Sunday, December 28, 2014

What's the Cause of Chronic Abdominal Pain?

I see patients with abdominal pain every day.  Over my career, I’ve sat across the desk facing thousands of folks with every variety of stomach ache imaginable.   I’ve listened to them, palpated them, scanned them, scoped them and at times referred them elsewhere for another opinion.  With this level of experience, one would suspect that I have become a virtual sleuth at determining the obvious and stealth causes of abdominal distress.  

I wish it were the case.

Some Cases Defy Sleuthing

The majority of cases of chronic abdominal pain that I – and every gastroenterologist – see will not be explained by a concrete diagnosis.   Sure, I’ve seen my share of sick gall bladders, stomach ulcers, diverticulitis, bowel obstructions, appendicitis and abdominal infections, but these represent a minority of my afflicted patients. 

Patients with acute abdominal pain are more likely to receive a specific diagnosis, such as those listed above.  However, patients who have abdominal distress for years, which constitute most of my stomach pain patients, usually will not have a specific, explanatory diagnosis even though these patients often feel otherwise.

Many of these patients come to the office advising me that “their diverticulitis is acting up” or that “their ulcer is back again”.  Usually, this is not the case and they may never have had diverticulitis or an ulcer in the first place.

Physicians often assign these patients a diagnosis of irritable bowel disease or functional bowel disease, which is a rather amorphous entity that cannot be detected on available diagnostic testing.  The labs and scans and scopes are all normal in these folks.  I believe that the condition is real, but it is a frustrating condition that is difficult to define.   It often coexists with other chronic painful conditions, such as fibromyalgia, chronic pelvic pain and migraine headaches. 

This is tough for patients and a medical profession that strive to label every symptom numerically and quantitatively.  The body does not work this way. 

Of course, I may be missing true diagnoses in some of my chronic pain patients.  Medical science isn’t perfect and neither am I.   How many celiac disease patients have I overlooked?  Should I test every individual who has a cramp now and then for celiac disease so I don’t miss a single case?  If every physician adopted this approach for celiac disease – and a hundred other conditions – we would elevate our current practice of overdiagnosis and overtreatment beyond the stratosphere. 

So, how much testing should a patient with chronic nausea or abdominal pain receive?   Patients and physicians don’t always agree here.   How much cost and care are patients, physicians and society willing to expend to approach 100% chance of not missing a diagnosis?   Is your answer the same if you or a loved one is the patient?

Sunday, December 21, 2014

Whistleblower Holiday Cheer 2014!

T’was the week before Christmas
And all through the House,
Boehner was stirring
No longer a mouse

The Senate as well
In GOP hands
Girding for battle
With toothless demands.

No government shutdown
That never played well.
Impeachment would surely
Damn them to hell.

Executive orders,
No self-deport.
Why diss the Congress?
He does it for sport!

In 2016,
Are Repubs aware,
That they need a candidate
With Romney’s hair?

GOP are no saints
They carp and complain,
Blaming Obama
With dripping disdain.

“He’s a king or a czar.
It’s all been a ruse.”
We know this is true
It was on Fox News.

So will there be progress?
Will they join hands?
Can we have hope?
As we watch from the stands?

Or can we expect,
More of the same,
Bickering, sniping
And pointing the blame?

Will Jeb give the nod?
Can Hillary lose?
Or Dancer or Prancer,
Or maybe Ted Cruz?

Sit back and relax,
For the start of the show,
It’s a rerun of sorts,
Gridlock 2.0!

Wishing you joy and peace.

Sunday, December 14, 2014

Does Quality of Colonoscopy Depend on Time of Day?

Over the past decade, there has been renewed effort to increase the quality of colonoscopy. New data has demonstrated that colonoscopy quality is less than gastroenterologists had previously thought. Interestingly, colonoscopy is less effective in preventing colon cancers in the right side of the colon compared to the left side. Explanations include that some pre-cancerous polyps in the right side of the colon are more subtle to recognize and that the right side of the colon has many hidden areas that are difficult to visualize. New examination techniques and equipment are addressing these issues.

The goal of colonoscopy is not to detect cancer; it is to remove benign polyps before they have an opportunity to become malignant. A new measure of medical ‘quality’ is to record how often gastroenterologists (GIs) remove polyps from their patients. For example, if a GI only detects polyps in 5% of patients, which is under the quality threshold, then someone will conclude that this physician is not diligent. So, now GIs may be scouring the colons to remove every pimple in order to reach threshold. While this may result in higher ‘quality’ colonoscopies, will patients actually benefit? We don’t know. Pay-for-performance and other quality initiative create opportunities and incentives to game the systems. Is our mission to help patients or to play the game?

An interesting issue regarding colonoscopy quality has been published in medical journals. GIs who are doing colonoscopies all day long lose their edge as the day progresses. It may be that that physician fatigue is a factor, or that afternoon patients are not as thoroughly cleaned out as morning patients are. This issue has been covered in the press and patients have asked me about it. I am not aware that my procedural quality is time dependent, but I haven’t looked at my own data. I wonder what my optimal colonoscopy time slot is. Perhaps, I should run my data and then charge fees in accordance with my polyp detection rate. In other words, if a patient is seeking a bargain colonoscopy, then he gets the last slot of the day. However, if a patient wants concierge medical quality, and is willing to put some cash on the line, then he’ll get scheduled accordingly.

I wonder if other medical specialties, including primary care, experience quality decay over the course of the day. I am interested if any physician readers are aware of published data on this issue or can share relevant personal experiences.

The lessons gleaned from the lower portion of the alimentary canal may apply beyond the medical arena. Do other professions perform better in the morning than they do in the afternoon?

Here are some studies I propose, which can be funded in our government’s usual manner – borrow.

Profession                    Quality Measurement per Shift Hour

Policeman                           Arrest Record

Thief                                      Successful Robberies

Financial Advisor             Profitable Advice

Politician                             Promises Kept

Stage Actor                         Lines forgotten

Judge                                    Decisions Reversed

Since pay-for-performance is the panacea that will cure the medical profession, why shouldn’t we share it with the rest of you?

Sunday, December 7, 2014

Should Your Doctor Consider Medical Costs?

This blog is devoted to an examination of medical quality.  Cost-effectiveness is woven into many of the posts as this is integral to quality.  Most of us reject the rational argument that better medical quality costs more money.   Conversely, I have argued that spending less money could improve medical outcomes.  Developing incentives to reduce unnecessary medical tests and treatments should be our fundamental strategy.  Not a day passes that I don’t confront excessive and unnecessary medical care – some of it mine - being foisted on patients. 

At one point in my career, I would have argued that physicians and hospitals were motivated only to protect and preserve the health of their patients, but I now know differently.  Payment reform changes behavior.
As an example, it is impossible for a patient with a stomach ache who is seen in an emergency room to escape a CAT scan, even if one was done for the same reason months ago.  I saw a patient this past week with chronic and unexplained abdominal pain.  She has had 5 CAT scans for the same pain in recent years.  This is a common scenario.  Once reimbursement policy changes to punish physicians and hospitals for overtesting, we will witness the Mother of All Medical Retreats!

Are 5 scans enough?

Physicians and the public have an interest in preserving medical resources to serve society.   There is an emerging debate if physicians who are counseling patients should be mindful of society’s needs while in the exam room.  In other words, if I am prescribing a medicine for a patient with Crohn’s disease that costs $25.000 annually, should I also be considering if this is a wise use of society’s resources?   Would this money be better spent giving influenza vaccines (‘flu shots’) to uninsured or medically underserved individuals?  If you were my patient, do you expect that I am focused exclusively on your medical interests regardless of the cost?  Do I have a responsibility to consider how my advice to you impacts on others’ health since health care dollars are finite?  Should patients be willing to sacrifice their own medical care in order to serve the greater good?

Cost-effectiveness is presumed if someone else is paying the bill.  If patients had some skin in the game, then they would exert some restraint on the current frenzy of diagnostic testing and treatment.  If my patient cited above had to pay a portion of the 5 CAT scans that she had undergone, there may have been only one scan.  And, if the hospital and the radiologists were paid only for necessary testing, there would have been a similar outcome.

More medical care often means lower medical quality.  How much longer do we want to pay more to receive less?

Sunday, November 30, 2014

Thanksgiving - A Chance to Spread Sunlight

This is the only Thanksgiving holiday in my memory that I was not on call for hospital work.   Physicians, like many other folks, are not automatically off on holidays and weekends.  I’m not complaining here, but there are times that I am envious of individuals who are home on every weekend and holiday.  Americans need health care, law enforcement, and various emergency services even on days of national leisure.  When I am driving to the hospital on one of those days, I remind myself that the sick person I am headed to see has a much worse deal than I have.

I have been bestowed with many blessings, and I am grateful for all of them.  Some of them, I may have earned, while others just fell my way.   Similarly, life’s travails can result from a bad decision or just bad luck.  Life isn’t fair.

Spread Sunlight

I admire folks who always spy a rainbow through a storm, and I want to be like them. Appreciating one’s lot in life, especially a midst dark days, brings much light into the world.  It becomes a contagion for good.  The opposite approach becomes a powerful force spreading discontent and unhappiness and has a wide ripple effect. We've all seen this.  There’s a reason that most of us enjoying spending time with folks who exude sunlight. We don’t all have to be supernovas that can enlighten the universe, but we can try to spew off enough photons to bring some light into the world.

Last week, my family converged in New York City to surprise my mother for a milestone birthday.  She was in the presence of the most important people in the world to her.  A week later, I am still in the rarefied aura of this unforgettable event.   I am so thankful for this incredible blessing.

Let's seek out light and spread some of our own.  

President Lincoln's 1863 Thanksgiving Day Proclamation opens with the following sentence. 
The year that is drawing towards its close, has been filled with the blessing of fruitful fields and healthful skies. 

Remembering what his world was like in 1863, we can agree that this man could see light during the darkest days we ever had.  Our gratitude endures.

Sunday, November 23, 2014

Are Doctors Good Businessmen? Get a Second Opinion!

We’ve all heard or used the phrase, ‘leave it to the professionals’.  It certainly applies to me as the only tools that I can use with competence are the scopes that I pass through either end of the digestive tunnel.  Yeah, I have a ‘toolbox’ at home, but it is stocked similar to the first-aid kit in your new car, which contains a few BandAids, adhesive tape and, hopefully, the phone number of local doctor.  My home tool box has an item that can practically fix anything – the phone number of a local handyman.

Nothing for Hemorrhoids Here.   

It is essential to know one’s limitations, regardless of one’s profession. 
  • Politicians shouldn’t speak authoritatively as if they are climatologists.
  • Gastroenterologists should not prescribe chemotherapy, even though we are permitted to do so.
  • Bloviating blowhards on cable news shows are likely not military experts.
  • The guy who fixed your toilet might not be a top flight kitchen remodeler even though his business card includes home remodeler, along with railroad engineer, IT professional, seamstress and stand up comic.
Some of us are good at a lot of stuff.  Some of us have a narrower, but deeper range of competence.  Yes, we’re all good at something, as our moms and teachers taught us during our early years.   Without doubt, most of us are not good at lots of stuff, and it’s important to know where our comfort zone approaches the chaos zone.   In my own profession, it is absolutely critical that physicians readily solicit assistance from a colleague when additional knowledge, experience or judgment is needed.   Asking for help to help a patient is evidence that the physician is focused on his patient’s welfare.  Every doctor has witnessed circumstances when a physician is reaching too far beyond his tool box, and it’s not pretty. 
  • Should a surgeon perform a complex operation that he only seldom performs?
  • Should a local oncologist treat a patient’s rare cancer or refer the patient to the expert downtown?
  • How long should an internist struggle with a patient’s hypertension before recruiting an expert?
  • If an allergist’s patient keeps losing weight, is it time to consider a cause beyond the scourge of gluten?
Last year, our practice needed some restructuring.  We met with our accountants for advice on streamlining and managing our practice.  I was impressed how quickly these pros looked over our financial statements and readily understood the state of our practice.  Of course, these guys see the world through Excel spread sheets, just like we GI physicians do through our colonoscopes.  To us physician clods, these reams of number filled pages containing every permutation of various financial reports were encrypted codes that would require NSA cryptographers to decipher.  Most physicians are not good businessmen, although many feel otherwise.  Luckily, my partner and I know the truth about ourselves.   We didn’t ask the accountants for a ‘second opinion’.   We came to them first, and we’re glad we did.   I presume that when they need a colonoscopy, they won’t try it themselves.

Sunday, November 16, 2014

High Drama in an Ambulatory Surgery Center

A few days before I wrote this, a patient had a complication in my office.  I have discussed on this blog the distinction between a complication, which is a blameless event, and a negligent act.  In my experience, most lawsuits are initiated against complications or adverse medical outcomes, neither of which are the result of medical negligence.   This is the basis for my strong belief that the current medical malpractice system is unfair.  It ensnares the innocent much more often that it targets the negligent.

I performed a scope examination through one of the two orifices that gastroenterologists routinely probe.  In this instance, the scope was destined to travel inside a patient’s esophagus on route to her stomach and into the first portion of the small intestine.  Sedation was expertly administered by our nurse anesthetist (CRNA).   The procedure was quickly and successfully performed.  The patient’s breathing became very impaired and her oxygen level decreased markedly, a known and uncommon complication of sedation medications.   We took the appropriate measures, but her low oxygen level did not respond.

At that point, our experienced and calm CRNA decided to intubate the patient by passing a breathing tube into her lungs, in the same manner as is routinely performed prior to surgery.   The RN on the case, an ICU veteran, showed how quickly and superbly her medical skills and judgment could be recalled.  In decades of medical practice, I had never had a patient whose scoping test and sedation led to a breathing tube insertion.   Moreover, this procedure was performed in our outpatient ambulatory surgery center, not in the hospital, so drama like this is exceedingly rare.

Physicians prefer to see drama in the theater.

The patient’s oxygen level immediately returned to normal and she was transferred to the hospital in stable condition.  She was appropriately treated and discharged after a few days. 

I was so grateful to have a team in place that had the skills to rescue a patient who was in a dire situation.   I told this to them directly and they seemed to regard the matter in a more routine manner than I did.  They saved her life.   Nothing routine about this, as I see it. 

For nearly all of the patients we see in the office, our staff is overqualified.  But, once or twice a year, we need these folks on site, locked and loaded.

Physicians and the rest of us need back up.  Do you have a contingency plan in your job if a crisis befalls you?  Will you wait for a catastrophe before implementing one?  We’ve all heard vignettes about cities who were warned about a dangerous intersection, but failed to ask until a tragedy occurred.

Finally, if someone helps you out of the abyss, give the credit to whom it is deserved.   Conversely, if something goes wrong and it’s your fault, do the right thing.  

Sunday, November 2, 2014

Ebola Hysteria in Ohio

The Ebola hysteria continues.  True, we might have a greater chance of being struck twice by lightning, but the press would have us think we need to purchase Hazmat suits for our families just to be prepared.  I’m surprised that an entrepreneur hasn’t at least constructed prototypes for Hazmat suies for newborns, popular dog breeds, pet rodents and heirloom tomatoes.


Yes, tomatoes.   I have not heard any authoritative official from either the NIH, the CDC the WHO or Medicins Sans Frontieres (Doctors Without Borders) who have stated unequivocally that you cannot contract Ebola from an heirloom tomato.  To me, the hypothesis is entirely plausible as the sneaky virus  can hide in the heirloom’s surface crevices just waiting and hoping to gain access into an unsuspecting mucous membrane. 

Smooth Skin Tomatoes Probably Safe

As of this writing, there are 159 contacts in Ohio who have had contact with an Ebola infected nurse who for reasons known but to God was cleared by the CDC to board a commercial airplane with a fever after she had treated an Ebola patient in Texas.   Each day, the number of Ohio contacts grows, so by the time these words are posted on Sunday, I expect that there will be more contacts.

Gerbils Need Ebola Protection

The definition of what constitutes contact with an Ebola patient is evolving.  As of today, the new and improved definition of contact is being an enclosed space with the patient for any length of time.  Hmm, if I am watching the Cleveland Cavaliers in our downtown stadium from the last row, and an Ebola patient is in the first row on the opposite side, am I now considered a contact?  Would all 10,000 fans be forced to enter into a 21 day period of quarantine? 

Does it matter that medical experts have consistently explained that you cannot catch this virus unless the infected individual is symptomatic and you are within reach of that individual’s bodily secretions?
An Ohio school was closed as a staff member was on the Frontier airplane that the nurse had traveled on although on a different flight.  Two hospitals in Cleveland sent nurses home with pay and admitted publicly that this was for PR protection, not for patient protection.   What hope is there when our medical institutions are lubricating our hysteria instead of battling it?

This past Monday, I noticed a new procedure had been implemented in our office.  On the advice of local and state medical authorities, we were asking every patient who enters our office, if they have in to West Africa or had contact with an individual who has been there.   This nonsensical policy would protect no one.  There are zero known Ebola patients in Ohio at present.   This is a difficult disease to contract as contracting this virus requires that one is in direct contact with bodily fluids of an infected person.  Querying every patient about recent travels from West Africa only feeds the hysteria, while it burns up our staff’s time.   Asking Granny who comes to see us from her assisted living facility if she’s been to Sierra Leone recently, doesn’t seem to be sound preventive medical policy.

I think that our moratorium on heirloom tomato ingestion makes more sense than the Ebolaphobia policy. Can this post go viral?

Sunday, October 26, 2014

Governors Mandate Ebola Quarantine

Who says that bipartisanship is dead?  Just recently, Governors Cuomo and Christie – a Democrat and a Republican – were shoulder to shoulder as they announced a new and improved Ebola policy to protect their voters,  I mean citizens.  Now, every individual who was arriving at Newark and Kennedy International Airports from Liberia, Guinea and Sierra Leone who had direct contact with an Ebola patient, would face a mandatory 21 day quarantine. 

This policy exceeds restrictions advocated by the Center for Disease Control and Doctors Without Borders, two organizations who presumably are better qualified in infection control than politicians are.
Might this policy discourage our health experts from traveling to West Africa to help to control the Ebola epidemic as they would face a 3 week quarantine upon their return home?

Might some folks who are returning home who don’t agree with this new policy lie about their Ebola contacts?

What if travelers returning home from West Africa didn’t touch down in New York or Newark?  Don't the other 48 states deserve to be safe?

Does this policy seem more political than medical?

Future CDC Director?

Future NIH Director?

Maybe the governors’ new edict doesn’t go far enough?  I'm surprised they did not consider the following scenarios.
  • If an Ebola patient in Sierra Leone sends an email to a New Yorker, should the American be required to take his temperature twice a day?
  • If a Rutgers University student looks up Ebola information on an iPad, and used the touch screen without two sets of surgical gloves, should the student be quarantined and the iPad confiscated?
  • If a Manhattan commuter enters a cab driven by a Liberian…
Why stop at Ebola?  Why not force returning passengers who have been exposed to influenza, which unlike Ebola, is extremely contagious via air, to be quarantined?   

There is a reason that politicians should not make health care policy.  Let them do what it is that they do best – saying and doing anything to get elected.  Will other governors now compete to establish the strictest guidelines?   

Scientists are testing an Ebola vaccine. We pray for their success.  I hope that the NIH is working on a vaccine against hysteria.  I know two politicians who need it desperately.  

Sunday, October 19, 2014

Ebola Virus Outbreak Goes Viral!

While I haven’t devoted significant space on this blog to the news media, it is not because I do not have strong opinions on the current state of journalism.  Indeed, I could write an entire blog on the subject, and many have.

News acquisition and analysis have always been important facets of my adult life.  I spend many hours every week reading various newspapers and other materials to gain new perspectives on the issues of the day.  Nearly every morning, I send items of interest to a close circle of friends and family.  I read news and opinion, although sometimes it’s hard to tell one from the other.  I am always drawn to opinions that differ from my own. While there is excellent journalism today, the profession is deeply flawed by a blow-dried approach that appeals to our tabloid lust and their desire for increased ratings. 

Just because it’s above the fold on Page 1, doesn’t mean it truly deserves this prime real estate.  Pick up your own newspaper and see what the leading articles are.  It’s likely to be some local crime outbreak, while news that really matters is either a small item pages later, or may not appear at all.

TV News - If It Bleeds, It Leads!

Turn on CNN.   Set your stopwatch to measure how many minutes it will take before the bright banner of BREAKING NEWS flashes across the screen.  All that’s left is for Wolf Blitzer to announce:


How has the media performed with the Ebola issue?  Poorly, in my judgment.  First, the coverage has been absolutely suffocating on major TV stations and has been on Page 1 of newspapers for days now.  Is this an important issue?  Of course.  Are there public health ramifications?  Definitely.  Has the media heightened public fear beyond the science?  Without question.

When the media, particularly television, sinks their fangs into an issue, they will feed upon it until either the ratings start to ebb or some new fresh meat draws them away.  Remember how CNN covered the Malaysian airplane disappearance?  

While Ebola is clearly newsworthy, the number of infections and fatalities that have occurred here in the U.S. can be counted on one hand, with a few fingers to spare.  My point is that the coverage has been disproportionate to other issues that have been sidelined, as the media routinely does.
  • 30,000 Americans will die of flu this year
  • 11,000 expected U.S. deaths by firearms this year.
  • About 100 U.S. highway fatalities daily with a yearly estimate of 30,000 victims
Where’s the proportionality?   While every life is sacred, why are big stories buried and much smaller ones sensationalized?   Last night, I came home and declared that my domicile would be an Ebola-free zone for the evening.   This meant there would be no TV news for us.  I feared that even turning on a random TV channel could violate my edict as Ebola coverage is omnipresent.  To make sure that we were in compliance, we pursued a safe entertainment alternative.  Netflix!

Ebola, a deadly virus, has gone viral in the press.  The media, as always, perpetuates journalistic contagion.  Maybe they should be quarantined?

Sunday, October 12, 2014

Is Hepatitis C Treatment Cost-effective?

One catch phrase in health care reform is cost-effectiveness.  To paraphrase, this label means that a medical treatment is worth the price.  For example, influenza vaccine, or ‘flu shot’, is effective in reducing the risk of influenza infection.  If the price of each vaccine were $1,000, it would still be medically effective, but it would no longer be cost-effective considering that over 100 million Americans need the vaccine.  Society could not bear this cost as it would drain too many resources from other worthy health endeavors.  Economists argue as to which price point determines cost-effectiveness for specific medical treatments.  As you might expect, insurance companies and pharmaceutical companies might reach different conclusions when the each perform a cost-benefit analysis. 

Remember, it’s not just cost we’re focusing on here, but also effectiveness.  If a medicine is dirt cheap, but it doesn’t work, it’s not cost-effective.  Get it?

Pharmaceutical companies who are launching extremely expensive medicines often boast about the medical benefits while they ignore the cost factor entirely.  We see this phenomenon regularly when the pharm reps come to our office or we are listening to a paid speaker.

Understandably, when expensive medical care is being paid for by a third party, patients and their families are not considering cost-effectiveness.  They are focused on their own health and welfare.  If the doctor advises that our mom needs chemo, we’re not wondering if the cost would be a fair allocation of societal resources. 

A new hepatitis C (HCV) drug, Sovaldi, has recently been launched.  The 12 week course of treatment costs $84,000, or $1,000 a pill.  This bargain doesn’t include the costs of other drugs that are taken with Sovaldi as part of the treatment program.   The cost of curing HCV, a worthy objective, approaches $200,000 including the costs of medicines, physician services and laboratory and radiology testing.  Assuming that there are over 3 million Americans who are infected with HCV, the costs for curing them all approaches $300 billion.   That’s billion with a ‘B’.

Electron Micrograph of HCV

Consider these facts before deciding if hepatitis C treatment is cost-effective.
  • Most patients with HCV feel well.
  • Most patients with HCV are not aware that they are infected.
  • The majority of patients with HCV will not develop cirrhosis or other serious complications of the disease.
  • Many HCV patients who are ‘cured’ of the virus would never have developed any health issues.  They were silently infected.
Here’s what’s needed.
  • Identifying HCV patients who are destined to develop severe complications.
  • Proof that treating these patients changes the course of their disease.
  • HCV treatment that is cost-effective.
TV or print ads about HCV treatment suggest that you ‘talk with your doctor to see if the drug is right for you’,   When you do so, ask for the evidence that the treatment will allow you to live longer or live better.  Clearing your body of HCV sounds like a triumph and is marketed as such, but this might not change your life at all.

Information is power.  I wish there was some way this post could go viral.

Sunday, October 5, 2014

Why I Won't Refill Your Prescription

Giving prescription refills is not quite as fun as it used to be.  Years ago, we doctors would whip out our prescription pads – often sooner than we should have – and we’d scribble some coded language that pharmacists were trained to decipher.  I’m surprised there were not more errors owing to doctors’ horrendous penmanship.  On occasion, the Food and Drug Administration (FDA) would require a pharmaceutical company to change the name of a drug so it wouldn’t be confused with another medicine with a similar name.   The name of the heartburn drug Losec was too similar to congestive heart failure drug Lasix, so the former drug name was changed to the familiar Prilosec. 

Pharmacists Used the Rosetta Stone to Decode Prescriptions

Nowadays, we physicians refill medicines with point and click techniques within our electronic medical record (EMR) system.  When this works, it’s a breeze.  Three clicks and the refill has been transmitted to the patient’s pharmacy. Alerts notify the physician of any potential drug interactions with a patient’s other medicines.   A record of all prescriptions and refills becomes a part of the EMR system for all time.

Often, the drug interaction alerts are too sensitive.  More than once, an alert has appeared warning me that if I hit the ‘prescribe’ button, that my patient will suffer the same fate as did the Wicked Witch of the West when Dorothy doused her with water.  When I can’t verify this doomsday scenario using old fashioned techniques, I call the pharmacist directly who may reassure me that the drug is safe to use.  So, I prescribe the drug knowing that my EMR system will document that I have been duly warned and have chosen to cavalierly override the admonition.  Guess which profession likes this EMR function?

Patients contact us nearly every day for prescription refills.  Of course, we beg them to do so when they are in the office, but life doesn’t work this way and I understand this.   Here are some instances when I will not refill the requested medicine.

  • One of my partner’s patients calls after hours for a refill on narcotics
  • A patient wants a refill beyond my expertise.  I won’t be refilling your cardiac medicines as this should be done by the prescribing physician for several self-evident reasons.
  • I haven’t seen the patient recently.

It is a common scenario for a patient whom I have not seen for a year or two to request a refill on their GERD or heartburn medicine.  When this occurs, I politely request that the patient see me in the office first.   The patient may not grasp any urgency as he is feeling well and only wants another year’s worth of acid-busting pills.  However, the moment I refill it, I am in effect accepting responsibility for this action and any resultant consequences.  Here are some pitfalls with refilling a patient’s heartburn medicine who has been AWOL.
  • Does this specific drug still make sense?
  • Can the dosage be lowered?
  • Have any new symptoms developed that might require diagnostic investigation?  Suppose the patient has been losing weight, for example?  What if the ‘hearturn’ has worsened and a new disease is responsible?
  • Is the patient experiencing side-effects from the medicine that he or his primary care physician might not appreciate?
  • Could the heartburn medicine interfere with new drugs that the patient is now taking?
  • Is the patient up to date on other issues within a gastroenterologist’s responsibility such as colon cancer screening?

Refilling routine medicines may not be routine and should be done with care and caution.   The patient from 2 years back who has GERD might think he needs Nexium for his 'heartburn'.  What if his symptom is actually angina?  Get my point?

So, when we ask you to stop in for a brief visit, it’s not because we delight in hassling you or are hungry for your copay.  We’re trying to protect you and to keep you well.   Doesn’t this seem like the right prescription?

Sunday, September 28, 2014

Which Medical Specialty Should Medical Students Choose?

A medical student recently asked my advice on her decision to pursue a career in dermatology.  It was about 25 years ago when my own parents encouraged me to pursue this specialty.   What was their deal?  Perhaps, they anticipated future developments in the field and were hoping for free Botox treatments?   As readers know, I rejected the rarefied world of pustules and itchy skin rashes for the glamor of hemorrhoids, diarrhea and vomit. 

My parents were making a lifestyle recommendation.     Dermatologists are doctors who sleep through the night.  Spying one in a hospital is a rarer sighting than spotting a liberal Democrat at a Michelle Bachmann rally (unless a planted heckler).  Nocturnal acne medical emergencies are uncommon.   And anyone who has had cosmetic work done understands painfully that this is a cash business.

Diagram of Skin
Luckily, the Whistleblower is thick-skinned

Here’s where some readers or Dermophiles will accuse me of skin envy.  Not true.  Some dermatologists may be a tad thin-skinned over this assertion, but facts are facts.  These docs have a soft lifestyle and earn much more money than most physicians do.   Sure, these guys and gals see some serious stuff, but the nature of their specialty is less intense and frenetic than that of other colleagues.  

Many professions push back when it is suggested that they are afforded unique and soft perks that most of us don’t have.  Teachers, for example, never state out loud that having every Federal holiday off, enjoying school vacations every few months and having 10 weeks off in the summer are unbelievable soft padding that no one else has.  We know you work hard under difficult circumstances and we respect you and your profession.  But just admit that you have some unbelievable professional cushions.  This won’t diminish your self-worth or contributions to society. 

Many medical interns and residents don’t consider lifestyle when they are making their career choice, and they should.  Obstetrics is thrilling when you are 30 years old.  Fifteen years later when you are overworked, tired and have your own kids, it may be slightly less thrilling to bring new life into this peaceful world in the middle of the night on a regular basis. 

For me, leaving my own bed at an ungodly hour to haul out to the hospital is an unwelcome activity.  I do not relish being awakened with phone calls or having to attend to an individual in the emergency room when the rest of Cleveland is soundly snoring.   While gastroenterology is a more taxing specialty than the skin gig, it is still uncommon for me to have leave for the hospital during the black of night.   Since we are in the era of medical hospitalists who are on staff around the clock, there is only a rare need for me to make a personal appearance.   On most nights, my scope rests securely in its holster. 

Do I think that medical students should consider lifestyle as they are contemplating their future?   Absolutely.   Indeed, the emerging culture of the medical profession has morphed from the prior culture when doctors worked 24/7 and interns were proudly on-call every other night.   Medical doctors today are increasingly employed by institutions, work shifts and delegate the hassles of hospital life to hospitalists. Doctors are self-prescribing R & R.  

Leisure, relaxation, avocations and personal time for reflection are not evil pursuits.  They are the fuel that cultivates and sustains our humanity.   Who wouldn’t welcome a little more humanity in the medical profession?

Sunday, September 21, 2014

Medical Complications Torture Doctors Too

If you are a physician like me who performs procedures, then rarely you will cause a medical complication.  This is a reality of medical life.  If perforation of the colon with colonoscopy occurs at a rate of 1 in 1500, and you do 3000 colonoscopies each year, then you can do the math.

Remember that a complication is a blameless event, in contrast to a negligent act when the physician is culpable.  These days, for many reasons, an actual complication is confused or misconstrued as an error.
Some complications are more difficult on physicians than others.  For example, if I prescribe a medication and the patient develops a severe rash, I do not feel personally responsible.  It’s the drug’s fault.  However, when I perforate someone’s colon as a medical complication, I feel responsible even if this act was a blameless event which will occur at a very low but finite rate.  (Of course, there are perforations of the colon which result from medical negligence, but I am leaving these aside to make my point here.)  

I Didn't Cause This Rash.  The Drug Did It!

I feel responsible because my hand was on the instrument that caused harm.   I can’t as easily blame the scope, as I blamed the rash-causing drug.   I’m sure that surgeons feel the same painful emotions when they perform a routine operation and serious bleeding results that requires additional surgery and complicates what should have been an uneventful recovery.

When your hand is on the colonoscope or the scalpel, and the unexpected happens, it’s an awful experience for the doctor even if we have performed according to proper medical standards.
Of course, serious medical complications are much more difficult for the patients and families involved than they are for us.  But, we physicians suffer greatly when a patient is harmed from a procedure that we recommend and perform.    You can imagine how we torture ourselves with second-guessing when these events occur.

Complications are inevitable.  The only gastroenterologist who hasn’t had a perforation of the colon is one who is brand new.   So, if you are drawn to a gastroenterologist because he has a 0% perforation rate, caveat emptor!   Paradoxically, the most experienced colonoscopists have accumulated many more complications over their career because of a much higher volume of cases or that they are referred very challenging cases by virtue of their skill and experience. 

A medical complication is an especially difficult event when it occurs in what was expected to be a routine outpatient examination.   Patients who come to our office for a screening colonoscopy understandably expect to be home 2 hours later.  So do we.  On those rare occasions, when this recovery path is altered, we must have a very serious, sober and unexpected conversation with the patient and the family.  Our plan is always to tell the truth and reassure all involved that we will do all that we can to make it right. 

Medicine is not a simple or predictable endeavor.  Sometimes, it can be rather complicated.

Sunday, September 14, 2014

Should You Trust Your Doctor's Advice?

Is your doctor a hammer and you're a nail?  Here's some insider's advice coaxing patients to be more wary and skeptical of medical advice.  Should you trust your doctor?  Absolutely.  But you need to serve as a spirited advocate for your own health or bring one with you.  Ask your physician for the evidence.  Sometimes, his medical advice may result more from judgement and experience as there may not be available medical evidence to guide him.  Make sure you have realistic expectations of the medical out me.  And most importantly, try as best you can to verify that the proposed solution is targeted to your problem.

Is Your Doctor a Hammer?

Consider a few hypothetical scenarios.

A 66-year-old patient has chronic right lower back pain.  Physical therapy has not been helpful.  Radiological studies show a moderate amount of hip arthritis.  A hip replacement is flawlessly performed.  The orthopedist discharges the patient from his practice.  The pain is unchanged.

A 60-year-old patient has chest pains that are not typical for angina.  Her internist arranges a stress test and the results are equivocal.  A cardiologist performs a cardiac catheterization and a moderate narrowing is found in an artery.  A stent is successfully placed in the proper location.  The patient is reassured that her cardiac pipes are all wide open.  She returns to see him a month later wondering why the pains have continued.

A 50-year-old patient sees his gastroenterologist for stomach pain.  An ultrasound confirms the presence of gallstones.  The patient accepts the specialists advice to have his gallbladder removed.  The operation proceeds smoothly.  You can guess the rest.

This is not meant to serve as an indictment of the medical profession.  The examples above have been highly simplified to make a point.  First, making accurate diagnoses are complex undertakings that can frustrate even seasoned diagnosticians.  Patients' medical histories are often vague and evolving.  Many diseases and conditions have clever mimics that can lead doctors astray.  Every doctor can regale you with anecdotes detailing episodes when they have been fooled.  There isn't a medical doctor alive who hasn't fumbled over a case of chest pain. 

Just because medical advice doesn't lead to the desired outcome, doesn't mean that the advice was wrong.   I concede, of course, that bad medical advice can cause adverse outcomes, a self-evident statement. 

Despite the vagaries and uncertainties in the medical arena, physicians try as best we can to propose a remedy that is directed to your symptom, rather than serve as a fix for something that is not ailing you.  My advice to patients is that when your doctor is raising the healing hammer, is to try not to get nailed. 

Make sure this inquiry is in your tool box.  "Doctor, can you please explain why the treatment will cure the symptom that brought me to you in the first place?

Maybe a hammer is the right tool for you.  Without doubt, the time to have this conversation is in advance of pulling the treatment trigger. Having realistic expectations can prevent future frustration when a treatment doesn't bring you to the end zone. 

So, next time your physician proposes a plan of action, hammer away.


Sunday, September 7, 2014

Bariatric Surgery: Pulling the Gastric Bypass Trigger Too Soon

If losing weight were easy, we'd all be skinny.  If exercise were fun, we'd all be doing it.  If quitting cigarettes were effortless...

What should our response be toward rising societal tonnage?

A Weighty Issue
  • Pass laws restricting access to the wrong type of food.  Former Mayor Bloomberg got stiff-armed on this approach by the courts.  It's also always fun to watch folks argue over the definition of a 'wrong food'.  The debate on which foods warrant prohibition at least brings some entertainment into the public square.  Imagine trying to achieve consensus over 20 or so food items that should be banned.  If this task were actually accomplished, cigarettes and alcohol would still be legal.  Make sense?
  • Initiate a massive public education campaign to scare us skinny. Show ads of scary pictures with scary music reminiscent of an iconic anti-drug ad (This is your brain on drugs...) from a few decades ago.
         "This is your heart."  Screen shows cartoon of a happy and vigorously beating heart.
         "This is heart on ice cream."  Screen shows depiction of gasping and quivering organ, coughing up fat              globules.
          How would we fund this effort? Simple.  Tax the manufacturers of 'wrong food''.
  • Allow individuals to choose their food and beverages freely and to accept any health consequences of their decisions.  (LOL on steroids here.)
  • Give tax breaks for every 5% loss of excess body weight.  Interesting concept.  Might thin folks file a discrimination lawsuit here?
Most folks who are overweight want to be thinner.  The reasons why folks carry extra weight are complex and are not simply because they eat too much.  There is a powerful mental component that for many people is part of the problem and must be part of the solution.   Sure, caloric control is fundamental, but many overweight people do not eat just to satisfy hunger.  They do so for other reasons which must be attacked directly if a successful outcome is to be achieved and sustained. 

The quick fix has been luring folks with false promises for generations.  Infomercials on the air every day hawk agents that will melt fat away, although there always appears a disclaimer in a font size too small for the human retina to discern that states that 'results not typical'.  The threshold for recommending bariatric surgery is getting progressively lower, and it has not hit bottom yet.  My sense is that this treatment is becoming regarded as a routine remedy, rather than a last resort measure after multiple other attempts have failed.  I suggest that many dieters may not be as disciplined and determined with conventional weight loss programs knowing that a bariatric rescue is available. 

Obesity is a serious health issue without an easy external cure.  Weight  loss medicines are either ineffective or dangerous.  Fad diets don't work.  Gastric bypass surgery is a serious operation that profoundly changes every day of your life by design when it is working properly. 

Weight loss can be viewed as two distinct tasks.  Losing weight and maintaining the loss.
Success, in my view, will come from within. 

Weight loss is not a sprint, but is a long distance run.  Consider this point.  Very modest lifestyle changes over time can deliver big results.  Lose a pound per month, for example.  Do the math and calculate your new weight 2 years later.  This cold math works the same way if we gain a pound each month.

Write down your reasons why you are overweight.  Are these reasons stronger than you're desire and commitment to change?  If not, then get yourself to the starting gate.  Your marathon run is about to commence.

Sunday, August 31, 2014

The Meaning of Labor Day

Labor Day is here.  Like many of our National Holidays, we have forgotten the meaning of the day.  Is Memorial Day a time to reflect upon those who sacrificed so we would be free, or a time to grill burgers on the barbecue?   Same with the Fourth of July.  Martin Luther King Day is just a day off for many of us.  If greater participation and reflection on MLK is the objective, then why would this day be on a Monday when most of the country is at work?  Even Christmas, a holiday season that I enjoy but do not celebrate, has shed its deep religious significance having become a commercial enterprise.  This reality, I suspect, must sadden and disturb many believing Christians.

Labor Day, when many of us will be laboring over charcoal-broiled ribs and chicken, was created to remember and honor this country’s labor unions. 

Triangle Shirtwaist Factory Fire 1911

While I am hostile the politics of unions today, I readily acknowledge that they were a necessary response to egregious abuse by management.   The percent of workers who are organized today, and their influence, has been steadily declining.  Right-to-work support has risen as workers and the rest of us resist practices such as non-union workers being compelled to pay fees to the union.  I do not believe that an individual should be forced to join a union or to pay them fees.  Such coercion violates the free choice that a worker is entitled to, in my view.  Yes, I know the argument that union protections extend to non-union workers who should not receive a free ride by enjoying benefits that they do not pay for.  I simply believe that the right-to-work argument is more persuasive.

I am not against unions, but I do not support forcing people to pay them who do not wish to join.  If participation in a union will deliver greater benefits to workers, then these workers will want to join on their own free will.  If you have to force someone to do something, then I wonder if the ‘benefit’ is real. 

Years ago, while attending the National Storytelling Festival in Jonesborough, Tennessee, I remember listening to professional storyteller Gay Ducey tell a few thousand of us her rendition of the Triangle Shirtwaist Factory fire in 1911, a disaster where nearly 150 workers perished, when they could not escape from a burning building as the doors and exits were locked by management.  I was spellbound during her hour long recitation, and I have never forgotten it. 

Let’s give a nod to all those who go to work every day, supporting their families, and bringing goods and services to all of us.

I support a Right-to-Read principle.   I can’t compel anyone to read and meditate on my weekly homilies.  You have to want to come here.  And, I hope that you will.   

Sunday, August 24, 2014

Good Riddance to Routine Pelvic Examinations

So much in medicine and in life is done out of habit.   We do stuff simply because that’s the way we always did it.  Repetition leads to the belief that we are doing the right thing.
In this country, we traditionally eat three meals each day.  Why not four or two? 

We prefer soft drinks to be served iced cold.  I’ve never tried a steaming hot Coke.  Maybe this would be a gamechanger in the food industry?

Life gets more interesting when folks question long standing beliefs and practices forcing us to ask ourselves if what we are doing makes any sense.
In the medical profession, a yearly physical examination was dogma.  Now, even traditionalists have backed away from this ritual that had no underlying scientific data to support it.  Yet, patients would present themselves to this annual event believing that this ‘check-up’ was an important health preserver. 
Here were some medical routines that were never questioned.
  • Yearly ear drum examinations with the otoscope.   Always exciting.
  • Palpation of the abdomen.
  • Listening to the lungs with a stethoscope.
  • Testing your reflexes (Sure, this was fun, but did it help anyone?)
Keep in mind that I am referring to components of the physical exam that are performed on asymptomatic individuals who feel well.  Obviously, listening to a patient’s lungs has more value if a patient has fever and a cough.

Yes, I recognize that there may be an intangible value in having a physician make physical contact with his patients, which some argue help to create a bond in the relationship.   This may be true in part as patients have been taught to expect this from their doctors.  Indeed, a ‘hands off’ physician may be construed by patients as being an inattentive or even an incompetent practitioner. 

Recently, the American College of Physicians issued a new guideline published in the Annals of Internal Medicine stating that routine pelvic examinations should not be performed.  Why?  Because there is no persuasive evidence that they do any good.

Hands Off Gynecologists!

Sure, there will be pushback.   In medicine and elsewhere, there is often resistance to change from those whose practices are being challenged.   Review the following complex table that I have prepared.

Procedure Under Review      Resistors
 PSA                                                       Urologists
Mammograms                                   Radiologists
Colonoscopies                                   Gastroenterologists
Term Limits                                        Politicians
Tort Reform                                        Take a guess

If all of the elements of a routine check-up were subjected to scientific scrutiny, we might be shocked at how little of the exam remained.   This might create an unintended benefit.  It would free up time that we physicians could use to talk more with our patients.  So far, no scientific study has deemed this to be a waste of time.   

Sunday, August 17, 2014

Physicians Lose Right of Free Speech

I’m all for free speech and I’m very hostile to censorship.  The response to ugly speech is not censorship, but is rebuttal speech.   Of course, there’s a lot of speech out there that should never be uttered.  Indecent and rude speech is constitutionally protected, but is usually a poor choice.    We have the right to make speech that is wrong.

Does First Amendment Apply to Physicians?

I relish my free speech in the office with patients.   I am interested in their interests and occupations and sometimes even find time to discuss their medical concerns.  I am cautious about having a political discussion with them, but patients often want my thoughts and advice on various aspects of medical politics, and I am willing to share my views with them.   I don’t think they fear that politics or any other issue under discussion will affect their care.  It won’t.

A Federal Appeal Court recently decided in a Florida case that physicians could be sanctioned if they asked patients if they owned firearms if it was not medically necessary to do so.  Entering this information into the medical record could also result professional discipline.  The court was considering such gun inquiries to be ‘treatment’ and not constitutionally protected speech.

I am on the record in this blog more than once that I do not think we should look to the courts to make policy.  Their task is simply to rule on the legality of a particularly claim.  In other words, we should not criticize a legal decision simply because we do not like the outcome.  Nevertheless, this decision is simply beyond wacky and could create a theater of the absurd in every physician’s office

Could the following examples of physician inquires be prohibited?

  • A psychiatrist cannot ask about cigarette smoking as this is not relevant to the patient’s depression.
  • An internist cannot ask what the patient’s hobbies are as this is not germane to the medical encounter.
  • A gastroenterologist asks his patient who is a chef for a recipe and risks professional sanction for crossing a red line.
  • A surgeon asks a patient’s opinion about the town’s new basketball coach and hopes that this patient is not a planted mole recording the conversation.
So for those physicians who practice in the 11th Circuit, no gun inquires unless you can demonstrate with clear evidence that it has direct medical relevance.  The court left open for now asking patients about sling shots, fly fishing and skeet shooting, but medical practitioners are advised to consult with their attorneys regularly.

Apparently, idiotic judicial decisions can still be the law of the land.

Sunday, August 10, 2014

Testing Doctors for Drugs and Alcohol

I read recently that the left coast state of California is contemplating requiring physicians to submit to alcohol and drug testing.   Citizens there will be voting on this proposal this November.I do think that the public is entitled to be treated by physicians who are unimpaired.  Physicians, as members of the human species, have the same vices and frailties as the rest of us.

Traveling leftward

I have no objection to this new requirement, if it passes. This will not be a stand-alone proposal on the ballot, but is a part of the ballot initiative.   Why would trial lawyers in the Golden State want to include it?  The meat of their ballot effort is to reverse effective tort reform that had been in place there for several years.   Click on the Legal Quality category on this blog for a fuller explanation of why the medical malpractice system has been screaming for reform, and is slowing getting it.  Sure, there are always two or more sides to every issue.  But, when the different points of view here are fairly weighed, trial lawyers’ self-serving positions are overtaken.  They offer a different spin, of course.  While I acknowledge the validity of some of their arguments, I believe that the system they advocate helps very few at the expense of many more innocents.

The California ballot initiative aims to increase the financial cap for a medical malpractice award from $250,000 to $1.1 million.   Trial lawyers and other supporters were concerned that the public may reject raising the cap as they have been enjoying the benefits of tort reform.   Focus groups supported the notion that the public would find the drug and alcohol testing proposal appealing, which would raise the probability of passage of the bill.

There’s nothing evil about any of this.  Every player in every issue uses polling and focus groups to create and tailor their message.   (Ever notice how politicians claim they never read polls whenever poll results are against them or their positions?)   I’m sure that the insurance companies who champion tort reform are using the same techniques to manage their message. 

But, voters there and the rest of us should recognize why the drug and alcohol provision is included.  It was just a spoonful of sugar to make the legal medicine go down.  Why not just include the medical malpractice vote on the ballot by itself,?  We’ve seen our politicians use this same technique over and over again.  Add a popular poison-pill provision to an unpopular piece of legislation.  When it’s properly voted down, criticize those who voted against it by pointing out their opposition to the popular add-on provision.  Follow this example.

Legislator A:   I am adding an amendment to the Quadruple the Minimum Wage Bill that would give all veterans and their families free First Class seating on all domestic flights.
Legislator B:  I am voting against the bill because I think that quadrupling the minimum wage is bad economic policy
Legislator A:  Shame on Legislator A for trashing our veterans who have sacrificed so much for this country.

Should other professions be subjected to random drug and alcohol testing?  Which would you suggest?

Will Californians see through the smoke here?   We’ll find out this November?

Sunday, August 3, 2014

Should Doctors be Political in the Office?

Our nation is highly polarized today, and often bitterly so.  Democrats rail against the GOP.  Pro-lifers face down pro-choicers.  FOX News disses MSNBC.  Isolationists push back against expansionists.  Traditionalists disdain the politically correct.  Free marketers duel against government advocates.  Carnivores deride the gluten-free crowd.  Martin Bashir trashes Sarah Palin, two proxies in a culture war.  

There's a philosophical divide among physicians also.  Would you prefer a liberal physician or a conservative practitioner?  I'm not referring here to fiscal policy or legalizing recreational marijuana use.  Consider the following hypothetical scenario and the 2 physicians approach from opposite sides of the medical philosophical spectrum. Which physician would you choose?

Dueling Doctors

The Patient:  She is a 50-year-old female with chronic fatigue syndrome (CFS).  She is only able to work part time because of her condition.  She has consulted with an internist, an infectious disease specialist and a naturopath, but her fatigue persists. 

A new treatment for CFS has just been launched by a reputable herbal supplement company.  Two well-designed studies suggest symptomatic improvement in afflicted patients after 6 months of treatment.  As the product is an herb, there is no formal Food and Drug Administration (FDA) oversight. 

Physician #1: "I'm reluctant to recommend this product, despite the optimistic preliminary results from two medical studies.  These studies were funded by the herb company and there may be bias present.  Moreover, it is very typical in medicine for initial results to be favorable, with unforeseen side effects and complications emerging later when after more widespread use of a drug.  I'm concerned that the FDA had no role in validating that the drug is safe and effective for its intended use.  Additionally, there is evidence that the active ingredient in the product disrupts the immune system, which may have serious future consequences that may not become manifest for several years or longer.  While CFS is decreasing your quality of life, your condition has been stable and will never threaten your life.  I recommend holding off until we have an FDA approved medicine for CFS or the herbal supplement has been used long enough that we have a better sense of its safety and efficacy."

Physician #2: "I recommend that you try this new herbal product.  It is completely natural and showed promising results in two medical studies.  Importantly, no serious side-effects developed in either study.  Of course, we have no long term data on safety, but the vast majority of herbal supplements on the market are safe.  No other treatment thus far has been successful for you, and your condition is adversely affecting your professional and personal lives. The choice is to try something new or to continue suffering as you have been.  Try it for 6 months and then well reassess."

So, that's my herb blurb.  This is a common situation in the medical world where medical advice must pass through the prism of Risks and Benefits.  These analyses are limited when the risks and benefits are unclear or disputed.  Treatment acceptance also depends heavily on the patient's risk tolerance.  What if the herb referenced above had a 5% risk of cancer?  What if the herb needs to be taken indefinitely?  Clearly, when the disease poses a serious medical threat, the patient may be willing to accept greater risk of new or investigational therapies.

So, which of these physicians would you choose for yourself?  Are you a medical liberal or a conservative?