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.

Sunday, August 11, 2013

The Sunshine Act Exposes Physician Payments: New App Suggested

A few weeks back, a drug rep, aka a pharmaceutical representative, came to the office hawking a new constipation medicine.  These guys are in a tough racket.  They need to sell products that we physicians are often unable to prescribe.  It’s the Formulary, Stupid.

The Best Disinfectant

In the olden days, before I entered the hallowed halls of healing, pharm reps, or drug detailers, developed relationships with physicians who would then prescribe their drugs.  Physicians to this day deny the incontrovertible truth that we are influenced by pharmaceutical company marketing techniques, which still feature face time between sales folks and prescribing physicians. 

These days, many of the sales tools used years ago have been properly prohibited.  Physicians cannot be flown to exotic locales and paid big bucks so they can serve as ‘expert consultants’ who will be subjected to push polling on the new pharmaceutical product.  (Why didn’t any company ever ask me to serve as an ‘expert’?)

As is often the case, the new laws that are designed to promote ethical behavior and restrain corruption have become OperationOVERBOARD.   The Sunshine Act, a part of our beloved Obama Care Affordable Care Act (ACA), is now fully operational.  Pharmaceutical companies are now required to report to the Federal Government if a physician receives an individual item valued at $10 or more, or accrues an annual total of more than $100.  These ‘transfers of value’ will be posted for public viewing. 

We physicians do not want to be on the government’s Sunshine Act Wall of Shame, which conveys that we are evil and corrupt practitioners.  Will the public really be able to distinguish a tainted doctor who has taken possession of a $12.99 tote bag from another rogue who has  acquired a $14.95 breakfast tray for the staff?  Did the ACA consider that these dilemmas will vex and torture patients who may miss their doctors’ appointments as they will be spending so much time scrolling through the roles of tarnished physicians?  This will directly and negatively impact on their health.  The ACA should have had their IT folks incorporate a time limit on Sunshine Act website viewing.  This is an individual mandate that I could enthusiastically support.

Here’s how I intend to remain just under the government’s radar, although we are now learning that government surveillance is slightly more intrusive than it has admitted.

Consider these contraband items:

Tuna sub                             $5.99
Tuna sub with cheese     $7.49
Medium size beverage   $1.69
Large size beverage        $2.19
Chips                                     $.89
French fries                       $2.49       
Cheese fries                       $2.99
Cookies                                $.99

I will assume that the $10 total includes sales tax, but I will have to consult my accountant and attorney to verify this.  Obviously, if tax is excluded then I will have more funds available and would probably be able to add a peppermint patty to my food order while remaining comfortably under the mandated threshold. 
Although I enjoy cheese, and I am fortunate not to suffer the dreaded disease of lactose intolerance, I will order a cheeseless tuna sub so that I will have greater ordering flexibility.  I now have $4.00 left to spend, leaving aside the critical tax issue referenced above.   Readers who are computationally advantaged have already determined that I cannot enjoy a large size beverage along with cheeseless French fries.  Even a medium size beverage will put me over the limit.  I could order any beverage size with either chips or cookies.  I don’t really like these two items, but if eating vitamin fortified potato chips and omega-3 laced cookies will keep me off the list, then I will do the right thing.

I suggest that an entrepreneurial whiz kid design an App that can instantly provide physicians with all permutations of menu choices from area restaurants that will not cross the Sunshine Act’s $10 limit.   Hurry before Yelp administrators, who are avid Whistleblower readers, incorporate this feature into their App.

Does anyone out there think that our government needs a little sunlight shining on it?

Sunday, August 4, 2013

A Tale of Divine Healing: Faith and Reason

I’ve posted a piece on this blog on the issue of faith and reason in healing. Indeed, the protagonist of that post is an inspirational figure, a selfless man who exudes grace and humility. I was honored that the post was shared with many Catholic clergy who appreciated my heartfelt words for one of their own.

Faith and reason reentered my medical universe recently.

A patient underwent surgery to resect a colon cancer. The tumor had metastasized to the lymph nodes, an unfavorable prognostic event. The surgeon entered the room and advised the patient that her survival is likely limited to 1-2 years. The patient and her husband were devastated. The distraught husband spent the next 24 hours sobbing in a painful and despondent state. He related the tragic news to his 3 children, ages 3, 5 and 8.

Was this the appropriate time for the physician to relay such ominous news to a patient and family?

Was it prudent for the overcome husband to share this traumatic news with his 3 young children?

Readers’ responses to the above two inquiries may be influenced by knowing that the long term survival of colon cancer that has spread to the lymph nodes is 50%, which varies substantially from the physician's doomsay scenario.

The patient, while still recovering from surgery in the hospital, experienced a healing experience that she will remember until the end of her days. Her 3-year-old daughter approached her and told her that she is not going to die because God told the young child that her mother will live. The patient related that she felt an unusual sensation that began at the top of her head and rippled slowly down her body until it reached the soles of her feet.

The woman received no chemotherapy or any other treatments to the tumor.

So, whom do you believe, a trained medical professional or a 3-year-old child?

Since this surgery occurred in 1985, and the woman is thriving and well today, it is clear which of these two were correct.

The patient is convinced that she was divinely healed and this experience has understandably deepened her Christian faith.

I am not a Christian but I have enough humility to know how limited physicians like me are about the art and science of healing. Faith and reason can coexist. Is there truly a will to live? Can prayer heal the sick? Men of hard science also pray to God. Is this a dichotomy or a fusion?

Every physician has seen patients recover whom we were certain would succumb. Does science have all the answers? Does faith?

I do not offer this woman’s anecdote as proof of divine healing, although her young child's bedside pronouncement seems providential. There are many medical cases that carve a course that I would not have predicted and do not understand. What forces may be at play there? I can’t say for sure, but I know many believe that prayer may be more powerful than our most potent prescriptions. When you’re staring down a miracle, is that the time to diss the Divine One?

Will traditional medicine enter the New Age universe?  Will the Gates of Reason welcome Faith?

Any readers with relevant experiences are invited to share them.