Sunday, June 30, 2013

The Cost of Treating Uninsured Care - The Whistleblower Weighs In

Last week, I posted on whether physicians should modify their medical advice in response to patients who cannot afford the recommended care.  A hypothetical patient was presented who had no medical insurance.  The clinical particulars suggested that a CAT scan of the abdomen was the ideal diagnostic test, but the patient would not be able to afford this.  I, therefore, offered readers several choices of medical advice, some of which was tailored to the patient’s financial situation. 

Here’s my view.   While there is very little in medicine or the world which should be absolute, medical advice must remain pure.  It should depend only upon the physician’s best medical judgment regardless of the patient’s financial situation.   A millionaire and a pauper who present to the doctor with an identical medical issue should receive the same medical recommendation.  Yes, I realize that patients are not interchangeable and that there are cultural, personality and religious differences that may affect the medical advice.  Leaving that aside, every patient is entitled to the practitioner’s best advice, regardless of the ability to afford this care.  If the right advice is an MRI examination, a colonoscopy, surgery or a medication whose yearly cost exceeds his yearly income, then the doctor must advise these options.  While we may feel we are being compassionate and understanding by trying to treat the patient on the cheap, when we do so, we are failing in our healing mission.  It’s not possible for an uninformed patient to provide informed consent. 

The patient will decide what he can afford.  First, it may be possible that he has access to resources that the physician does not suspect.  More important, the choice of rejecting medical advice because of cost is properly the patients’ – not ours.  It is for the patient to respond that he cannot afford the preferred medication and to then ask us what the alternatives are.  It is not for physicians to leapfrog over expensive medical care with the misguided view that we are being sensitive to a patient’s financial predicament.

So, do readers think that I am on the money here?

Sunday, June 23, 2013

The Cost of Treating Uninsured Patients

I treat uninsured patients and insured folks who face high deductibles who are under financial strain because of the sagging economy and other personal pressures.  These folks need care that may be unaffordable.  Medical diagnostic testing is expensive.  Even routine laboratory testing can be very costly as those without insurance may be forced to pay the ‘retail cost’, which is quite different from insurance company discounted pricing.  This absurdity is often seen in the emergency room where an uninsured patient can be billed thousands of dollars compared to an insured person who has received identical medical care whose insurance company will pay a fraction of this amount.  Crazy.

Because I am a human being, I try to be sensitive to my patients’ financial concerns.   Does the uninsured patient before me really need a CAT scan or a colonoscopy?  Couldn’t we just watch and wait for a week or two and spare him from the expense?

Consider this scenario.  A 50-year-old uninsured patient comes to see me with fever and right -sided lower abdominal pain for 3 days.  The pain is nearly constant and has awakened him from sleep.  He had a night sweat during the night prior to my seeing him.  In the office, he looks uncomfortable and had a temperature of 100 degrees Fahrenheit.  His abdomen was moderately tender when I palpated him.   I am aware that he cannot afford medical care.

Which of the following responses do readers endorse?

“While normally I would advise a CAT scan, I am going to prescribe antibiotics instead.  Call me 2 days from now to let me know how you are doing.”

“Let’s do an ultrasound (US) test to see if you have appendicitis.  While a CAT scan gives much more information, the US is much cheaper.”

“You probably have a ‘bug’ that has been going around.  I’ve seen a lot of it lately.  Just take fluids and rest.  Use Tylenol for fever.  Give me a call in a few days.  If it gets worse, you had better head to the emergency room (ER) to make sure you don’t have a burst appendix.” 

“I advise a CAT scan as you may have any of a number of conditions that the scan may identify. I know money is very tight for you, but I can’t back off this.”

“Go to the emergency room.  I know that you are still paying off the $1,900 bill from your ER visit 2 years ago.  This visit will cost even more, but I can’t put a price on your health.”

I’m interested in what readers think here.  Do you favor any of the above responses or, perhaps, you can suggest one that I’ve omitted.  How should doctors’ advice be modified in response to patients’ financial conditions?

I’ll offer my view on this next Sunday.

Sunday, June 16, 2013

Why Road Rage Should Make Us Feel Good

My personal paradox is that I have railed against the intrusion and dehumanization of technology, and yet I am tethered to my iPhone.   Do I feel differently when it’s my technology and not someone else’s?  I hope not or I might be forced to add hypocrisy to my list of flaws.  I’ll have to monitor myself in a fair and balanced manner.  Will I conclude that my phone call while at a restaurant is of monumental importance while another patron’s phone use is a selfish and unforgivable threat to world peace that should be prosecuted? 

Purple Heart - Read on...

This morning, I was halfway to work when I felt for the phone in the inside pocket of my jacket.  Not there.  I palpated other pockets none of which contained the desired item.  The car seat was bare.   I did not fear the most dreaded explanation, that being that the phone was mistakenly left in Starbucks and purloined by a Frappuccino felon. 
As a U-turn seemed hazardous on the highway, I took the next exit and headed back home.  There it was, resting peacefully on the night table, just where I had left it.  To quote Peaches & Herb from 1978, Reunited and it feels so good.

Of course, I was annoyed by having to burn up an extra 40 minutes in the morning.  This is my daily opportunity to read the New York Times, contemplate my existence, sip a beverage that Mayor Bloomberg wishes were illegal or hack out a blog post.

Which of the following life events would depress, irritate or annoy you?
  • You lock the car door while your keys are dangling from the ignition.
  • You arrive in Memphis but your luggage flew to Detroit.
  • Your copay for a physician office visit soared to $20.
  • An aggressive driver lurches into your lane forcing you to break.
  • A slow driver approaches the intersection so lethargically that the light turns red just for you.
  • Your boss takes credit for your work.
  • A flight departure delay is announced at the gate, for the 3rd time.
  • Your GPS has given you precise directions to the wrong destination.
  • Your stuck in traffic on route to a job interview.
  • You race across town to your favorite store, but arrive 100 seconds after closing.  Employees inside point to their watches and stare at you as if you’re an alien being. 

We’ve all had these annoying experiences which may prompt us to utter language or display hand gestures that we don’t typically use.  But should this stuff really get us down? Here’s some news that I’ve confronted in the past 48 hours.
  • Called a physician colleague for a routine issue and discovered his daughter just passed away.
  • An endoscopy nurse recently retired and now has stage 4 breast cancer.
  • A patient I saw yesterday is living in her car.
  • A patient I saw an hour ago earned a Purple Heart for wounds he suffered in the Philippine Islands in 1945.  He spent 5 weeks in a hospital.

Are you having a bad day today?

Sunday, June 9, 2013

Addiction and Substance Abuse Can Strike Anyone

Over the course of a year, I have an alternating pattern of caffeinated coffee ingestion.   As readers should know, I will not swallow Starbucks ‘Joe’ as I do not think that I have sufficient stomach acid and other bodily defenses to successful prevail against this corrosive elixir. Of course, everything has a benefit if one is resourceful enough to discover it.  For instance, I have found their coffee to be quite useful as a paint remover or shark repellent. 

The best coffee in Cleveland is found at Dunkin’ Donuts (DD).  Perhaps, one of the reasons their java is so smooth is that my order of coffee with cream is mixed at a 1 to 1 ratio.  Cream at DD is no half and half concoction; it’s the real thing.

As I write this, there is an environmentally unfriendly Styrofoam cup beside me. I’ll down this coffee every day for weeks reaching a point where if I skip a day, I will enjoy the pleasure of an ice-pick, throbbing headache at 4 pm.  It’s a pounder that stays with me for 3 hours, until it fades allowing my neurons to regain some level of function.  At this point, I am aware that I have developed a physical addition to the stimulant, and need to resume daily use if I am to avoid the afternoon cranial crusher.

Coffea Arabica Plant
Opium of the People?

I now face a choice.  Resume the daily caffeine or break it off and tolerate the withdrawal phase until I am successfully detoxified.

In general, I opt for the latter and survive on decaf for several weeks until I convince myself that a single caffeinated morning brew can’t hurt me.  And so, resumes the cycle. 

While this is a real addiction with real withdrawal, it is a mere wraith of the addictions that I confront as a physician.  While the tobacco habit is most common, there’s an abundance of alcohol abuse in my practice, which I am sure is substantially underestimated.  I surmise that most of the alcoholics in my practice are unknown to me.  I see a fair amount of pain medication addiction, which was initiated for short term pain control, but over time has morphed into a new disease. 

It’s a sad reality to recognize how difficult it is for alcoholics and other addicts to recover successfully, even when they strive to do so.  Booze and cigarettes over time become tentacles that wrap around their victims, squeezing tightly, such that most addicts don’t have the strength or the will to remove them.  It is humbling to appreciate the power that these substances exert over the users.  These are folks who simply cannot throw these chains aside, despite suffering profound personal and professional losses and serious medical consequences.  And, no one can do this work for them, as I have witnessed time and time again.

There is no comparison of these tragic and recalcitrant conditions to a coffee fling, which poses a small challenge to the afflicted individual, as I know.  While some addicts manage to slay the dragon, most will serve as prey to the beast.   

I’ve got a few more swigs of DD left this morning.  Addicted?  Of course not.  I can stop anytime I want.  Maybe tomorrow, or the next day…

Sunday, June 2, 2013

Gastroenterologist Preaches Healthy Food Choices - Secrets Shared for Longevity and Healthy Living

It’s morning and I’m imbibing a beverage that has no nutritive value.  I only hope it won’t cause me harm, as it’s a beverage that slides down my gullet with regularity.  Of course, today’s poison may be tomorrow’s panacea.  This is one of the amusing ironies in the medical arena.  Every 10 years or so, it seems that what was felt to be medical dogma gets tossed out by a new set of studies, which will be reversed a decade later. 
Remember when every peri-menopausal woman was advised in the strongest terms to take hormone replacement to protect her bones?  That was then...

As to our diet, these recommendations are also subject periodic mutations.  Butter in.  Butter out.

I am presently planted in what can safely be regarded as a fast food establishment, where in a single meal, one can exceed his daily caloric need.   With my fidelity to personal responsibility, I don’t blame the establishment for the free choices that its patrons make.   Some years ago, Burger King (BK) was sued by parents who demanded justice (read: money) blaming BK for their kids’ obesity.   If you suspect embellishment on my part, open your browser in a new window and search for this judicial absurdity.  Afterwards, take some antacids and return to this post.

I won’t divulge the specific restaurant I am in presently, as I don’t want this to serve as either as an endorsement of a specific restaurant by a gastroenterologist, or as repellent considering the politically incorrect food choices that I routinely make.  I will only divulge that I am feeling rather McHappy at this moment, and trust that this opaque reference will not be sufficient to disclose my location, although discerning Whistleblower readers might be able to crack this enigma. 

Meanwhile, Europeans are galloping off in anger as their precious beef has been horsed around with.  Yes, their beef has been surreptitiously fortified with horse meat, which I’m told ‘does not taste like chicken’.  The silver lining here is that a horse pain reliever (phenylbutazone) has also been detected in European meat,  which may bring some relief to arthritis sufferers who are eating shepherd’s pie and beef lasagna. 

Escaping from European Butchers

A report was just released by the Hudson Institute that showed that restaurants that offered lower calorie options sold more food and beverages than competitors that continued serving lard glazed delicacies.  One of the study’s points was that these establishments offered low calorie delights, not as a promotion to create wellness buzz, but in response to market forces.  In other words, menus were adjusted to conform to consumer desires.  In other words, businesses will sell what we will buy.

I’m not against corporate societal responsibility, but their mission is to sell goods and services legally and to cash in.   If we disagree with a particular corporate culture or deem a product to be frivolous or injurious, than we are free to hold on to our cash.  I’d rather that the choice of what I can purchase be mine.  

People often ask for personal references from folks who are insiders.  Ask a chef which restaurants he likes.  Ask an athlete which personal trainer can fashion a six-pack from jiggling and sagging abs.  Ask a doctor who his doctor is.  So, what does this gastroenterologist eat regularly?  Surely this response will be a road toward nutritional nirvana. 

Whistleblower Food Choices

Item                                  Frequency of Ingestion
Probiotics                          Not deliberately
Diet Soda                            Twice daily
Vitamin Supplements    Never
Red Meat                            Mmmmm, say the word…
French Fries                      Never enough
Greasy French Fries       See above response
Ice Cream                           Upon awakening
Seaweed                              Only during ocean swim
Steamed anything           Never willingly
Fried anything                 On call

What kind of nutritional example am I setting?  Hard to say.   Ten years from now, the nutritional standards may be a mirror image of what today’s wellness playbook advises.  A recent obesity study, for example, published  in the Journal of the American Medical Association concluded that modestly obese individuals live longer than those with ‘normal’ body weights.  Today’s heresy may become tomorrow’s gospel.

So, in 2023, when nutritional gurus are pushing fries, fast food ,a doughnut a day and a milkshake chaser, will I be regarded as a pioneer who was ahead of his time, or a crackpot charlatan who drank diet pop and tried to serve up Kool Aid.