orifice need to be violated or do we do just because we can?

Is the narrowed artery, bile duct or artery actually a medical threat that needs to be stretched, or do we widen these narrowed structures because we can convincing ourselves and others that we have averted a medical crisis?

Is the fluid we drain actually bothering or threatening a patient or should it have been just left alone?
My patient is not getting better under my care and I want the advice of an expert.  I cautioned the patient that the mere presence of abnormal fluid doesn’t mandate its removal.  I am hopeful that he will receive a sober assessment.

Sure, we all like men  of action, medical swashbucklers wielding tools and weapons to slice into our diseases and make us well.  Would we rather watch a warrior slay a dragon or a farmer plant seeds?

Sometimes, a quiet contemplative man of inaction is the true healer.  

Sunday, November 10, 2013

Why Won't President Obama Tell us the Truth about Keeping our Doctors?

Morality, truthfulness and personal integrity do not command the currency that they should or used to.  Truman’s phrase, ‘the buck stops here’ is of historical interest only.  Consider authors and journalists who admit to plagiarizing and then go on to resume their careers.  Resourceful students use modern technology to cheat on standardized tests.  Our government refuses to classify a military replacement of a government in Egypt as a coup d’etat.  Teachers strike for more money claiming that their only interest is their precious students.  Politicians deny that campaign contributions will confer any special influence by the donors. A parade of overachieving athletes over the years denies they have ingested any banned substances.  Our intelligence services are not spying on Americans.  Physicians order diagnostic tests claiming they are only for medical reasons.

Sometimes, the dishonesty is stealth while on other occasions it is transparent.  I suggest that the phrase ‘it has nothing to do with money’ signals that mendacity is just around the corner.

Reporter:  “You are suing Kellogg’s for $7 million dollars because your Rice Krispies didn’t crackle properly?”

Plaintiff:  “Yes, but this has nothing to do with money.  I’m doing this to send a message to Battle Creek and Big Business everywhere that our kids matter.”

Our then U.N Ambassador last year appeared on multiple Sunday morning news programs offering a Benghazi narrative that she knew or should have known was entirely false.  Her fate?  Promotion!
The leader of any organization sets the standard for conduct of the entire team.  If a boss plays it a little fast and loose, then those who report to him are likely to accommodate to his ‘relaxed’ style.  This is why police chiefs, school principals, spiritual leaders, coaches, department heads and editors play such critical roles.  When they set a high bar for themselves, they raise everyone’s standards.  The converse is also true.

The most important leader in the country is the President of the United States, who sets an example for over 300 million people.  Remember, when Jimmy Carter told us that he would never lie to us?  While he was honest, he wasn’t a successful president.  In 1940, FDR campaigned that “you boys are not going to be sent into any foreign war.”  Did he really believe this?    Must we choose between honest leaders and successful ones?

I am deeply troubled by President Obama’s false pledge that we could all keep our insurance plans and our doctors, when we now know that this is completely false.  I am not calling the president a liar, but I am stating that his promise was not the truth.  If he simply was misinformed or uninformed, which would demand an explanation, why doesn’t he simply admit to his error in the same manner that we counsel our children to come clean when they need to do so?  Instead, the president repeats the pledge but now makes it conditional on insurance company decisions, which is a different beast entirely.  Is duplicity and responsibility avoidance the standard he wants us to emulate?

An honest administration would admit that we were deeply misled and would accept the political cost of this admission.  Not only is this the proper course, but it is also the wiser one.  When they continue to fail to admit what we all know to be true, they only deepen the hole they are trying to crawl out of. 

The president offered a statement on Thursday which some described as an apology.  I don't.  Here's the statement:

"I am sorry that they are finding themselves in this situation based on assurances they got from me."

You call that a mea culpa?  What happened to clear expressions of contrition, such as "I screwed up"?
The president added that "we weren't as clear as we needed to be.".  I disagree.  The president's repeated promise that we could all keep our doctors and insurance plans couldn't have been any clearer.  Indeed, it is this clarity that keeps the anger and frustration burning.

Which slogan is operative here?  The Buck Stops Here or The Spin Starts Here.

Sunday, November 3, 2013

Has Your Health Insurance Policy Been Cancelled? Who Knew?

I feel bad for Jay Carney, the president’s spokesman.  Each day, he faces the Washington Press Corps -piranhas on the hunt – and he must dodge and obfuscate.  I am surprised that the velocity of his spinning hasn't resulted in him drilling himself a mile below the earth’s crust.  He is a human spinning tornado. Presumably, this role must be challenging for Carney, who formerly practiced as an actual journalist who was charged with ferreting out the truth.  Now, he is under orders to avoid the truth.  While I do not suggest that he openly prevaricates, withholding the truth qualifies as dishonesty, as I see it.

Tornado or Jay Carney?

Carney and all politicians leapfrog over the specific questions being asked.  Their non-responsive responses are exasperating to the questioner and to the public.  There are many rhetorical techniques that these professional double talkers use to change the subject.  Let me illustrate with a hypothetical interview.

Interviewer:  “If the vote were held today, senator, would you support it?”
Astute Whistleblower readers recognize that this is a ‘yes or no’ question’ that could be answered in a single word.

Response from Fantasy Senator #1:  “Yes.”
Response from Fantasy Senator #2: “No.”

Responses from Actual Smarmy Senators (ASS) Who Think We’re Too Dumb To Notice:

ASS #1:  “Well, what I WILL say...”
ASS #2: “Let me be as clear as I can…”
ASS #3: “The real question you should be asking…”
ASS #4: “The point I’ve been trying to make is…”

We’ve all seen and heard this spin cycle before.  When a politician of one party has behaved badly, we can expect two results.   

o         (1) The oppposing party will pile on demanding censure, public rebuke or resignation.
     (2)  Political colleagues of the offender will spin wildly with comments such as “both sides need to dial      back the rhetoric”, when in reality only one side deserves blame.

The more we learn about Obamacare, the more hostile to it the nation has become.  Even liberal Democrats are having difficulty defending what is indefensible.   The arrogance of an administration that uses the term ‘glitch’ to describe a disastrous and failed rollout of the insurance exchanges on October 1st is astonishing.  Of course, this is not merely a technical fiasco.  It is symptomatic of a government behemoth that hopefully will fall under its own weight before it crushes the country. The rollout is a preview of a program whose rotten guts are starting to be exposed.  Then veneer is fading and the public is now able to inhale the noxious aroma from its innards. 

Millions will be tossed off of their insurance plans and will have to pay more to receive the same or less coverage.   Or, they will be forced onto the exchanges; and we see how smoothly that operation is proceeding.

The news media has been reporting aggressively that the administration knew that millions will be kicked out of their plans.  This has not been just a Fox News story.  I heard hard reporting on this on CNN and NBC, which are not known to be outlets of the political right.

We all heard the president – Salesman-in-Chief – promise us the following in 2009.

“Let me be exactly clear about what health care reform means to you.  First of all, if you’ve got health insurance, you like your doctors, you like your plan, you can keep your doctor, you can keep your plan.  Nobody is talking about taking that away from you.”  

This was at worst an outright lie.  At best it is a broken promise of a core pledge that the president gave to mollify our anxieties over a government takeover of our health care system. 

When the president was pressed on this issue recently, he now says that the government won’t force anyone off their plans.  This Clintonian utterance is beyond disingenuous.   The insurance companies are baling as a direct result of Obamacare.  If the government pushes insurance companies to the edge of a cliff that has been doused with oil, who’s responsible if the companies fall over the side? 

From 1996-2002 there was a TV series called Spin City.  Spin City is alive and well today.

Sunday, October 27, 2013

Should Michael Jackson's Doctor Practice Medicine Again?

Before Michael Jackson, most folks didn’t know what propofol was.  Now, patients are asking me for it by name.  It’s an awesome drug.  It provides a beautiful sedation, is extremely safe and rapidly clears after the procedure.  Under its effects, colonoscopy has become a sublime experience. 

We administer it in a different manner than Conrad Murray did.  For those who may have just awakened from a 5 year coma, Conrad Murray was Michael Jackson’s personal physician who administered propofol to Jackson in his home to promote sleep.  Murray succeeded and received the modest salary of $150,000 per month for his medical services.

Sleep Aid?

Administering propofol in a patient’s home without necessary monitoring and training is an egregious breach of standard medical practice.  Those of us who use the drug properly were shocked to learn of this doctor’s reckless and indefensible care.   Here are a few hypothetical examples of similarly negligent care.
  • A surgeon removing your appendix in the back seat of your car.
  • A psychiatrist hanging up on a patient who is threatening suicide.
  • An internist invites recovering alcoholic patients to a wine tasting event.
Murray will be released this month after serving time for involuntary manslaughter.  At present, he does not have a valid license to practice medicine, but hopes to be reinstituted into the profession.
Should he be barred from medicine for life?   I believe that the depth of his negligence warrants expulsion from the profession.  If fact, if his conduct doesn’t result in permanent loss of a medical license, then what would? 

Is there a different outcome that would allow this man to use his medical skills and serve the greater good?  What if he were given a medical license with stringent restrictions and strict oversight?   If he were required, for example, to practice in an underserved community and was tightly supervised by a physician, would we support this outcome?  

I have my own view here, but I’d like to know yours.

Sunday, October 20, 2013

Obamacare Health Insurance Exchanges Crash and Burn. Tweaks and Glitches

A few days ago, lawmakers sealed a deal to reopen the government and to relax the debt limit.  This was no O’Henry story with a surprise ending.  This was the outcome that all of us knew was forthcoming.  The GOP not only had no cards to play, but their empty hand was known to all.  It’s very hard to bluff when your cards are face up and you don’t even have a pair of deuces.   Obamacare was the GOP target that quickly became a phantom.  It disappeared.  Afterwards, there was nothing for them to shoot at except each other.

GOP vs Dems

A perusal of my posts nestled in the Health Care Reform Quality category will demonstrate my skepticism and hostility against Obamacare, which is an interim step toward something even worse.   But, the law was legally enacted, approved by voters in the last general election and was upheld by the U.S. Supreme Court. 
That such a monumental program was passed in a unipartisan manner is wrong, but is not illegal.  The roll out of the exchanges has been so abysmal that even Robert Gibbs, former Obama spokesman, has sounded more like a Tea Partier when commenting on the failed implementation. 

Even the Huffington Post, hardly a Tea Party outlet, trashes the exchange roll out. 

While Obamians may try to gloss over this colossal failure, amply documented in the media, by using words like ‘tweaks’ and ‘glitches’, the rest of us are not so easily hypnotized.   They are desperate to lure young healthy folk into the exchanges to pay for older Americans with health issues.  Those young indestructible Americans in their 20s, will pay a premium, particularly as they must pay for mandated insurance benefits that they may not want or need.   The penalty next year for those who opt out of the exchanges is $95, which young folks may choose over coverage.

And, if young folks do sign up, they will likely choose the low premium and high deductible option.  So, they will face high out of pocket costs for medical care and would be covered only for a catastrophic event that is unlikely to happen.  Will young people in these exchange plans become Obama cheerleaders?   I doubt it. 

Remember the president promising that if we wanted to keep our own doctor that we could?  Each week we read about another large company that is getting out of the medical insurance business and pushing folks onto the gleaming exchanges.    Once planted there, will they have free choice?  If their deductible is now $5,000, might this curtail their freedom to choose?  What if their doctor isn't on the plan?  The web site makes it nearly impossible for folks to determine if their doctor is on the plan.  This adds some adventure to the process.  And, it might be fun to meet a new doctor.  Another glitch?

The failed roll out is not an aberrational event.  It’s a symptom of system that is clumsy, controlling, expansive and broken. 

Let's stop the spinning.  When something is a disaster, then call it by its true name.   We’ve just seen how the legislative branch has served the nation over the past few weeks.  Would you call this a glitch?  Does Congress just need a tweak or two?   Let’s describe them in terms that pass the honesty test.  They are a group of self-promoting, petty and conniving partisans who spurn the public trust as they pursue their own personal ambitions while demonizing the opposition. 

Since the new agreement funds the government through January 15th and extends the debt limit through February 7th, we’ll be spectating once again the Congressional Theater of the Absurd in a few short months.

Last week, Congress’s approval rating has dropped to 5%.   My question to my learned readers is who are these 5%? 

Sunday, October 13, 2013

Ted Cruz Filibuster Misses the Mark

Even the most casual Whistleblower reader is aware of my hostility toward Obamacare, which appears destined for incremental implementation.  Ted Cruz’s paper mache weapons were no match for the Democrats' artillery brigade.   When the Chamber of Commerce, corporate America and organized labor are all on the same side of this issue, it suggests that healing this forerunner of socialized medicine will take more than a tweak or two to smooth it out. 

Cruz Takes Aim

There’s nothing unexpected or unfair here.  Romney campaigned hard against Obamacare.  The country had an opportunity to elect him, and declined to do so.   Did we expect that Obama would dismantle his signature legislative first term achievement in his second term?   When Romney lost, Obamacare won. The Affordable Care Act was legally enacted, albeit without a single Republican vote.  The Supreme Court determined that the law was constitutional.  Elections matter.  So, a flawed program, whose ultimate consequences are not yet entirely visible, was legally enacted and will be nearly impossible to derail.

Of course, serious reform was needed.  I written throughout this blog that our health care system was not enjoying optimal health.  There were glaring deficiencies and inequalities that I could never satisfactorily explain to my patients.
  • Why are drugs in Canada so much cheaper than the same drugs purchased here?
  • How can a hospital charge exorbitant fees for simple items that would cost a few bucks at CVS?
  • Why did it take so long for colon cancer screening to be a covered benefit, when colon cancer was always paid for?
  • Why is our per capita health care cost so much higher than other nations who demonstrate superior health outcomes?
  • Why can’t patients receive medical bills that they can understand?
  • Shouldn’t patients and their families have some skin in the game as a brake on the profligate spending of other people’s money for health care?
  • Why do physicians permit, if not encourage, futile medical care?
  • Why is it possible that so many working Americans can’t afford medical insurance coverage?
Obamacare emerged because the dysfunctional system demanded a response, and no prior president since the Truman administration was able to move the ball down-field.  Had Obamacare antagonists passed reform measures incrementally during past decades, then we wouldn’t be subjected to the clumsy and heavy hand of government healing now.

I don’t like Obamacare and I wish it could be repealed.  But, the program didn’t emerge from nowhere.  Those who coasted along for decades clinging to the status quo, created a target so large that you could hit it without aiming.  In Ted Cruz’s 21 hour and 19 minute speech, he never explained what brought us all to this moment.  We can't blame Obama for this.  His aim was wild, but the target we all created was so large, that he couldn't miss.

Sunday, October 6, 2013

Gun Control and Gun Violence - Is the Right to Bear Arms Absolute?

I’m writing now in the wake of another tragic shooting here in the United States.  For most of us, we have never experienced the current pandemic of senseless violence that we read about and visualize every day.  I challenge you to find a newspaper tomorrow morning, or listen to a news broadcast, that will not report on dark and pernicious inclinations and accomplishments of evil practitioners. 

If that challenge is not sufficient, then find an American over the age of 70 to attest that the world is better today than it was during his youth.  

I listened to the every word that President Obama said at the ceremony honoring the fallen Navy Shipyard personnel.  He spoke well, and his reference to congressional inaction with regard to gun violence didn’t trouble me at all.   It was beyond shameful when craven congressman couldn’t pass any piece of legislation in the wake of the Newtown catastrophe.   This was a bipartisan failure that broke congress’s already abysmal performance level.

I’ve never been a gun control supporter, and I’m still not persuaded by their arguments.  I do believe that some classes of weaponry should not qualify as an absolute constitutional right of law abiding citizenry.  Should folks be able to purchase unlimited numbers of weapons and ammunition?   Explain why background checks somehow don’t apply to gun shows and ‘private sales’?  I have some flexibility on these issues.

Although I would support some restrictions on gun ownership, I do not accept the views of gun control zealots that lack of restrictions are responsible for recurrent episodes of senseless violence.   Somehow, these folks demonize the NRA while they give a free pass to Hollywood, the video gaming industry and the music business, all of whom bathe us with violence every single day.   Do we believe that the media can’t influence us, especially those of us whom might be vulnerable?   To those who deny that media can influence our behaviors, explain why gazillions are spent on advertising for this very purpose.

Is the NRA a Scapegoat?

Criminals will not surrender their weapons or fail to procure new ones because of more restrictive laws.  These guys do not obey laws.  That’s why we call them criminals.  Get it?   

Outlawing assault rifles – red meat for the gun control crowd – will keep these guns from law abiding citizens, not others.  And, even honest gun control fanatics admit that these classes of weapons account for a very small percentage of violent American deaths, which are largely caused by handguns.   That’s where our collective outrage should be focused, although this is a more difficult and elusive target.

I’m hostile to the argument that’s often issued as a question, “Who needs an assault rifle”?   The fact that it is a right means that there is a legal entitlement that doesn’t require an explanation for exercising it.  How often do courts permit speech, for example, that many of us don’t understand the purpose or need for its expression.   Indeed, having a right means you don’t need an explanation.

I am aware that no constitutional right is absolute including the Second Amendment.   Personally, I do not feel that I should be entitled to purchase unlimited numbers of any kind of weapon available.  But, if I did so, I don’t think that I would be threatening the fabric of America society. 

As far as keeping guns from the mentally ill, a goal that every thinking person supports, explain how you would do this.  I don’t have a clue.  What’s your definition of mental illness with regard to this issue?   Depression?  ADHD?   Having seen a psychiatrist or a counselor in the past year?   On Paxil or similar medicines?  Being regarded as a loner in school?   Being moody?  Should a family history of mental illness be relevant?

While there have been obvious lapses in mental health that we should address, it’s an easier task to look backwards after a catastrophe has occurred and recognize missed opportunities than it is to do so prospectively. 

I vigorously support stronger background checks, even if this is not a proven remedy for reducing gun violence.  These are guns, not toothbrushes.   Guns can hurt people.  Stronger background checks by themselves would not restrict weapons that eligible folks can purchase and should be palatable to the pro gun crowd, in my view.   I am perplexed that one can purchase a weapon and not be required to have sufficient training in its safe use and storage.   Cars can hurt people if not used properly.  You cannot obtain a driver’s license without demonstrating that you know the rules of the road and can manage the vehicle safely.  Should we relax these requirements?

The explanations for the horrible violence that is our new reality are deep and complex.  Gun ownership may be an easy target, but I think that this argument misses the mark.   

What do you think?   Do you think that the primary reason that so many thousands of murders occur in America each year is because of lax gun laws?   While I’m willing to listen, that argument is no bull’s-eye for me. 

Sunday, September 29, 2013

Force-feeding Guantanamo Prisoners Tortures Medical Profession

Nearly every physician regards himself as an ethical practitioner.   Nearly none of us are, at least not fully.   There is no bright line that separates ethical from improper behavior.  Indeed, it is because the boundary is fuzzy that ethicists and the rest of us wrestle with contentious controversies.  It is, therefore, expected that ethicists are divided on many issues, much as the U.S. Supreme Court is often split in its decisions.  If the Court’s cases were easily decided, then most of its decisions would be unanimous.

Finding the balance.

While there are some bedrock ethical principles that should remain immutable, the field needs some breathing space to accommodate to societal changes and new research findings.  Analogously, the Constitution prohibits cruel and unusual punishment, but the definition of this evolves, so that today’s court may decide a punishment issue differently from its predecessors.  Similarly, it is possible that an issue deemed ethical today, might be considered unethical tomorrow.

Medical professionals confront ethical tension regularly.   These situations can be tough to navigate through as a physician weighs one person’s rights against another.   If a doctor ‘modifies’ a diagnostic code so that an insurance company will pay the bill instead of the unemployed factory worker, has an ethical foul been committed?  Is dispensing free drug samples, beloved by patients, ethical as this increases costs and raises drug prices for other patients?   Is it ethical for a medical specialist to withhold from his patient that his primary care physician is mediocre and there are superior alternatives available?   If a sick patient won’t pay his bills, under what circumstances, if any, can the physician ethically terminate the relationship?

There have been physicians present during enhanced interrogation events (read: torture) ostensibly to guide interrogators against causing permanent serious injury or worse.  Perhaps, these physicians have rationalized their role to be protectors of detainees, but this is nonsensical.  This role is so far removed from the medical profession’s healing mission, that it deserves no debate.  Indeed, this practice tortures the medical profession that is under oath to heal and comfort the sick, not to provide flimsy cover to ‘interrogators’. 

I am not opining here on whether protecting our national security requires enhanced interrogation techniques.  I am stating that the medical profession should not participate in the sessions.  As to whether physicians and psychologists should contribute to developing ‘interrogation’ techniques to ensure that they conform to our nation’s laws and values is grist for a true debate.  Even if this preparatory training function were to be deemed ethical, I would never participate in it.

Physicians have been participating in force-feeding ‘detainees’ in the Guantanamo Bay detention camp.  It is wrong and unethical for a physician to have a role in force-feeding an individual who has the mental capacity to refuse medical care.  I condemn this practice which tarnishes my profession and undermines the ethical scaffolding that supports and guides it.    The World Medical Association, the American Medical Association and the British Medical Association have each firmly denounced force-feeding.  Our military counters that the practice is legal and proper.  If force-feeding is ethical, then why shouldn’t we extend the practice into our hospitals and nursing homes?  

President Obama has stated, “I don’t want these individuals to die”, with regard to the Guantanamo detainees.  If our Commander-in-Chief wants to force food down someone’s throat, he is free to give the order.    But, no doctor or nurse should carry it out. 

First published in The Plain Dealer on 9/6/13.


Sunday, September 22, 2013

Syria Chemical Weapons Agreement: President Obama Declares Victory

Outcomes matter.  One will forget a tortuous path if it leads to a sanguine outcome.  This is true in medicine and in life.  Look at the recent path of American foreign policy and where it has led us.

Can You Choose the Right Path?
  • The president announces that Assad has to go.
  • The president lays down a red line for Syria with regard to chemical weapon use.
  • The Syrians detonate a few chemical weapons, testers which we ignore.
  • 100,000 Syrians are killed.  We ignore this as this is not a ‘red line’ violation. A death by sarin gas is more objectionable than a death by a grenade.
  • There is a chemical weapon massacre in Syria which shocks the world.
  • The president and the administration give daily public briefings on our intended limited military response. The administration assures that this "will not be a pinprick".  The Syrian regime watches CNN and FOX News so they can be apprised of the date and hour of our response.
  • The Secretary of State makes a persuasive case on why we must respond militarily now, not only to restrain the Syrians, but to set a precedent for other nefarious adversaries.
  • The president speaks to the nation.  After echoing Secretary Kerry’s case, he retreats and announces that he wants Congress – the body he regularly derides – to vote on a military strike, although he adds that he already has the necessary authority to authorize a strike.
Confused yet?
  • Within hours, it is apparent that Congress has the same zest for action in Syria as did our British ally across the pond.  The congressional vote would be against the president.
  • The president has boxed himself into a policy that he obviously rejects.
  • Vladimir Putin gives our president a lifeline and is thereby elevated on the world stage.
  • Syria agrees to sign chemical weapons ban.
The Outcome
  • The United States and the president are diminished.
  • Congress is not diminished as they are already known as a feckless and self-serving lot.
  • Putin and Russia are elevated.
  • Assad, whom are president stated should be replaced, is now treated as a head of state.
  • Syrian rebels are demoralized and face longer odds of achieving regime change.
  • U.S. inaction has given time for the Syrian opposition to become infested with unfriendly elements.
  • Iran and North Korea see that we “walk softly but carry a small toothpick”.
  • Assad has no incentive to withdraw from ongoing massacres using conventional weapons.
  • Chemical weapons inspections in Syria will quickly become bogged down with Syrian engaging in duplicity, evasions, denying inspectors access and putting forth challenges and obstacles that will derail the mission and will take years.
  • Assad will either remain in power or fall to a regime worse than his was.
So, did we do well here?  Is this George Bush’s fault? The president and his minions are gushing over the superb outcome that resulted.  Sure the path was little rocky, they admit, but they claim that Syria was brought to her knees without firing a shot.  They’re so giddy over the Putin rescue that their words and their heads are spinning wildly.

If the outcome is good, we will forgive a clumsy path.  If the outcome is bad, should we simply declare that it is good and celebrate our success?

Since this is ostensibly a medical commentary blog, let me offer a medical analogy.  In medicine, outcome is everything.  If the patient survives or recovers, then patients and families celebrate even if the result was accidental.  Many times I have been lucky to be presiding over a patient who recovers unrelated to my efforts.  Sometimes, I am given undeserved credit for these spontaneous healings.  But, it is harder for doctors than for politicians to tell patients that bad news is really good news.  Bad medical news doesn’t become good news just because we say it is.  If a doctor is over his head on a case and commits serial errors and misjudgments, and the patient barely survives, would we recommend this doctor to others?

Could Putin the peacemaker be awarded the Nobel Peace prize?  Then, he and Obama would have something in common.  Would Alfred Nobel celebrate these outcomes?  Would we?

Sunday, September 15, 2013

CME Medical Course Draws Hundreds of Physicians

Some time ago, about 200 physicians met one evening for a conference. This is not newsworthy. Medical education is deeply engrained in our professional culture. Indeed, physicians are committed to lifelong learning and self-improvement. To stay current, we read several medical journals and professional communications, we attend lectures at our hospitals, we engage in on-line educational pursuits, we learn from colleagues and we travel to medical conferences. Conscientious physicians devote many hours to educational activities each week

On this night, however, we were not learning about new treatments for heart disease or diabetes. We were not learning about emerging strategies to diagnose cancer at a curable stage. There was no talk about new techniques to reduce hospital infections or other preventable complications. We were not even learning about ‘soft’ subjects, such as medical ethics or doctor-patient communication issues.

We were together at the strong urging of our medical malpractice company who would discount our malpractice premium if we attended this evening soiree. So, 200 or so physicians were listening to lectures entitled, Avoiding Litigation Traps and Becoming Litigation Savvy. I’ve attended these annual seminars for several years.

The lectures are interesting and useful. In an indirect way, they serve to protect patients and improve medical quality. But, their true purpose is to minimize our legal vulnerability.

Is this how our patients want us to spend our educational time? Do they want us to learn about how to respond to sneaky questions at depositions? Do they want us to spend time learning about the legal discovery process? Do they want us to be focused on protecting our legal interests?

As busy as we physicians are, shouldn’t every minute available for our education be devoted to becoming better doctors?

Sunday, September 8, 2013

Medical Errors Earn Hospitals Money - Who Knew?

Though I have been accused by various commenters as protecting my own specialty when I point out excesses, flaws and conflicts of interest in the medical profession, this accusation would be handily dismantled after a fair reading of prior posts.  Indeed, my own specialty of gastroenterology and my own medical practice has felt the effects of the honed Whistleblower scalpel.   If an individual or an institution will not willingly engage in self-criticism, then it creates a credibility gap that may be impossible to bridge.  If you want a seat at the table, then arrive exposed and humble.

My Preferred Instruments

A study was published in the prestigious medical journal JAMA, the Journal of the American Medical Association in April 2013 publishing what we have known for decades: hospitals make more money when medical errors are committed.   As an aside, I have much more respect for JAMA than I do for the AMA, but I’ll resist the strong temptation to digress.

Here’s how it has worked in the past.  If a patient is hospitalized with an inflamed gallbladder and is discharged a day later after surgery, the hospital would be reimbursed according to a specific fee schedule.   (Payment systems for hospitalized patients are more complex than this, but accept the above example for the moment.)  If this same patient undergoes complications after surgical removal of the gallbladder, the hospital would be paid more.   If an infection at the incision site, or the patient develops a reaction to medication that may lead to more testing, then the hospital bill will understandably increase.  The issue is if hospitals or physicians should be able to charge more for extra care that was preventable.
There is an inexorable movement away from fee-for-service medicine which antagonists argue lead directly to excessive care.  Value based care is the new concept where quality, not quantity, will be measured and reimbursed.    There is a growing Never Events list where certain medical complications that are designated as events that should never happen, will never be reimbursed.   While this concept sounds attractive in a sound bite, my view on Never Events is more nuanced.

The argument to withhold payment for care that resulted from medical error is potent.   Keep in mind that defining a medical error is not as easy as it sounds.  One can easily imagine how easy it would be to confuse a medical complication, which is a blameless event, from an error or a negligent act.   If I perform a colonoscopy and a perforation develops as a complication, should the hospital and surgeon I consult not be paid for the additional care that would be required?

Would every profession consent to returning fees for mistaken advice or service?  Do you agree with the following?
  • Financial advisors should return fees if investment performance is below a designated threshold or differs from their peers.
  • Attorneys who have been found on appeal to have offered ineffective legal arguments at trial, should surrender their fees.
  • A professional baseball player who drops a fly ball should lose a day’s pay.
  • A newspaper publisher should offer a rebate to all readers if a news story is found to be inaccurate owing to a lack of proper editorial oversight. 

I realize that medical mistakes cost money, as do some of the hypothetical examples above.   I also accept that financial incentives can change behavior and can be an effective tool.    But every human endeavor has a finite error rate and we should be cautious before using a financial drone attack against only the medical profession.  Let’s use a scalpel here and not a sledge hammer.  And those of you outside of medicine, explain why your occupation should be spared from this reform strategy?

If to err is human, and doctors are human, then should we punished for our humanity?

Sunday, September 1, 2013

Unnecessary Colonoscopies: Confessions of a Gastroenterologist

We gastroenterologists are regularly summoned to bring light into dark places.   We are the enlightened ones who illuminate anatomical shadows.   Sure, we have ‘tunnel vision’, but we like to believe that we can think broadly and creatively as well. 

We are the scope doctors.

Am I Just a Tool?

We are commonly consulted by primary care physicians and hospitalists to perform colonoscopies, upper endoscopies (EGDs) of the esophagus and stomach and other gastrointestinal delights.  We deliver a probing element to patient care. 

We are called to serve as technicians – plumbers, if you will - although we actually have cognitive knowledge of our specialty.  Yes, we can think.  Often, we have tension over what we are asked to do and what we think we should do.

Do I think that every procedure I am asked to do is medically necessary.  Of course, not.  Before you target me for investigation and professional censure, realize that every physician in America and beyond would fall under indictment.   Indeed, a legal defense often offered by accused individuals is that they have been unfairly and selectively targeted.   For example, if a company’s human resource officer puts an employee on warning for habitual tardiness, her case may be weakened if others who commit the same offense are left alone.

So, before you throw me in the dock for pulling the procedure trigger prematurely, I will depose physicians across the land to respond to the following interrogatory. 
  • Have you ever prescribed an antibiotic that was not medically essential?
  • Have you ever admitted an individual to the hospital who could have been safely treated as an out-patient?
  • Has every CAT scan you ordered been medically essential?
  • Has every cardiac stent you have placed been in accordance with best practices?
  • Do you consistently practice evidence based medicine?
  • Has every batch of chemotherapy you prescribed been reasonably shown to improve patients’ lives?

My point is that the system is riddled with overdiagnosis and overtreatment and it won’t be easy to clean the rot out.  While physicians have responsibility here, they are not exclusively culpable.  Indeed, no player at the table has clean hands.  Whistleblower readers have endured many posts on these issues.  Those who are new to this blog, can't even imagine what they have been missing and are encouraged to invest the time necessary to memorize prior posts.

I wish that physicians who consult me would ask more often for my head and not just for my hands.   Typically, we are asked specifically to do a colonoscopy or some other procedure.  We usually acquiesce in the same manner that radiologists perform every x-ray test that they are asked to do, whether it is needed or not. If you order an ultrasound of the gallbladder, it will be done even if it makes no medical sense.  (Good doctors consult regularly with radiologists in advance so the correct radiology exam can be arranged.  Radiologists, who can also think, find these conversations to be useful and refreshing.   In my case, they have often spared my patient from the wrong test.)  Referring physicians order a colonoscopy in the same manner that they order a chest x-ray.  They expect that the test will be done on demand.   A scope, however, unlike an x-ray, has risk of harm and should not be blithely done. 

Medicine is not a math problem that has a single solution.  Just because I might not advise a colonoscopy that another physician has requested, doesn’t mean the procedure is a wrong choice.  There’s nuance and judgment in the medical world.  Of course, if a procedure would be reckless or idiotic, then we keep our scope securely holstered.

On those occasions when my opinion is being sought, I consider a few issues before greasing up the scope.

  • Is the scope essential to the patient’s care?
  • Is there a safer alternative to answer the clinical question?
  • When should the procedure occur?  (We are often asked to do routine procedures on very sick hospital patients that should be deferred until after the patient is discharge and has recovered.)
  • Has the patient provided informed consent to proceed?

Do you want my advice or don’t you?   Or, am I just a tool using tools?

Sunday, August 25, 2013

Don't Call Me a Health Care Provider - I'm a Doctor

One thing doctors like to do is to use fancy language.  Patients, however, want physicians to use simple terms.   Perhaps, using highfalutin language makes physicians feel more scholarly and important.  Of course, this bombast only confuses patients who may be too timid to respond that they don’t have a clue what we're saying.  If your doctor is speaking in tongues, then ask for a translator. He'll get the message.

Icon of Pentecost when Apostles spoke in tongues

Many professions have their own technical languages which is necessary for internal communications or scholarly work.  Beyond this, there is also a pomposity that drives this lexical elitism. 

In the medical profession, medical terms seem to offer no advantage over colloquial alternatives.  Yet, physicians want to ‘speak like doctors’, whatever that means.

Cool Medical Term            Lame Alternative

Thrombus                                    Clot
Stenosis                                        Narrowing
Cephalalgia                                  Headache
Transient Ischemic Attack   Mini-stroke
Nevus                                            Mole
Exanthem                                    Rash
Cholelithiasis                             Gallstones
Pyrosis                                         Heartburn
Epistaxis                                      Nosebleed

Folks following health care reform need their own glossary to explain the new lexicon.  I can’t keep this stuff straight and I’m in the business. One must be familiar with pay-for-performance, comparative effectiveness research, accountable care organizations, insurance exchanges, medical homes, pharmacy benefit managers and value-based pricing.  See how warm and fuzzy the medical profession has become? 

Here are a few antiquated terms that are rarely included in the medical policy and health care reform articles I peruse.
  • Compassion
  • Healing
  • Empathy
  • Caring
The new medical rhetoric is so sanitized, or should I say antiseptic, that it threatens to anesthetize the profession.  Want proof?  Look at how medical apparatchiks describe me.  I’m no longer a doctor or a physician.  I’m now a health care provider.   I’m not hung up on the doctor title.  I never introduce myself as ‘Dr.’, even to my patients.  But, to regard me as a health care provider attempts to redefine who I am and what I try to do.  It aims to circumvent the core of what doctoring should be – humanity.    While health care reformers can redact the term humanity, they can’t extract true humanity that must be the essence of the profession.  If we accept that we are health care providers, then we're not doctors anymore.  When the government health care reformers and its minions are speaking in tongues, let's demand a translator.    

Sunday, August 18, 2013

Does Your Doctor Know Advanced Cardiac Life Support (ACLS)?

Folks must think than all doctors know all things medical.  I know this is true by the questions that I have been asked over the years.  While my expertise spans hemorrhoids to heartburn, I am routinely queried on medical issues well beyond the specialty of gastroenterology.  When I can’t answer questions about a new medicine for hypertension or if an MRI of the shoulder makes sense, folks look at me quizzically as if I must not be a real doctor.

Today, more than ever, physicians are highly specialized with a very narrow medical niche.  There are ophthalmologists, for example, who only treat retinal disease.   Perhaps, there are even retinal specialists for the left eye only.   It wouldn’t surprise me. 

My partners and I perform routine gastroenterology procedures in an ambulatory surgery center.   Patient safety is our priority and our staff and us are dedicated to this mission.  All of us are required to be certified in Advanced Cardiac Life Support in the unlikely event that a medical urgency develops.  We re-certify every two years, and recently did so.


Ordinary readers will view this requirement as sensible.  Physicians who perform procedures should be conversant with advanced life support measures including defibrillation and cardiopulmonary emergencies.   At our recent re certification, an experienced paramedic spent 4 hours in our office transferring ACLS knowledge to us and pointing out all of the new doctrine that had developed in the past two years.  In other words, the stuff from two years ago that we had long forgotten was no longer operative.  At the conclusion of the session, we all passed the re-certification examination.

Does this really make sense?  Physicians understand that clinical skill depends upon case volume.  Indeed, medical research has confirmed that physicians and institutions that perform surgeries and procedures more often do so with greater skill and fewer complications.   While volume is not the only consideration when choosing a surgeon, one who does the operation regularly has a clear edge.

How often do gastroenterologists like me practice ACLS?  Never.  The only time this is on my agenda is every two years when I must re certify.   In the interim, I don’t read about it, witness it or practice yet.  This is why ACLS should be performed by professionals who are in the ACLS arena regularly.  Should a physician who hasn’t been responsible for reading electrocardiograms (EKGs) for decades, be asked to interpret complex heart rhythm disturbances on the spot and then know immediately what the treatment should be?  This is absurd and we know it. 

ACLS is not just performing chest compressions and mouth-to-mouth resuscitation, skills that should be known by everyone. (Note that the latter feature of basic life support (BLS) has been revised by the American Heart Assocation. ).

ACLS is s complex specialty requiring  deep knowledge and regular exposure if its practitioners are to remain sharp.  Gastroenterologists need not apply.   Leave it to the professionals.