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?