Sunday, May 29, 2016

Memorial Day 2016 - We Remember

I am in coffee shops several times per week.  I prefer independent establishments with atmosphere and authenticity.  For that reason, it is rare to spot me in a retail coffee outlet whose HQ is in Seattle, Washington.  This past week, as I was carrying my cafĂ© mocha to my table, I spied some board games stacked up on a table.  On top was the game pictured below.

This brought back warm memories of playing this game as a young kid.  It recalled the wholesome and beautiful childhood that my parents gave me.  Millennials might not appreciate the raw and fierce competition of games such as Candyland, Chinese checkers or Trouble, which has caused a huge void in their lives. 

Looking back and remembering gives meaning to our lives.  We remember a song, a joke, a celebration, a concert, a speech and relationships.  Isn’t it amazing how hearing a song from years ago captures a mood?

This weekend, we remember and ponder something of infinite meaning and importance.  We remember what so many Americans have done and still do so that folks like me can blog without fear, read a newspaper that criticizes our government or protest lawfully in the public square.

I have never served so I cannot begin to grasp what you have done.  But, I have met many of you, and I am inspired by your heroism and your modesty.

Sunday, May 22, 2016

Measuring Physician Quality - Bully or Just Plain Bull

Patients are amazing creatures.   The current breed is hyperinformed on medical information and has an ever expanding reservoir of physician data to trove through.  I’m not just referring to physician reviews on Angie’s list.  Soon, the public will be encouraged to review our success and failure rates with respect to medical treatments, how much cash the drug companies grease us with, all disciplinary actions, comparison with peers, complication rates, medical malpractice entanglements and how much Medicare reimbursement we have received.

There will be published quality benchmarks on physicians so that the public can see how their physicians scored on these various quality measurements.  I have opined throughout this blog that I feel that these measurements are tantamount to taurine excrement.   Sadly, reimbursement will be tied to these results with physicians who don’t rate high enough having some of their income confiscated.  Physicians who don’t make the grade may game the system to achieve higher grades, which has nothing to do with true medical quality.  Is that what our patients want and deserve?

Source of Taurine Excrement

I was poised to begin a colonoscopy on an informed woman who asked me what my ADR was.  I will presume that readers are not aware of what this means.  Most physicians are likely also ignorant of what these letters stand for.  In fact, I’ll bet a decent percentage of gastroenterologists are clueless here as well.  The ADR refers to the Adenoma Detection Rate, which is one of the silly statistics that ‘experts’ feel separate skilled colonoscopists from pretenders.  Adenomas are polyps which are precursors to colon cancer and are the target lesion for screening colonoscopies.  When you consent to undergo a colonic delight at age 50, your gastroenterologist is seeking out adenomas, removing them before they can morph into a cancerous condition.

‘Experts’ advise that competent gastroenterologists should have an ADR of 25% in males and 15% in females who are undergoing screening colonoscopies.  Lower rates, they claim, suggest sloppy or rushed examinations.   Now, some colonoscopists are removing every pimple they find to make sure they will surpass these thresholds.  Does this sound like good medicine?

Remember, colon polyps are surrogate markers.   The true objective of colonoscopy is to prevent cancer, not finding small benign polyps.  A patient should be more interested to know if their gastroenterologist prevents colon cancer, which is not that easy to measure.   In contrast, measuring the ADR is simple, so it is used as a substitute for colon cancer prevention because it is so easy to do.   Similarly, the statin drug companies boast about their cholesterol lowering properties, which is easy to measure.  Cholesterol levels are also surrogate markers for what we should really care about – heart attacks and strokes – events that can’t be studied and measured as easily as simple blood test results.  A surrogate marker ‘benefit’ may not lead to the desired medical outcome, despite claims that it will.

My nurse assured the inquisitive woman on the gurney that my ADR was above threshold.   Am I a high quality gastroenterologist?   I must be.  I’ve got ADR mojo.    Let’s give a shout out to the government and the insurance companies for adopting the ADR standard.  Can we agree that it’s Another Dumb Regulation?

Sunday, May 15, 2016

Medical Insurance Companies: Heroes or Villains?

Physicians are expected to be hostile to insurance companies.  Indeed, a prior Whistleblower post directed arrows in their direction.  They are an easy target, often vilified for their greed and perceived indifference toward those they insure.  Ask most of us if we think insurance companies favor profits over patients, and most of us will respond that profits prevail.

Insurance companies are businesses, not charitable undertakings.  Sure, we all like free stuff.  Or, if it’s not free, we prefer that someone else pays for it.  We are outraged at the costs of chemotherapy, hepatitis C treatment and biologic treatments such as Humira and Remicade, leaving aside the zillions of dollars it takes to research, develop, manufacture, market and monitor innovative new drugs. 

We want to drive a Cadillac, but only pay for a Chevy.

We want to pay for this...

...and drive this.

No person, business or organization is wrong all of the time.  Consider the following practices.  Who’s side are you on here? 

A patient has chronic back pain and ran out of his pain medications on the weekend.  He calls the doctor and is connected to a weekend covering physician who declines to refill the medicine.  The patient then proceeds to an emergency room, where he is evaluated and given the desired prescription.  Who should pay for the ER care?

A patient is seen in the office and prescribed a 2 week course of antibiotics for diverticulitis.  The medicine nauseates him and he stops them in 3 days.  He does not contact his physician.  Ten days later, he develops severe abdominal pain and fever and needs to be hospitalized for severe diverticulitis.  He is in the hospital for 5 days and is seen by numerous medical specialists.  Who should pay the costs of this hospitalization?

A 55-year-old individual has never had a colonoscopy performed.  His primary care physician advises him to proceed, but the patient declines.  A decade later he is discovered to have colon cancer and needs to be hospitalized for surgery and evaluation by an oncologist.  Who should pay for the costs of his care?

If a patient with high blood pressure, skips appointments and his medications, and a complication develops…

I’m not carrying water for the insurance companies.  I am pointing out, however, that we often expect them to pay for medical care that is either inappropriate or should not have been necessary.  That’s not reasonable or fair.   Don’t we have a responsibility to be personally responsible?

Sunday, May 8, 2016

Should the FDA Approve Experimental Treatment for Severe Diseases?

I’ve never had the pain and agony of having a kid who is truly sick.  Broken bones and minor surgeries don’t count.  Even one of my kid’s bout with malaria doesn’t rate, as this illness was easily cured.

Parents of kids with chronic illnesses would sacrifice anything to help their kids get better or to suffer less.  In the news recently is a conflict between families of kids with Duchenne muscular dystrophy and the Food and Drug Administration (FDA).  A very small study of an experimental drug called eteplirsen suggested some benefit.   Understandably, the families want the FDA to grant approval so that their kids and others could have access to this drug that will fight a dreadful disease that is fatal.  Families argue that these kids have nothing to lose and can’t wait another 5 years waiting for more definite evidence of efficacy to emerge. 

The FDA is legally required to approve drugs that are safe and effective.  Obviously, the definitions of safe and effective are subjective, but the agency requires that a reasonable threshold be crossed for both of these parameters.  Gray areas create agonizing conundrums for agency officials and patient advocates. 

Should Unproven Treatements be Approved?

The FDA commissioned committee, which will advise the agency proper, did not advocate drug approval, which caused great consternation among family members and their supporters.  These wrenching decisions must be guided by science and medical evidence, not hope and emotion.  Here are some potential objections to approving the medicine.
  • The study was too small to have persuasive scientific validity.
  • The study did not have a proper control group, which further weakened the conclusions.
  • The drug may have unknown and serious side-effects.  Once the drug is approved, physicians can prescribe it lawfully for a variety of diseases and illnesses, some of which may not be life-threatening.
  • Acceding to understandable family demands for premature FDA drug approval will prevent patients from entering larger clinical trials, preferably in a randomized study with a placebo control, where safety and efficacy can be more accurately verified.
  • If the FDA weakens its standards for approval for a single drug to respond to a constituency, then be prepared for mission creep to erode standards across the board over time.  
It's the parents' job to everything they can do to protect their kid.  It's the FDA's job to protect all of us.  I wish we could protect and save everyone.

Sunday, May 1, 2016

Should Women Who Seek Illegal Abortions be Punished?

Every four years, abortion gets more press and attention as the candidates compete for electoral support.  My own position on this issue is not relevant for the points I offer here.  We all know that candidates massage their position on abortion and on other issues in an attempt to maximize their voter support.  It’s fun to watch them thread the needle as they dance and pirouette for us.  They are performers who can be as flexible as the amazing acrobats on Cirque du Soleil.  The emphasis, if not the content of their message, changes depending upon the audience.  Al Gore was ridiculed when he sported a more southern accent when he was campaigning below the Mason-Dixon line. 

Donald Trump was clearly unprepared for the abortion question when he rhetorically collapsed during a typically vigorous and frenetic interview with MSNBC’s Chris Matthews.  Of course, you don’t really have to prepare on an issue if you already have a principled position.  You can just tell the truth. 

Trump's Interview - Not Star Quality

Donald Trump initially responded that women who are seeking an illegal abortion should be legally accountable.  This was the bombshell.  While Trump walked this back in record time, I do not understand why his initial position was wrong.  And yet, even the most conservative politicians, such as Cruz and Huckabee, do not advocate targeting women in these cases.

Why not?

If abortion is against the law, then why isn’t a woman who seeks the procedure violating the law?  I suspect the reason that there is no support for this – and I’m not saying that I support it – is that such a view would be the equivalent of swallowing political cyanide.  I ask readers here to calmly explain from a legal perspective why the doctor and the abortion facility would be legally vulnerable, and not the woman.   Yes, I know the argument that woman is already a victim, etc., but this is not how we approach other legal violations.

If gambling is illegal, and the police raid an illegal casino, do we expect the gamblers would be set free?  If an illegal prostitution ring is discovered, are the clients not prosecuted?  Of course they are. 

To me this issue sounds like a duel between Principle and Pandering.  We know how these contests usually end.