Sunday, November 29, 2015

Why Do I Have to Work on Thanksgiving Day?

I began this past Thanksgiving Day seeing patients at two local hospitals.  Yes, I was working on Thanksgiving, as I have done on many holidays over the past 25 years.  Many folks have the luxury of jobs that offer every weekend and holiday off automatically.  Many don’t.   For example, on Thanksgiving, the hospitals were staffed by nurses, secretaries, security personnel, housekeepers and cafeteria workers.  And, of course, every patient was seen by his attending physician and various specialists.  If any of us contemplated complaining that we had to work, a quick glance at any of the patients confined to their hospital beds would have quickly set us right.

It’s not only medical care that must be available every day of the year.  Law enforcement, firefighters, utility companies, and national security institutions simply can’t clock out on Friday afternoons.  If you call 911 on a Sunday, you will not be greeted by a recorded message. 

The day is a national opportunity to express thanks for what we have, for what we have been given. I know that many of us have been given what seems to be an unfair measure of misfortune and pain.  Life is not fair.

A Depiction of the First Thanksgiving

I have seen so many people over my career who have faced challenges and obstacles that dwarf my own, and yet demonstrate grace and thankfulness for what they have in their lives.  How do these ordinary people find extraordinary strength?   It’s effortless to be appreciative when you are coasting downhill.  Anyone can do this.  What really matters, however, is when we can do so when our downhill glide has taken a tortuous path.  This is a lesson that I contemplate often, but I haven’t mastered.   I am thankful for the people in my life who inspire me to try to be better than I am.

Sunday, November 22, 2015

Is E-mailing with Patients a Good Idea?

Physicians speak with patients every day on the phone for a variety of reasons.   Our practice now uses a portal system, giving patients access to some of their medical data and to us.  Although I was resistant to having e-mail communications with patients, I have come to appreciate the advantages.

  • It relieves our ever congested phone lines
  • It relieves patients from a state of suspended animation as they hope and pray that a living breathing human being will return to the line after being placed on hold
  • It saves our staff time who no longer have to triage calls as the patient directly reaches the doctor

While this streamlined cyber communication system is useful, it does have limitations.  It can’t solve every problem.  Indeed, some issues are not appropriate for either a phone call or an e-mail.

Calling his doctor?

Consider the following scenarios.  Which can be appropriately handled on the phone and which merit a face to face encounter with a physician?

  • I was in the emergency room yesterday and they told me to call you for pain medicine.
  • My diverticulitis is acting up and I need an antibiotic.
  • My breathing is worse.  I think it’s a side-effect of the new heart medicine I started last week.
  • What can I take for constipation?
  • My cousin had the same symptoms and it ended of being her gallbladder.  Can you give me the name of a surgeon?
  • I’m dizzy and my hemorrhoids have been bleeding for a week.  What can I take?
  • I have hepatitis C.  Is is okay if my grandchildren visit?
  • I had some chest pain yesterday when I was shoveling snow.  Should I double my Nexium?

The practice of  medicine is not fully wireless, at least not yet.  Sure, e-mail is convenient for everyone, but if used too casually it can become quicksand.  Often, the patient feels an e-mail is sufficient, but the physician may not be comfortable, depending upon the medical facts and how well the doctor knows this patient.  When you are face to face with your doctor, the medical history will be more detailed, there may be a physical examination, and there will be a dialogue and review of treatment options.  It’s a lot easier for us to assess your pain, for example, when you are in front of us.  Moreover, when you return to see us for a follow-up visit, we have a baseline to use as a comparison.

What are your thoughts on all this?   Feel free to e-mail me, but I’d prefer if you came to see me
face to face.

Sunday, November 15, 2015

Gadzooks! There's Gluten in my Cheerios!

Gluten is in the news again.  Gluten and probiotics are among the two dietary issues that most consume my patients.  I am asked for my opinion on them several times each week.  Although my opinion is solicited, these patients have largely already made up their own minds as they are often avoiding gluten and swallowing zillions of ‘good bacteria’ with zeal and enthusiasm.

Why do they do this in the absence of corroborating medical evidence?  Why do millions of voters support Donald Trump’s mantra that he will ‘make America great again’?  Both of these groups do so on faith.  When our need to believe something is overpowering, our demand for proof recedes.  Many of us need to believe that gluten is the agent responsible for our vague medical complaints that have stymied our doctors.  Similarly, our frustration with so many aspects of our society and conventional candidates makes us believe that Trump will turn the nation into yellow brick roads leading to Emerald Cities everywhere.

Wheat Attacks General Mills

I take care of patients with true celiac disease who need to avoid gluten.  Most of my gluten-avoiding customers are not celiacs, but feel better on their self-prescribed diet.  When these folks see me and relate their clinical improvement, I support their decision.  Why do I do so after I just mocked the gluten-free zealots?
  • Just because there is no medical evidence, doesn’t mean it’s not true.
  • There is scientific basis of true ‘gluten intolerance’ in folks who do not have celiac disease.
  • Never talk a patient out of anything that seems to be helping him. 
Recently, General Mills recalled nearly 2 million boxes of gluten-free Cheerios and Honey Nut Cheerios, because these boxes were contaminated with wheat, which contains gluten.  The company voluntarily and properly undertook this recall.  If a product is represented to be ‘gluten-free’, then it should be.   Folks who have life threatening allergies to peanuts, for example, depend upon true labeling for their very lives.  However, not every manufacturing goof will result in such a dire risk for consumers. Yet, the Cheerios recall is labeled a Class 1 recall which means that there is a reasonable probability that it will cause serious health consequences or death.  Give me a break.  The phrasing states will cause, not even may cause.  Gluten is not botulism.   If a celiac patients ingests some gluten by error – which every one of them does throughout their lives – they live to see another day.  This FDA’s Class 1 designation is over-the-top hyperbole of the first order, if you will forgive my redundancy.  We would expect a Class 1 recall to be invoked for a faulty pacemaker, for example. 

Who makes up these definitions?  Obviously, the FDA wasn’t thinking clearly when they did so.   They were probably on a sugar high after wolfing down too many bowls of Fruit Loops.  

Sunday, November 8, 2015

How to Increase Medical School Enrollment

Lawyers and physicians have so much in common, despite some benign grievances that occasionally reach the level of homicidal rage.  Just kidding.  Calm down, juris doctors.  Consider the similarities.  Both professions serve a public who needs help.  Both wield professional advice and judgment that must be tailored to an individual’s unique circumstances.  Neither professional is ever 100% certain of anything, and an outcome cannot be guaranteed.  Both are charged to put their clients' and patients' interests above their own.  (Snickering permitted here.)
Let's see what our legal brethren are up to.  Law schools in America are having a serious problem that they are struggling to remedy.   They need more students.  Of course, they could fill their classrooms by recruiting qualified candidates to apply to their institutions.  This strategy apparently couldn't fill the seats, assuming that it was even considered.  So, here is their plan, brilliant in its simplicity.  I will state it here in boldface italic type.
Lower admission standards!
Dozens of law schools are deliberately lowering admission standards to increase their class sizes, as reported by The New York Times.  Of course, these students will face a high bar of passing the bar, assuming that they make it to graduation.  Apparently, generating highly qualified legal professionals is not the objective. The true objective appears below.

The Objective
My blog's readers are among the sharpest in the blogosphere.  Let me post some queries, which I hope will stimulate some insightful responses.
  • You don’t think law schools are accepting unqualified applicants just for the money, do you?
  • Will the exorbitant debt they will incur benefit them and society?
  • When these struggling students fail the bar exam, have they still enjoyed a valuable life experience?
  • Should we support lowering the admission standards to conform to the emerging norm that excellence is overrated and every competitor should go home with a trophy?
  • Should we encourage this process as society desperately needs more lawyers, particularly underqualified professionals?
What's next?  Lowering the passing rate for the bar exam?

Maybe there's a lesson here for the medical profession.  We all hear that many areas of the country are medically underserved.  Surely, there is some way we can recruit more doctors?

Any ideas?

Sunday, November 1, 2015

When Should a Doctor Lose His License?

This afternoon, as I write this, a professional football player was ejected from a game for committing the transgression of unnecessary roughness.  This infraction should be taken seriously in a game where violence is not only legal, but desirable.  I’ll leave it to the reader to imagine how unnecessary the roughness was if it resulted in an ejection. 

It is self-evident to any thinking person that the human body is not designed to withstand the punishment of this game.  Keep in mind that most of us are only seeing the actual games, and not the hundreds of hours of brutal practicing.  I take care of an octogenarian who played for the Cleveland Browns decades ago.  While this profession lifted him out of a Pennsylvania steel town, it is challenging for him to identify a part of his body that is working properly.   The National Football League (NFL), which showed us all last year how they fumbled their domestic violence issues, has belated admitted what most first graders would readily recognize.  Getting smashed in the head hundreds of times per season over many years is not good for the human brain. One must wonder about engaging in an activity that requires a helmet and body armor for protection.

Legalized violence

There are rules to govern this mayhem, and sometimes a player is kicked out.

Are errant physicians kicked out of the medical profession?  Yes, it does happen, but these are rare events.  Some have argued that there is a ‘white coat wall of silence’ that protects physicians who need to be sanctioned or sidelined.  A few times a year, I receive a list of Ohio physicians who have been disciplined by the State Medical Board of Ohio.  Most of these offenses involve personal substance abuse.  ‘Pill mill’ doctors are also targeted.  Physicians who engaged in improper and inappropriate behavior with patients are on the list, as they should be.

Losing a medical license is the most serious professional sanction that a physician can receive.  Such a penalty should be implemented only for a egregious act, or a pattern of wrongdoing, provided that the physician has been afforded due process. 

When do readers think that a doctor should be tanked?  I’ll offer a few hypothetical scenarios below.  Let me know if the physician is salvageable or should be cut loose.
  • A gastroenterologist misses a diagnosis of colon cancer three years in a row.
  • A surgeon refuses to repair a patient’s hernia because the patient has no insurance and cannot afford the operation.
  • A physician is a recovering alcoholic and is now found guilty of a DUI.
  • A review of a psychiatrist’s medical records confirm that 10 patients committed suicide in the past 36 months.
  • An internist is found guilty of domestic violence.  No drugs or alcohol are involved.
  • An investigative reporter discovers that an orthopedist was paid $250,000 last year to promote a medical device to colleagues across the country, and never disclosed this relationship.
  • A physician is discovered to be double billing Medicare over the past year.
  • A physician persists in asking one of his patients to date him.
Do these offenses merit surrendering a license?  Would this be unnecessary roughness?