Sunday, May 31, 2015

When Your Loved One is an Alcoholic

I was asked to consult on a 43-year old female with abnormal liver blood test results.  It took but a few minutes to determine that she was an alcoholic, which was the likely explanation for her abnormal blood results.  She drank several beers daily over several years.

My diagnosis was alcoholism, but did the patient concur?

“Do you feel that you are drinking excessively or do you have it under control,” I asked.

She replied, “I’ve got it under control.”

That sad reply indicated that the probability of helping her to help herself was zero.  Ultimately, the addict must forge a pathway to healing.  Sure, we can help, coach and support the effort, and we should.  But, no addict ever reached the Promised Land by force or persuasion.

Pouring One for the Road

Sure, we’ll got this patient out of the hospital, back into the cauldron of inexorable self-destruction.  Did we help her?  I don’t think so.  This is not like treating a urinary tract infection where healing requires no effort from the individual.  The addict, in contrast, can never be healed from without. 

I have witnessed family members of alcoholics agonize in their frustration and disappointment that they cannot coax their loved one onto a path leading toward sobriety.  If I were in their place, I might behave similarly. 

I have many patients who have conquered addictions.  I admire them for vanquishing demons that prey upon so many of us.  Some struggled ferociously and prevailed while others curiously threw off the yoke with seemingly little effort.  Life isn’t fair.  Without exception, these folks broke free because they decided to pursue a different direction.   No yelling, screaming, threatening, begging or bribing can bring an afflicted addict across the finish line.

When loved ones reach the point where they realize that they can’t be the solution, they experience a sense of resignation and peace, even though the pain remains. 

The serenity prayer offers wisdom to us all.

God, grant me the serenity to accept the things I cannot change.
The courage to change the things I can.
And the wisdom to know the difference.

Sunday, May 24, 2015

Memorial Day - A Time to Reflect

It’s Memorial Day tomorrow.  What is it exactly that we are charged to remember?

Cole Slaw?
Lighter Fluid?
BBQ Sauce?

My father was a member of the greatest generation, having served in the U.S. Navy for 39 months.  He was stationed in California and was never in combat, despite some apocryphal vignettes he regaled us with.  I’ve never served in the military and none of my friends have served.  If not for my job, I would have very scant exposure to military professionals.  I have numerous patients who have served in all branches of the military during the 1940's and 50's.  Many are true heroes who recall their service with understated modesty.  I have also cared for many Vietnam vets who still bear physical and psychological scars of a war we couldn’t win and should never have joined.

Freedom is not free, a quote that moved me deeply when I first saw it on the Korean War Veterans Memorial in Washington, D.C.  I know that Memorial Day has deep meaning for families who have sacrificed or have a loved one wearing the uniform.  Folks like me just can't have the same depth of appreciation of what Memorial Day means.  

I’ve never worn the uniform.  I’ve never marched in formation.  I’ve never endured boot camp.  

I wish I had learned to salute so I can salute you all.

Sunday, May 17, 2015

Is Office Colonoscopy Ethical?

While I consider myself to be an ethical practitioner, I am not perfect, and neither is the medical profession.
I will present a recurrent ethical dilemma to my fair and balanced readers and await their judgment.
Our gastroenterology practice, like all of our competitors, has an open access endoscopy option.  This permits a physician to refer a patient to us for a colonoscopy, without the need for an initial office visit.

Ready, Aim, Fire!

Patients can also schedule procedures themselves, such as a screening colonoscopy, without a physician referral, if allowed by their insurance carriers.  These patients enjoy the convenience of  bypassing an office visit.   We agree that an office consultation should not be required for routine screening procedures or to evaluate minor gastrointestinal symptoms.

Of course, if a patient wants to see us in the office in advance – and some do – we are happy to do so.  I enjoy these pre-op visits which allows me to develop some measure of rapport with the patient and to discuss the upcoming endoscopic adventure, before the patient is naked with an IV dripping into his arm.

When these open access procedures are scheduled, we carefully screen patients on the phone to verify that bypassing an office visit does not pose any safety risks for the patient.   We do not want to meet a patient for the first time for a screening colonoscopy, who is on kidney dialysis and uses an oxygen tank.

Here’s the rub.  There are times when I meet an open access patient who is prepped and primed for a colonoscopy that is not necessary.  In the most recent example, I greeted a patient who was poised to have a colonoscopy because there was a prior history of colon polyps.  However, according to current professional guidelines, the patient didn’t need the exam for a few more years.   I was meeting this patient for the first time.  She had taken a day off of work and had a driver with her.  She had enjoyed the delight of the gentle cathartic agent that colonoscopy patients imbibe with gustatory pleasure on the prior evening.  She believes, of course, that the procedure is necessary as her physician had recommended it.

What should my response, if any, to her be?

One of the pitfalls of open access is that we can never screen patients as carefully as we do during an advance office visit.  Should we halt a procedure that an internist has requested even if we may not believe the procedure is of medical necessity?   Should we be willing to serve as ‘technicians’ for referring doctors in the same manner that radiologists serve their colleagues?  When we order a  CAT scan, for example, the procedure is always done whether it’s needed or not.

I sit in judgment now awaiting your verdict.  May it be as probing and enlightening as a colonoscopy.  

Sunday, May 10, 2015

Is Medical Research Rigged?

Practicing physicians like me rely on scientific medical journals to keep us current on medical developments.  We learn about new treatments for old diseases.  New diagnostic tests are presented as alternatives to existing methods.   Established treatments, which are regarded as dogma, may be shown to be less effective or less safe than originally believed. It’s a confusing intellectual morass to sort among complex and conflicting studies some of which reach opposite conclusions in the same medical journal.  What’s a practicing physician to do?

While the medical journals that physicians read are fundamental to our education, paradoxically most physicians have only rudimentary training in properly analyzing and assessing these studies.  For example, the quality of medical studies often depends upon statistical analysis, a mathematical field that is foreign to most practicing physicians.
Doctors like me hope that our peer-reviewed journal editors have done their due diligence and vetted the studies they publish ensuring that only high quality work reaches readers.  On a regular basis, a study in a prestigious medical journal is challenged by other experts in the field who refute the study’s design or its conclusion.   Medical progress does not proceed linearly.

The Path of Medical Progress

Although I am a neophyte here, I will offer some examples to readers highlight defects in study design that can lead to tantalizing and exaggerated headlines and sound bites.

The Study is Too Small:  If a new treatment is tested on only 5 patients, and one of them happens to get better, is it really accurate to announce that there is a 20% response rate?  Would this hold up if the study had 100 patients?

Where’s the Control Group?:  Doctors know that many patients get better in spite of what we do.  If a new treatment brags a 35% response rate on a group of sick individuals, was there a second group of patients called the control group in the study who were not treated and compared?  In many cases, the control group shows a significant ‘improvement’ without any treatment, for various reasons.  If the treatment group and the control group both show a 25% improvement, then the drug is not quite the magic bullet.

Is the Study Randomized? Ideally, the treatment and the control group should be identical in every respect except for the treatment being tested.  This is why higher quality studies randomly assign patients into each group.  Randomization maximizes the chance that the two groups being compared will be very similar with regard to all kinds of variables including smoking, weight and other risk factors.

Beware the False Assocation!  This is a very common and deceiving practice where investigators try to link events that are much too far apart to be connected.  Newspapers and airwaves love this stuff as they have sizzle.   “Study shows that Gym Membership Reduces Cancer”.  This ‘study’ might be sponsored by the Society of Calisthenics and Aerobic Medicine (S.C.A.M.).  Sure it might be true that gym members have lower cancer rates, but this has nothing to do with pumping iron.  These folks are more health conscious and are likely to be fit, non-smokers who pursue preventive medical care.  Get the point?

These are just a few examples to give readers a glimpse of the issue.  Of course, I just barely peeled the onion here.

Designing medical studies is a profession.  Most physicians have barely a clue on how to properly design a study or to interpret it.  Most of us rely upon others to perform the quality control function.  However, just because it’s a published study, doesn’t mean the study is worthy of publication.  Medical research may contain sleight of hand, confusion, obfuscation, all of which can be hard to recognize.  The fact that our highest quality medical studies are routinely challenged shows how difficult it is for ordinary doctors to make sense of it all.  Medicine can be murky.   Caveat lector!

Sunday, May 3, 2015

Whistleblower Wins Hospital Recognition

Everyone likes to be recognized for a special achievement or accomplishment.   Every career has special awards and commendations for everything.   While there’s no reward that matches cold hard cash, many of these honorable mentions have no tangible value whatsoever.  Pull into a fast food parking lot and you may see a parking space designated with a sign proclaiming, Employee of the Month!  Such an award conveys appreciation but does little to enhance the standard of living of the recipient.

It seems that every other week there is some award show on television for the arts and entertainment industry. 

99.44 Pure!

I’d like an award, or at least a citation, for the work that I do as a gastroenterologist.   Fortunately, there are many awards and honors that I am eligible for.   Here are some of the prestigious honors that would illuminate any curriculum vitae.

  • Fellow of the American College of Flatulence
  • Honorary Doctorate of Hemorrhoidology
  • Election to the Sphincter Preservation Society
  • Light at the End of the Tunnel award
  • 20.000 Scopes Under the Sea Award
Sadly, I wasn’t nominated for any of these prestigious designations, but I have not been left empty handed.  I received a special letter of commendation from my community hospital signed by a physician of authority.  When I say signed, I mean that a living breathing human being applied a real pen to paper.  This was no autopen or stamped signature.  The document is suitable for framing.  In fact, despite my legendary modesty, I posted the letter in the break room of our practice so that my colleagues and staff would confer the measure of respect that was now due me.  After a few days, the letter was taken down, probably by one of my envious partners who was not similarly honored.   As a result of this action, the break room is now monitored by a webcam to deter such acts of vengefulness. 

The letter did not speak to my diagnostic skills or to my rapport with patients.  It said nothing about my cost-effective care or my peer evaluations.   The letter commended me for my consistent hand washing.  I assume that nurses in the hospital are now charged with monitoring physician hand washing practices, which is a task they can easily perform in their abundant free time.   If funds would permit, the hospital might hire professional hand washing monitors who could verify that physicians and everyone are scrubbing up consistently.

Contemplate the notion of a doctor being complimented for washing his hands.   Can we set the bar just a little higher?