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.