Sunday, December 25, 2016

Whistleblower Wishes Readers Merry Christmas!

A close acquaintance of mine voiced objection to the lighting of the National Christmas tree, which occurred on the first day of this month.  Red, white and blue LED lights were illuminated.  I find no offense in this practice, which for me is a secularized event, even though I acknowledge its connection to the Christmas season.   Kids who visited Santa, as I did decades ago, do so in the days and weeks before Christmas.  Neither Santa nor his elves visit us during Arbor Day, the Fourth of July or Veterans Day.  He is connected with Christmas, although like the tree, his purpose is far removed from the true religious meaning of December 25th

A Christmas tree is not quite the nativity scene.  Readers who have more knowledge of the New Testament than I can inform us if a Christmas tree with a star on top and wrapped gifts underneath is mentioned in the Gospels.  Perhaps, Santa truly is a religious figure, since like the three wise men, he comes bearing gifts.

Religious icon?  
Santa and saint are separated by only 1 letter.  Hmm...

I am sure that many children have contemplated the mystery of how Santa was able to appear in so many department stores simultaneously.  Any thoughts here?   I assumed that his reindeer simply transported him at supersonic speed, although, perhaps, there is another explanation.

Similarly, I do not fine our national motto ‘in God we trust’ offensive or a violation of the separation of church and state.  It has taken on, in my view, a secular meaning.

Fear of offense has led many individuals and organization to sanitize their Christmas greetings using phrases that contain all the mirth and meaning of a recorded phone menu message from airline companies.  Doesn’t Seasons Greetings really nail it?  How about Happy Holidays?

At 4 p.m. today the National Menorah will be kindled on the White House grounds.  The menorah, arguably more of a religious symbol than a tree, is generally not the object of public protest. Both the menorah and the tree are illuminated.   Who would object to bringing a little more light into the world?

Sunday, December 18, 2016

Whistleblower Holiday Cheer 2016!

Jingle bells, jingle bells,
Romney’s at the door,
Standing there with cup in hand,
“Please sir, may I have some more?”

Who will be the chief at State?
Mitt or Dave or Rudy?
How ‘bout tough guy JR Bolton?
Isn’t he a beauty?

Kellyanne, she’s our man!
Smiling like a shark,
Oh what fun it is to see
Her ever present snark.

Hillary, gets shellacked!
Trump has doused her flame,
Except for Comey, racists, assorted haters, Fox News, deplorables, poor messaging, Russians and Wiki leaks,
She freely accepts the blame.

How did he win? How did she lose?
Did she have disdain
For forgotten heartland’s pleas,
While he felt their pain?

Will we ever see the wall?
Mexico pays the bill?
Or was that just campaign red meat.
A huckster’s ‘sugar pill’?

The game is done. We must move on
And think of lessons learned.
Demonizing couldn’t halt
Millions who’ve been spurned. 

I challenge you to reach inside
And summon your good sense
Is President Trump scarier than
President Mike Pence?

Joy and Peace!

Sunday, December 11, 2016

Hospital Consent Forms and Other Stories

Even though I am over 40 – by a long shot – I am familiar with the abbreviation TMI.  We are inundated with so much noise, chatter and static.  I feel that we are bombarded with information that we must sift through and ultimately delete.  The news cycle is 24 hours and hits us from so many electronic sources simultaneously.  I am deluged each day with so many unwanted and unsolicited e-mails from organizations that I have never heard of.  One of my favorite words on their e-mails can be found when I scroll to the end.  UNSUBSCRIBE!

Another genre of information assault is the panoply of warnings and disclaimers that we confront.  Of course, we are all numb to them since we have been so supersaturated.  I’ll prove it to you.  The next time you are about to take off on an airplane, the flight attendant will review safety information in the event that a catastrophe occurs.  While one might think that folks would be attentive to information that might be useful if the plane loses altitude or is headed for a ‘water landing’; no one is paying any attention at all.  Most of us are browsing through the Skymall catalogue which showcases amazing gadgets, such as a device that can dispense feedings to your cat during a week of your absence.  For the cat’s sake, I hope there won’t be a power failure.  Moreover, the flight attendants who are issuing the briefings seem more bored than the passengers. 

How often do we hear the nonsensical phrase, this product is not intended to diagnose, treat, cure or prevent any disease?  In other words, we admit our product does nothing, but please buy it to for your ailing bones and prostate glands.

How often do we hit the I Agree icon, which follows pages of lawyerly small print, just to get to the next page? 

We have been over-warned, over-disclosed and over-disclaimed. 

While rounding at the hospital, I saw the following sign posted on a coffee machine.

Newsflash!  Hot Coffee is Hot!

Look what fear of litigation has done for us.  Prior to ligitomania, we might not have realized that hot coffee is actually hot and might injure of us if we spilled its steaming contents onto us.  Now, we are all much safer knowing that hot beverages, which we desire to be hot, are hot.

Of course, these protections extend beyond steaming beverages.  If I were in charge, I’d issue rules and regs that would mandate the following warnings.
  • Caution: these steak knives are sharp and not intended to remove feet callouses
  • This chain saw is for industrial use by trained lumberjacks.  It is not intended as a toy for children under the age of 7.
  • This lighter fluid is dangerous and should not be stored in a child’s crib.
The medical profession is a part of this game also.  Every day, I have informed consent discussions with patients regarding procedures that I have advised them to undergo.  These are informal conversations when I try to give patients sufficient information so that they can make informed decisions.  This is reasonable and a fundamental part of the doctor-patient relationship.

The hospital, however, is not satisfied with my efforts and requires that patients sign lengthy consent forms, which most patients sign blindly without reading them.  For any readers here who have had the pleasure of having enjoyed hospital life, I’m sure that you can attest how many different forms you have signed from the moment you arrived at the hospital door to your discharge.  Most patients and physicians regard these signings to be mere formalities, which are intended to protect hospitals, and not patients.  If patients actually took the time to read through all of these legal CYA forms, it might grind the hospital to halt.  There's not enough time for patients to read and understand all this drivel.

Caution readers!  This blog is not intended to inform, enlighten, provoke, challenge or amuse readers.  Readers accept all responsibility for any resultant angst or mental torment and hold blogger harmless for any and all perceived damages until the end of time.  Click I AGREE.

Sunday, December 4, 2016

Why We Can't Control Medical Costs.

Most of us are skeptical that insurance companies are devoted to our health.  Answer the following question.  Do you think your insurance company is more interested in your health or in controlling costs?  Pretty tough question, huh?

There is a tension between medical quality and medical costs.  If we had a system that offered perfect quality, it would be unaffordable.  If we imposed rigid cost controls, then medical quality would be compromised.  Where do we draw the line?

 It is clear to most of us that the medical industrial complex is riddled with waste.  Keep in mind that one man’s medical waste is another man’s income.  For example, physicians define waste as excessive charges by hospitals.  Government officials define waste as excessively high drug prices.  Patients define waste as high co-pays and deductibles.  Drug companies define waste as outrageous legal expenses to get drugs to market and to defend against frivolous lawsuits.  Primary care doctors define waste as unreasonably high reimbursement that medical specialists receive.  Keep in mind that most folks don’t feel they are overpaid, but are quick to point to others whom they accuse of being overcompensated.  For example, when a politician floats a proposal to tax the rich, we hope that the definition of rich is anyone richer than we are.

Steak is cheap when someone else is paying for it.

Get the idea?  In summary, medical waste is easily defined.  It is money that someone else earns. 

This is why excising medical waste from the health care system is so difficult.  Who would you trust to decide which waste should be wasted?  The government?  Physicians?  Pharmaceutical companies?  I don’t have an easy answer here.   Part of the solution, in my view, is when patients have a little more skin in the game.  Here’s how this works.

A physician advises an MRI of the back on two different patients.  Patient A has full coverage for the study and would face no out-of-pocket costs.  Patient B has a $5,000 deductible and would have to write the radiologist a big check.

Patient A: “Thank you, doctor. My back has been hurting for over a week.  I’d like to get it done as soon as possible.”

Patient B: “$940!  Can I try those exercises you recommended instead?”

It’s always easier to spend someone else’s money.  Do you find that you order differently in a restaurant when it’s on someone else’s dime?

Sunday, November 27, 2016

Discussions at Thanksgiving Tables in 2016

While folks across the country were gathered around their holiday tables, I suspect that conversations were not focused on the First Thanksgiving when the Pilgrims broke bread with the Wampanoag native Americans over a 3 day feast in 1621.  There was no pumpkin pie or cranberry sauce served then, and it was more likely that venison was on the table than turkey.  Sometimes, myths are more fun than facts.

The First Thanksgiving at Plymouth

I surmise that the many of our Thanksgiving dinners were sites of spirited discussions regarding a recent political earthquake that convulsed this country.  Indeed, over the past 3 weeks, I have departed from this blog’s medical commentary, to offer some thoughts on what occurred and why.

The nation is sorely divided, but I sense that there will be healing, depending upon everyone’s ability and willingness to listen deeply and absorb the views of reasonable folks whose opinions differs from ours.  Reasonable people are rarely all right or all wrong. 

The campaigns were ugly and many of us abandoned the better angels of our nature.  While candidates must be held to account for what they said and did, I expect that the incoming administration will operate within normative restraints.  The republic is like an ocean liner whose course is not easily derailed. 

The American experiment is succeeding.  For over two centuries, we have witnessed a peaceful transfer of power in accordance with the wishes of the governed.  Not a shot was fired. The current president and his administration stepped up to assist the president-elect and his team to effect a smooth transition.  The fact that the president so vehemently opposed the president-elect, and yet pledges to help him now, only reinforces the majesty of our democratic republic. 

Can we all be thankful for this?

Sunday, November 20, 2016

Breaking News! Trump Chooses Conservative Advisors!

Let the whining begin!  Donald Trump, the president-elect, has chosen Mike Pompeo, Michael Flynn and Jeff Sessions to serve as CIA director, National Security Advisor and Attorney General respectively.  Here’s the shocker.  They are all conservative! 

Let me offer some guidance to the demoralized and deflated liberal, I mean ‘progressive’, political left.  When the nation elects a president who resides to the right of the political center (leaving aside that where Trump truly resides is an arguable question), he is going to choose personnel who share his philosophy.  Trump ran hard on immigration, trade, anti-terrorism policy and the Supreme Court.  Now elected, he should be expected to assemble a team that will further the objectives that he campaigned on.  Isn’t this what we expect when a candidate gets elected?

I think that Trump’s appointments mentioned above – all of whom are qualified – cause the left to hyperventilate in an effort to distract their base from their horrendous and systemic electoral defeats they suffered all across the country.   Keep in mind, cabinet positions are not lifetime appointments and all reasonable people agree that a president should be afforded great latitude in choosing his team members.  Americans today can expect very different priorities and philosophies regarding national security, immigration policy, law enforcement and foreign affairs.  This is the natural course of events  when the White House changes hands.

Intel Pros will be allowed to say, Islamic terrorists.

Isn’t this exactly what occurred when President Obama took office in 2008?  Elections matter, as the president himself has often stated.  Were we shocked that his choices for Attorney General of Eric Holder and Loretta Lynch focused on civil rights and were not regarded as champions of the law enforcement community?  Obamacare passed without a single Republican vote.  His Supreme Court choices of Elena Kagan and Sonia Sotomayor were not quite the judicial soul mates of the late Antonin Scalia.   Just today I read that the Obama administration will block new drilling in the Arctic Ocean, an example of several of the president’s actions that have tilted toward environmentalists’ concerns.  Liberal presidents tend to govern liberally.

Trump was criticized, properly in my view, for stating that he would only nominate pro-life individuals to the Supreme Court.  (I’m against judicial litmus tests for specific actions or policies.)  Before you criticize him over this litmus test, remember, that Hillary Clinton commited the same offense when she declared she wanted her nominees to overturn the Supreme Court’s Citizen United decision?  Were you critical of her also?  Trust me, when President Trump offers his nominations for the high court, and he may have more than one opening to fill, we should not be shocked that they will view the judicial world through a conservative lens. 

Instead of carping about a new president’s personnel choices just to offer balm to your political base, why not contemplate the hard lessons that caused your party to be thoroughly trounced and repudiated?  Then, bring your own ideas and vision into the marketplace of ideas and compete for votes.  Then, if your side prevails, you can choose your own team to carry out your mission. 

Sunday, November 13, 2016


Many folks talked about the possibility of an October surprise prior to our recent presidential election.  Rumors swirled of an FBI bombshell, more WikiLeaks or a Russian hack attack.  The predictors were off by a month.  We received instead a November surprise that many view as apocalyptic.  The nation was shocked, as were the candidates, despite Trump’s minions’ confident public exhortations of victory.  How did the press and the punditocracy get it all wrong?   Even days prior to the election, many pollsters were placing Clinton’s chances of victory in the 75-90% range. 

An Unexpected Guest

We are beginning to understand how a man who has never held elective office, who by all accounts is a boorish and vulgar narcissist, could vanquish 17 Republican adversaries to gain the nomination and then handily trounce the Clinton political machine on November 8th.   The brash outsider prevailed over the consummate insider.  We are beginning to understand why his unending stream of deeply offensive rhetoric and behavior, which would have doomed an ordinary candidate, seemed only to burnish his street cred and approval ratings.  
The answer is not pretty.

Both parties have been arrogant, hypocritical and corrupt as they ignored or chose not to be attentive to so many of their constituents.  Look at politicians' approval ratings in either party.  I think the electorate reached a tipping point.  Can you believe that Bernie Sanders, a cranky 74-yr-old annoying socialist nearly beat the Clinton machine?  (And he might have prevailed if the Democratic National Committee wasn't conspiring against him and he wasn't the victim of an unfair superdelegate system.)  Weren't you as amazed as I was that young people in their 20's favored crazy Uncle Bernie over Hillary?  What was she missing?  

Same issue with Trump who performed the political equivalent of scaling Mount Everest barefoot.  There was a level of disgust and a hunger for change that both parties missed or didn't care about.   Trump voters despised and distrusted the political establishment so much, that his horrendous personal behavior was irrelevant.  He was change, and that's all that mattered.  This is why, I think, that all of those comments that would have sunk any ordinary candidate didn't adversely affect him.

I hope and pray that good will emerge from this.  Both political parties - and perhaps some new ones - will realign and recalibrate and hopefully reach out to the tens of millions of people who deserve to be represented and valued. 

Yes, I know that many feel that they are in mourning now.  Let's hope that he surprises everyone and surrounds himself with wisdom and that he will govern differently than he campaigned. 

For those who suspect that I am a Trump apologist, try again.  I didn’t vote for him.  But, he is my president now, and he’s yours also.

The Republic will survive.   Yes, he will have to be held to his campaign promises, understanding that in every case, it's a lot easier to campaign than it is to govern.  Remember President Obama’s promise to close GITMO in a year?

Finally, let’s celebrate that we can witness a peaceful transfer of power every four years.  We take this for granted, but we shoudn't.  Wanna trade our system for the Philippines, Saudi Arabia, China or Russia?

Sunday, November 6, 2016

Clinton and Trump Give the Nation Chest Pains

Oftentimes, physicians and patients face bad options.  I wish that the choices that patients faced were all good ones, or at least had one option that was likely to yield a favorable result.   This scenario is further complicated as medicine is an uncertain discipline with moving goal posts and changing facts.  We make decisions and recommendations based on the current state of facts and our medical knowledge and experience.  We may counsel a patient against surgery, only to discover days later in retrospect that an operation would have been the right choice.  An adverse outcome may result from an excellent decision. 

There are many medical circumstances when the options are equally foreboding.   A man may be suffering frequent episodes of angina, chest pain caused by hardening of the coronary arteries.  He is on maximal medical treatment, but the symptom persists.  This is not only limiting his life activities and pleasure, but also significantly increases his risk of a heart attack.  His cardiologist has concluded that only a coronary artery bypass operation can help him.  However, the heart surgeon is greatly concerned that because of other illnesses and conditions that the patient is suffering from, that his surgical risks are substantially increased.  In other words, his condition after surgery might be worse than he is now. 

Surgery or Status Quo?

It may be that my hypothetical cardiac patient is suffering from chest pains as a result of the current state of our electoral politics.  Perhaps, his heart has been stressed from failure to accept that the two presidential candidates of our major political parties are the best that this nation produced.   In a country teaming with talent, we are left with two highly flawed candidates who most of us can’t stand.  I surmise that many Americans have developed chest pains and other ailments as a result of demoralizing and dirty politics that each week sink deeper into a slimy abyss.

I cannot count how many of my octagenarian patients - who have never missed a presidential election - are sitting this one out with disgust. 

With regard to this election, I also feel that I face two unpalatable options. How to choose between strychnine or cyanide.  Which option is better, quicksand or a cliff?    

Remember, when we read The Odyssey years ago and read of Odysseus’s ship navigating between Scylla the 6-headed monster and the deadly whirlpool Charybdis?  Two terrible options.  Many Americans today, in an electoral sense, are on a similar journey.

Sunday, October 30, 2016

Clinton vs Trump Agonizes Millions

Physicians and patients often face tough and agonizing choices.  Sometimes, there are no good options available.  On other occasions, there are two seemingly reasonable choices in front of you, but there may be a very different outcome from each pathway.  For example, a patient may be advised by a surgeon to submit to the scalpel while the gastroenterologist counsels to opt for another 48 hours hoping that the medical situation will improve.  Which physician is correct?  They both may be right.  If the patient were to deteriorate 24 hours later, then the operation that had been favored by the surgeon would have been the better choice.  If, however, the patient were to improve spontaneously a day or two later, then avoiding high risk surgery would be clearly favored.

Physicians make decisions based on knowledge and experience.  Often, there is a conflict between knowledge and experience that physicians struggle to resolve.  For example, a doctor may have read in a medical study that a medicine is not effective for a particular condition, and yet his personal experience supports the drug’s efficacy.   Does he deny his own experience and deny his patient the treatment?  And, medical judgement, as I have posted previously, is paramount. 

My points above apply to many professions and, indeed, to the life decisions that confront all of us.  We draw upon our prior experiences, consult others, engage in due diligence, weigh the options and make the best decisions we can based on what is known or knowable at that moment.  A bad outcome may be the result of an excellent decision. 

Clinton vs Trump
Choose Your Poison!

The presidential election that is upon us has posed a conundrum for millions of us.   Who to choose? I have spoken with several octogenarian patients who have told me that this is the first presidential election that they will not cast a vote for either candidate of the two major political parties.  These are not rabblerousing partisans, disgruntled NAFTA haters, culture war mercenaries, anti-immigrants or elderly alt right aficionados.  They are among our ‘greatest generation’ who express disgust and disgrace with the electoral choice that has been forced upon them.  Imagine how they must feel to have never missed a presidential vote in 60 years, until now. 

In my view, no reasonable person can argue that either candidate meets our nation’s highest ideals and values.  Making the case that one’s vote is the lesser of two evils is not exactly a rave endorsement of a candidate.   And, as is always the case, voters and supporters diminish the flaws of the candidate whose politics they approve of, while magnifying flaws of the same magnitude in the political adversary. 

Is not voting for either candidate a defensible and honorable option?

Sunday, October 23, 2016

Sign up for a No Frills Colonoscopy

Cleveland took a major economic hit a few years back when United Airlines cut most of its flights from our city.  An airport is the heart of a metropolis.  Lack of their direct flights means that business meetings, leisure travel, conventions and trade shows will likely opt for more convenient locales. This was a business decision for United which I am sure was rational.  Nevertheless, their gain was our loss.

As a result, we have had several low cost carriers who have swooped in to gain market share.  We have Frontier, Spirit, JetBlue and now Allegiant.  Not a day goes by that I don’t receive an e-mail blast from one of them announcing fares so low that it seems simply not possible.  Many of the flights’ stated fares are less than it would cost me to drive to the destinations.  How do they do it?

Of course, the fare price that is stated is not what you will pay.  The total cost of your flight has been fractionated resulting in an a la carte payment system where every additional service adds to the cost. The airlines justify this with idiotic PR pronouncements that state that this payment system serves the customer who can only purchase the services he actually needs. The fallacy here is that most travelers will need to purchase several airline services, so that the falsely low bait price is deceptive as nearly no traveler will pay it.  I suppose that if you were traveling without luggage, were departing at convenient times such as 2 a.m., eased yourself into the commodious middle seat and brought a carry on piece about the same size of the pencil cases we used in elementary school, then you could actually pay the base price.  If however, you have any checked luggage or carry on items, want to choose your own seat, want enough legroom to allow some circulation to reach your toes, want a beverage, want an oxygen mask that works, want a flotation device that floats, then you will pay for every one of these luxurious upgrades.

Wanna Newer Model?  It's Gonna Cost You!

Even with all of their pick-pocketing, the costs are still generally less than conventional airlines.  But the gap between them is less than you might think.

Perhaps, this is how we should market colonoscopy.


Once we’ve signed up the customers, we would review some of the optional services that they may wish to purchase to enhance their colonoscopy experience.  Just like with the airlines, they are free to bypass these extras and can then pay our low base price.  Here are some of the high end upgrades available to those who want a Cadillac colonoscopy.
  • Greeting from the receptionist.
  • A properly disinfected instrument.
  • Supplemental oxygen
  • Sterile needles
  • Economy class anesthesia
  • Business class anesthesia
  • Treatment for side effects of anesthesia
  • Monitoring vital signs beyond initial free blood pressure check
  • Sober nurses
  • Charge for withdrawing the colonoscope.  The base charge only includes insertion of the instrument.
  • Use of the restroom before or after the procedure.
  • Forward report to the referring physician.
  • Explain results to your family members, Base charge includes ‘thumbs up’ or ‘thumbs down’ gestures only.
There’s no reason that this pricing approach couldn’t apply to your business.  Soon, we’ll be reading ads for new cars for $2,500, vacations to exotic beaches for $149, Five Star restaurant meals for $7 and a remodeled kitchen for just $99!

Why not just tell us the truth.  How much extra would that cost?

Sunday, October 16, 2016

The Importance of Medical Judgement - Part II

Last week, I offered up an argument on why medical judgement means more than medical knowledge.  In other words, being a really, really smart doctor is not the essential qualification for practicing excellent medicine.  I ended last week’s post with some examples of medical ads that are familiar to all of us. 

Here are some ads and slogans that you won’t see on highway billboards or in press advertisements.

·       Bring your back pain to our orthopedists.  They probably won’t operate on you since most back pain is not effectively treated surgically.  You don’t want unnecessary surgery, do you?

·       Wanna lose weight?  Consult with our bariatric surgeons who will refer you to one of our certified dieticians so you can endure yet another diet.  Who wants a trigger happy surgeon anyway?

·       Come to our oncology center for a second opinion.  Don’t expect any new treatments, since ‘promising’ experimental treatments are exactly that – experiments.  We’re not rolling the dice with your life. 

The public equates technology and active medical intervention with excellent medical quality.  That’s why ad copy from doctors and hospitals often uses phrases such as, cutting edge, robotic, laser, state-of-the-art, etc.  Most patients would not react as positively to an ad championing conservative doctors who don’t order too many tests or write many prescriptions, even if these practitioners are better physicians.

Why Medical Judgement is Like Steak.  Read on.

We tend to respect medical professional who do stuff more than we do those who don’t do stuff or just slug it out preventing disease.   Which doctor will command more respect in the community, a cardiac surgeon who is renowned for his expert craftsmanship on performing bypass surgeries, or a family physician who succeeds in getting patients to quit cigarettes so they never need bypass operations?

Sure, I know how to do a colonoscopy, after having done 30,000 of them.  Any technician can be taught how to do this procedure skillfully.  But is this enough? Patients deserve sound medical judgment, not just technical prowess.  When you see your gastroenterologist in the office, and colonoscopy enters the conversation, judgement needs to be in the room also.

·       Is colonoscopy truly necessary?
·       Is there a better or safer test that should be done instead?
·       Are the risks of colonoscopy too high considering my personal medical circumstances?
·       Has my doctor explained how the colonoscopy results will affect my care? 

This last item is absolutely critical.  If your doctor orders a test, make sure that you are persuaded that the test result will shape or change your medical advice.  For example, if your doctor is going to recommend exercise and medications for your new onset of back pain as initial treatment, then an MRI of the back doesn’t make sense.

I hope that I have given you enough knowledge to make good judgments.

Medical knowledge has the sizzle.  But, medical judgement is the steak.

Sunday, October 9, 2016

The Importance of Medical Judgement - Part I

Would you rather that your doctor have excellent medical knowledge or medical judgment?  Answer this question before reading on.

Patients are drawn to doctors and medical facilities who boast ‘cutting edge’ medical knowledge and techniques.  Medical judgement, which is much more important in my view, is barely mentioned. 

Good doctors have great knowledge, but great doctors have superb judgment.  Consider the following vignette that I hope illustrates why judgement means more than knowledge.

A patient is comes to the emergency room with abdominal pain.  The physician refers him to two different physicians, Dr. Knowledge and Dr. Judgment.  Which of these physicians would you rather see?

Is the gallbladder the culprit here?

Dr. Knowledge:  I recommend that your gallbladder be removed.  I have trained in advanced robotic surgery which leaves only one very small scar.  My complication rate is extremely low.  Our operating room team is excellent.  I am the only surgeon in the hospital who is credentialed in robotic surgery.

If you visited only Dr. Knowledge, then you would likely be very impressed with his credentials and would schedule the surgery with great confidence that you would receive excellent care.  If you had family members with you, your conversation afterwards would mention how lucky you were to fall into the hands of such a talented surgeon.  Before you belly up to the scalpel, let’s hear from Dr. Judgement.

Dr. Judgment:  After listening to your medical history and examining you, I don’t think that your gallbladder is responsible.  While I’m not certain what caused your pain, I do not think that you should have surgery and remove an organ that is an innocent bystander.  Since you’re feeling better now, let’s just keep an eye on you for now.   I’ll see you in a month.  If the pain returns, then call me right away.

I know which of these doctors I would want as my doctor.  Medical knowledge, however, has a lot more sizzle than medical judgment.  Look and listen to the advertisements from our area health care institutions.  Knowledge sells.  Do any of these sound familiar?

·       Our orthopedists can make your back pain go away with a painless treatment that takes only 1 hour.
·       Make obesity history.  Make our bariatric surgery team, your team.
·       Our state-of-the-art oncologists specialize in giving second opinions.  You deserve state-of-the-art care.  Call us.

Check in next week for Part II on why I think a physician with good judgement is a better doctor than Dr. Mensa.

Sunday, October 2, 2016

Is Your Doctor Out of Date?

Years ago, I was having dinner with 2 members of The Cleveland Orchestra, one of the finest orchestras in the world.  I asked them, with my kids present, how much time they devoted to their craft.  As many parents know, getting kids to commit to practicing a musical instrument is about as easy as splitting the atom in your garage.  The musicians told us how much time they practiced, which was mind boggling, as one would expect.  Any artist, athlete, Green Beret or similar professional, has to demonstrate extraordinary commitment to maintain a superlative level of excellence and preparedness.

I asked one of the musicians, the violinist, how long he could refrain from playing his instrument before he noted some professional slippage.  Guess your answer.   At the end of this post, I will relate his reply.

How many hours are enough?

How long can you be away from your job before your performance ebbs?For most of us, we can take weeks or longer on holiday and return back to our positions seamlessly. 

A few examples.
  • Politicians return to Congress after long breaks and lose not a whit of their capacity for obfuscation and duplicity.
  • New York City cab drivers return from vacation and can still take you on a ride of terror to any destination.
  • An airline customer service representative a few continents away maintains state-of-the-art client service even after a month away from her cubicle.
What about doctors?  What about gastroenterologists?

 Yes, I do take vacations, but most of them are long weekends.  It’s rare that I take even a week off. Perhaps, the reason why I maintain such a keen colonoscopic edge is because my absences are brief.  If I took a sabbatical for 6 months, would I be rusty when I approached my first rectum on my return? 

Now, manipulating a colonoscopy when I bringing light into a dark world is not exactly the same as playing violin in the Cleveland orchestra.  I’ll leave it to the reader to contemplate which of these activities demands more skill. 

Seriously, do physicians lose their cognitive and procedural skills after an absence?  I’m not sure this has been tested, but I believe the question is a reasonable one for patients to consider.  Hospitals will track volume of surgeries from specific surgeons, but a busy surgeon could meet the yearly threshold, and still take several months off.  Should a patient who is to undergo a cardiac bypass or a colonoscopy after the physician has been away for a few months be concerned? 

Is medicine like riding a bicycle that one can do well after a hiatus of years or more?  Or should doctors who have been off the bike for a while put some training wheels back on. 

Consider this the next time you are hearing music from a master musician in a concert hall.  One thing is for certain.  He hasn’t been loafing on the beach.  My musician friend told me that if he is separated from his instrument for 3 days, he can hear the difference even if we couldn't.  

Sunday, September 25, 2016

Nursing Staffing Levels Threaten Patient Care

On the day that I penned this post, I rounded at our community hospital.   My first patient was in the step-down unit, which houses patients who are too ill for the regular hospital floor.   I spoke to the nurse in order to be briefed on my patient’s status.  I learned that this nurse was assigned 6 patients to care for – an absurd patient volume for a step-down unit.  “Why so many patients?” I asked.  She explained that some nurses called off work and the patients had to be spread around among the existing nurses.

This occurs every day in every hospital in the country.  Nurses are routinely required to care for more patients than they should because there is a nursing shortage on a particular day.  Why do hospital administrators allow this to happen?  If any are reading this post, I invite your response.  Enlighten us.  When a nurse is overburdened, how do you think this affects quality of care and nursing morale?

I suppose it saves a few bucks on payroll, but this strikes me as very short term gain that risks medical and financial consequences.   Providing high quality medical care can’t be a rushed effort.  If a nurse’s job description increases by 30%, do you think the quality of care and patient/family satisfaction won’t decline?   Don’t administrators fear the risk of medical errors from overworked nurses?  Would any of them like to be patients under these circumstances?

Nurses Need Help

Nurses have confided to me for years how demoralized they are that no one speaks for them.  Instead of watching their backs, they often feel that they are stabbed in the back.

I do not have warm feelings for labor unions and I support right to work initiatives.  But, when I see what nurses endure and the lack of support that they receive, I would support them if they moved to organize.

If a 3rd grade teacher is ill, we expect a substitute teacher to be called in.  The third graders are not simply herded into another classroom expecting one teacher to handle a double load. 
Many of us today are asked to do more with less.  Teachers, law enforcement, businessmen and government program administrators know this well.  At some point, you aren’t cutting fat anymore, but are slicing into bone. We are not taking proper care of those who have dedicated their lives to care for us.  Who will heal the healers?

Sunday, September 18, 2016

Why I'm Against Medical Marijuana

I have already opined on my disapproval of a medical marijuana law recently passed in Ohio.  Once of my points in that piece is that I did not want legislators making medical decisions for us.  They can’t even do their own jobs.

I am not against medical marijuana; I am for science.  The currency of determining the safety and efficacy of a medicine should be medical evidence, not faith, hope or belief.

Marijuana is a Drug Enforcement Agency (DEA) Schedule 1 drug, alongside heroin, LSD and Ecstasy.  I realize this seems odd since most of us do not believe that marijuana has the health or addictive risks of the other agents on the list.  It doesn’t.  But, danger is not the only criteria used in determining which category a drug belongs in, a point often misunderstood or ignored by medical marijuana enthusiasts.  An important criterion of Schedule 1 drugs is that they are deemed to have no proven medical use.

The federal government recently affirmed marijuana’s Schedule 1 status, which disappointed those who argue that this agent is the panacea, or at least an effective treatment, for dozens of ailments.  The government disagreed.  It reviewed several hundred medical studies and only identified 11 of them that were of sufficient scientific quality worthy of consideration.  None of them demonstrated a salutary effect of marijuana.

DEA Holds Firm 

An advocate of medical marijuana use was railing against this decision and stated that 80% of Americans believed marijuana had medical value.  His point demonstrates the vacuousness of his argument.  He might support letting polling determine if a drug is safe and effective; but I trust the FDA and hard science to make these determinations.

I am sure that if we polled the public on the medical benefits of probiotics, gluten restriction, GMO foods,  organic foods, radiated foods, colonic detoxification, yoga, veganism and meditation that we might find that the public’s belief in these practices doesn’t have firm scientific support.   I do not argue that these dietary and lifestyle practices do not have health benefits or enhance life in other ways, only that they are either unproven or disproven.  There are still folks out there who believe that the measles vaccine causes autism, even though this theory has been thoroughly debunked. In my view, releasing a medicine to market requires firm scientific support.  Anecdotes and low quality ‘studies’ should be afforded the weight they deserve.

Should we open up the gates to all kinds of potions and elixirs that are unproven for the public?  We do!  They are called dietary supplements.  These agents are considered safe until they are proven to be dangerous.  Is this the standard we want for prescription drugs?

Sunday, September 11, 2016

Nursing Documentation vs Patient Care - Who's Leading?

I work with nurses every day.  Anyone who doesn’t realize how hard these professionals work, has never been in a hospital.  Their job descriptions have expanded along with their work load.  This is not your father’s hospital ward.  Hospitalized patients today are older and sicker than ever before.  It takes a seasoned nursing professional to manage the care of these complex patients.   Their work days are full simply managing the expected tasks of dispensing medications, coordinating diagnostic tests and assessing their patients.  There is no time scheduled for unexpected events, which are expected as sick people’s conditions may change at any moment.  In other words, if a nurse must attend immediately to a patient with chest pain, then his or her other more mundane tasks are delayed or shifted over to another busy nurse.

I believe that the most potent barrier that is separating nurses from their patients today is the ferocious documentation mandates that nurses are required to perform.  The hospital corridors are clogged with nurses hovering over computers entering all kinds of data, most of which will never be viewed by physicians.   These nurses are not techies who want to be palpating a keyboard.  They are compassionate caregivers who want to be in their patients’ rooms caring for them.

Tomorrow's Nurse?

If you suspect that I am exaggerating here, then go ask a nurse.

Moreover, the hospital’s electronic medical record system has become deeply layered and complex. Often I can’t find the specific data I need.  Just last week, a couple of senior nurses and I were scouring through the computer to find a patient’s result of stool testing for blood.  We simply couldn’t find it, and these nurses are pros.  At that point we were left with the following options:
  • Reorder the test
  • Make up the result
  • Quit the profession and become an Uber driver
  • Ask the patient what the result was
  • Hire a 12-year-old who could find the results in a few seconds.
While the computer record is packed with data concerning every aspect of the patient's medical experience, I have my own approach to find out what’s going on.  Pay close attention here.  Read the next sentence very slowly as I want readers to grasp the complex process I use each day as I approach the nurse.

“Hi.  What’s going on with my patient?”

Sunday, September 4, 2016

Sunday, August 28, 2016

Mylan Defends EpiPen Price Hike

Why do smart people often do dumb things?  Would you plagiarize a speech that you know is going to be carefully scrutinized?   Would you respond to a robocall that congratulates you on winning a free cruise?  Would you keep eating sushi that didn’t smell right? 

I’m certainly not judging anyone here.  I’ve had plenty of my own misadventures and I periodically add to the list. 

Our presidential candidates fall prey to human error and misjudgments surprisingly often.  Aren’t these folks supposed to be pros or at least managed by honed handlers?  Why would Donald Trump have insulted nearly every constituency and rival during the primary election process knowing that this might render him unelectable in the general election?  Why would Hillary Clinton demand unconscionable speaking fees from special interest groups when she knew that she would pursue the presidency and her payoffs would be publicized?

I’ll leave it to readers to ponder their own responses to the above inquiries.

If the sushi doesn't pass the sniff test, head to Burger King.

Last year, I posted on a drug company that raised the price of a pill from $13.50 to $750.00.  Even if such a practice is legal, or is justified by market forces, it is very, very dumb.  It is guaranteed to provoke outrage and will surely result in scrutiny that will go much wider and deeper than the initial offense.  It did.  For more details, just click here.

One would think that rival pharmaceutical companies would be more cautious before enacting similar price gouging.   Guess again.  Mylan, who makes EpiPen, raised the price of this product about 500% over the past years, bringing the price to $608 for a two pack.   The company stands by the new pricing.  Sure, they have offered a few discount coupons, but they are leading from way behind. They are not likely to prevail, even if they have a potent economic argument.  

This stuff is ripe grist for politicians, who can rail against the pharmaceutical barons, in order to distract the public from their own abysmal performance.  And, angry parents will use social media and other methods to publicize their outrage.  The fact that many patients who rely upon EpiPens are young children doesn’t make the company’s case any easier.  

If Mylan’s CEO Heather Bresch is called to testify, how will the optics be when she states that her compensation last year was about $19 million?

Why are so many pharmaceutical folks so allergic to good judgment?  Perhaps, they should carry around an EpiPen, if they can afford it.

Sunday, August 21, 2016

Who is Responsible for Prescription Drug Abuse?

I have written about pain medicine previously on this blog, and it generated some spirited responses.  Let me be clear that I am completely against all forms of pain, whether foreign or domestic, physical, spiritual, psychic or even phantom.  The medical profession has superb tools to combat and relieve pain, and physicians should utilize them, within the boundaries of appropriate use.  We now have an actual specialty – pain management – who are physicians with special training on the science and treatment of all varieties of pain.  I utilize these specialists when necessary and I am grateful for the help they provide to my patients. 

There are two forms of drug abuse in our society – legal and illegal.  The latter has become a health scourge that is shattering families across the country.  A few days before I wrote this, I read the stats of overdose deaths in my state of Ohio.  I was shocked to learn that in our state alone, we lose thousands of individuals every year to drug overdoses, most of which are not intentional.  The street drugs are often impure, or laced with potent additives or substitutes that become a fatal concoction.   Extrapolating Ohio’s stats across the country would create a stunning number of drug deaths.  The causes and the potential solutions to this plague are vexing, but must be pursued.

An Opium Poppy - Cure or Disease?

There is also a legal avenue for drug abuse, medicines prescribed by doctors.  This sphere of abuse will be easier to control than the illegal counterpart, as the process is initiated by a doctor’s prescription and subsequently involves a pharmacist.  No doctor or pharmacist wants to be a pawn in this game.  I believe that these professionals have adapted to a looser culture of prescribing pain medicines and changing expectations on pain relief of the public.

Consider this staggering statistic:  According to the National Institute on Drug Abuse, Americans consume more than 80% of the planet’s opioid medicines, yet are less than 5% of the world’s population.  Does this make any sense?   Would advocates of the status quo argue that America has nearly 20 times more pain than other nations have?

I can state plainly that I have never seen so many patients in the hospital who are on intravenous and powerful narcotics for stomach pain.  These same patients a few decades ago were treated differently, and I recall that we kept most of them reasonably comfortable.  The risks of narcoticomania are self-evident.   Many patients and their families are suffering heartache and misery whose origin can be traced back to a narcotic prescription.  This is a great tragedy.

Narcotics have an important role in our patients’ care, and I support their appropriate use.  There are patients who need opiod use to manage chronic conditions.  But, opiods and narcotics are overused and we need to admit this so we can begin to remedy this reality.  Physicians and the public need to reach an understanding on what each expects from the other.  Both doctors and our patients need more training on this issue.  Doctors should do all we can to make our patients comfortable.  Indeed, relieving pain and suffering is fundamental to the healing mission.  Patients should recognize that physicians may not be able to guarantee 100% pain relief for every situation that you may face.   We have an obligation to minimize your pain and discomfort, but also a responsibility to protect you from wandering down a dark and destructive path that may lead you ensnared in a den of demons.

Sunday, August 14, 2016

Are Doctors Paid Too Much?

Years ago on Cape Cod, my kids and I stumbled across a man who had spent the day creating a sand sculpture of a mermaid.  It was an impressive piece of art.  “How long did it take you to make it? ” we asked.   While I can’t recall his precise words, the response was something like “25 years and 7 hours”.  I’m sure my astute readers will get his point.

We are transfixed now watching Olympic athletes performing in Rio.  So much depends upon their brief routines which can last seconds to a few minutes.  While a diver’s acrobatic plunge may take 2 seconds, it would not be fair to leave aside the years of work and training that prepared the athlete for this moment.

The same point can be made for anyone who has worked and trained hard to reach a point where the action performed seems easy to a spectator or a customer.   If an attorney prepares estate documents, we can assume that the fee for this reflects the prior training and research that the lawyer has done on this issue, as it should.  If an appliance repairman, by virtue of his expertise, fixed our ailing washing machine in 5 minutes and charged us $100, should we balk at this price gouging?  If a less skilled competitor spent 2 hours before finding and correcting the glitch, would we feel better about handing over $100?  Is this fair?  A musician doesn’t just wake up one morning and hop onto a stage to give a concert.  When we pay to listen to an artist perform for 2 hours, we are likely listening to the product of years of grinding work, disappointment, innovation and discovery.

What's a fair price for an hour of Aretha?

I believe that this same principle applies to my own profession.  Over the years I have heard patients complain about various medical charges and fees. While we all know that there have been excesses, many of their gripes are misplaced, in my view.   It’s not fair to equate the medical fee with the time that the physician expended on providing your care.  A cardiac bypass operation takes just a few hours.  A colonoscopy takes 10 minutes.   Treating a patient in an emergency room with a drug overdose may take just a few hours.  A psychiatrist might guide a suicidal patient to choose another path in half an hour.  A spine injection to relieve chronic pain takes only a few minutes.  A dermatologist recognizes a suspicious lesion in a few seconds.  A seasoned surgeon tells an anxious patient after a 20 minute consultation that surgery is not necessary.

Often, folks who make is all look easy are fooling us.  If we think it’s as easy as it looks, then we’re the fools. 

Sunday, August 7, 2016

Overtreatment and Unnecessary Medical Testing? You Make the Call!

Ok, readers.  I know how many of you fantasize about being part of the high drama and glamor of the medical profession.  Believe me, it’s even more exciting than the medical TV shows that have been part of pop culture for generations.  Remember Ben Casey?  Marcus Welby?  Dr. Kildare?  Dr. Seuss?   Rescuing folks hovering over the Grim Reaper was just another day at work for these guys.

The Grim Reaper

Here’s your chance to play doctor for the duration of this post.

A patient wants a colonoscopy, but it is not medically necessary.  Assuming he cannot be convinced to withdraw the request, should you perform it?

A physician wants you to perform colonoscopy on his patient, but it is not medically necessary.  Assuming the physician cannot be convinced to withdraw the request, should you perform it?

An elderly patient’s son wants a colonoscopy performed on his father, but it is not medically necessary.  The patient is ambivalent and delegates the decision to his son. Assuming the son cannot be convinced to withdraw the request, should you perform it?

A nursing home requests that a feeding tube be placed on an elderly resident.  While the tube would be much more convenient for the staff with regard to administering food and medication, the tube could be avoided if a staff member had sufficient time to assist the patient with meals and medicines.   Should you place the feeding tube? 

An anxious mom (please forgive the sexism here) demands an antibiotic for her child’s sore throat, which is not medically necessary.  Assuming she cannot be dissuaded from her request, reinforced by prior physicians who prescribed antibiotics under similar circumstances, should you acquiesce?

A man is critically ill in the intensive care unit and is nearing the afterlife.  The consensus among the treating physicians is that additional care would be medically futile.  There is no advanced directive or medical power of attorney.  The next of kin insists that the patient be placed on life support.  He is not persuaded to withdraw his demand and suggests that there would be consequences if his relative is simply allowed to die.   What would you do here?

So, ‘doctors’, any thoughts?

Sunday, July 31, 2016

Should Doctors Lie for Patients

Even the most honest among us do not tell the truth all of the time.  We are flawed human beings.  We covet, we gossip, we steal, we lie and we stand idly by. You don’t think you steal?   Have you ever ‘borrowed’ someone else’s idea and represented it as your own?

A few weeks before I penned this, I was presented with 2 opportunities to lie in order to save a patients a few bucks. The first patient wanted a refill for her heartburn medicine, which she takes once daily.  She asked if I would refill the medicine to take twice daily, so she could get double the supply for the same price.  The second patient asked me to write a note that he was at risk for Hepatitis B so that he could get the vaccine for free.   Writing the note would be easy, but claiming that he faced risk of Hepatitis B infection would require some prevarication. 

I’ll assume that Whistleblower readers know how I responded to the above two issues.   However, many patients, and perhaps some physicians, who are so harassed by insurance companies and an uncaring medical bureaucracy are looking for any measure of relief when they can grab it.  Many of them have risked rising blood pressures and panic attacks trying to talk common sense with insurance company ‘customer service’ representative,s who have less medical training than hospital housekeepers, about getting their medications approved.   I’ve been down that tortured road more times than I can count, and I feel their pain. 

I routinely receive disability forms for patients who are seeking this benefit.  I advocate zealously for every patient who has a legitimate claim for any benefit they are entitled to, often making the phone calls with the patient seated beside me.   There are occasions; however, where no matter how hard I squint at the patient’s chart, I just can’t discern any medical evidence of a disability.  Sometimes, I haven’t seen the patient for years.  (Often, disability forms are sent to every physician the patient has seen, so some of these physicians are not appropriate targets.)  

George Washington, not a doctor, didn't lie.

Ethical quandaries can be tormenting.   Let’s say a patient is sent to me to evaluate constipation.   A colonoscopy is scheduled.  Since the procedure is diagnostic to evaluate his symptom, he will have to pay much more out of pocket than if the procedure is coded as a routine screening colonoscopy.    Should I slightly adjust my coding to help the guy out?  

It doesn’t take much effort to rationalize siphoning a few bucks from insurance companies that many of us think deserve it.  Somehow, we don't regard this theft as we would shoplifting or stealing a neighbor's TV.

I could state here that I respect medical insurance companies because of their unwavering devotion to protecting our health and serving the greater good.  But, I’d be lying.  

Sunday, July 24, 2016

Is Medical Marijuana Safe and Effective? Who Decides?

Medical marijuana is a smokin’ hot issue in Ohio.  Marijuana enthusiasts targeted our state constitution again this year with another amendment attempt, which failed.  Instead, our legislature passed House Bill 523, which will legalize medical marijuana use. 

As a physician, with some training and experience in prescribing medicines to patients, these marijuana machinations are medical madness.  Is this how we want to bring new medicines to market?

I think it is absurd that a specific medical treatment – or any medical treatment - should become a constitutional issue.  Do we want to establish a constitutional right to a specific medicine?
Why stop at marijuana?  Why not start circulating petitions for constitutional amendments for screening colonoscopies, mammographies and MRI’s for back pain?  Patients with chronic lumbar disk issues have rights too! 

The Ohio bill specifies an array of medical conditions that could be treated with marijuana, including AIDS, hepatitis C, inflammatory bowel disease, Parkinson’s disease, PTSD and many other illnesses. Is it the legislature’s responsibility to decide that a medicine should be approved for a medical illness?  Do legislators have medical expertise?  Do we want the Senate or House weighing in on approving a new chemotherapy agent or artificial hip?

Will Cure Whatever Ails You?

Might I suggest with just a tincture of cynicism that medical marijuana mania has become a mite politicized? Do we want folks who stand to make money or enhance their political power from a new medicine – who have no medical expertise - to be the ones with a major role in approving its use? Are cannabis con artists using a political pathway because they fear that the medical avenue will less hospitable to their objective?

Once marijuana becomes a legal product, an inevitable outcome, will enthusiasts for its medical use support vigorous testing of its therapeutic value? 

I am deeply skeptical that the medical claims of medical marijuana adherents are supported by persuasive medical evidence. I remain open, however, to submitting marijuana to the same Food and Drug Administration (FDA) testing that all new medicines are subjected to. Let the scientific method with appropriate clinical studies and peer review judge the product for safety and efficacy. If approved, then the public and the medical profession can be confident that the approval was on the basis of science and not smoke.  Shouldn’t those who champion medical marijuana use demand this level of independent scrutiny?  If not, then why not?

Yes, I have heard powerful individual vignettes describing great benefits of medical marijuana. Every physician has similar anecdotes of patients who have achieved significant benefits from unconventional and unapproved medical treatments. But, anecdotes are not science. If medical marijuana is the healing elixir its proponents promise, then prove it. 

Let our politicians do what they do well, whatever that is, and leave medicine to the professionals.