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?