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Showing posts from 2018

Why I am Against Genetic Testing?

  Just because something is legal, doesn’t make it right.  Just because we enjoy a right of free speech, doesn’t mean we should be verbally insulting people. Just because the Food and Drug Administration (FDA) approves a treatment or a test, doesn’t mean we should pursue it. The FDA has given approval to 23andMe, a private company, to provide genetic testing directly to individuals.  The results provide genetic risks of contracting several medical conditions including Parkinson’s disease and Alzheimer’s disease.  No prescription or physician visit is needed.  While 23andMe execs and marketers will undoubtedly claim that their mission is to empower the public, this does not tell the whole story.   Indeed, many patients who undergo the testing will be worse for having done so.   I would never submit to the 23andMe home testing program myself, nor would I counsel my patients to do so.  It seems bizarre that the incredibly complex and nuanced medical issue of genetic risk

Whistleblower Holiday Cheer 2018!

‘Twas the night before Christmas, And all through the House, The creatures were stirring, And ready to pounce! Why wait for Mueller? What could he teach? We already know That we must IMPEACH! With Dems in the House So anxious to blame, Their strategy is… Ready! Fire! Aim! Both Chuck and Nancy, Will not take the fall, Not on their watch, Will there be a wall.  The Dems are all joined, In salivation, At the prospect of, Investigation! We watch GOP Twirl and deflect, Supporting a man, They just won’t reject. The only Repubs Who show any fire, Are senators who Announced they’ll retire.  While all of us watch With ire and confusion On Russia and Stormy And ‘No Collusion!’ The press and our pols Care nothing for us It’s ratings and votes That drive their bus.  Is there no honest man True to the bone Who can rescue us all, Perhaps, Michael Cohen? And Dancer and Blitzen And Warren and Boo

Medical Paperwork Overwhelms the Profession

Does any living, breathing human believe that there is not enough paperwork in our lives?  While we are all burdened, I believe that the medical profession is uniquely deluged with an absurd volume of documentation requirements, most of which should be filed under ‘N’ for nonsense.  Ask any physician or nurse about this and have antacids on hand as you will soon see some sizzling smoke emerging from the medical professional’s nostrils. Each hospitalized patient has a tremendous amount of recorded data which nurses painstakingly document.  This requirement fails on two fronts.  It takes nurses away from time at the bedside.  Additionally, most of the stuff they document is not viewed by physicians or others on the care team.  For example, I rarely read the nurses’ notes.   Is this because I do not value the nurses’ opinions on my patients?  Hardly.  Instead or perusing their written descriptions of my patients’ progress, I use a sophisticated, high-tech technique to obtain their in

Chinese Researcher Defends Gene-Edited Twins -The World Must be Wrong

Physicians confront alcoholism regularly.    Indeed, nearly every day on my hospital rounds, I treat patients who are suffering the ravages of alcohol abuse.    While these patients may have a genetic predisposition toward alcohol abuse, or faced other personal pressures and demons, ultimately the disease is initiated by a person who made an unfortunate decision.   I do not judge these individuals as their doctor, any more than I do my hepatitis C patients who contracted the virus as a result of intravenous drug use.    But, when are examining the causes of these maladies, personal responsibility and accountability must be considered.   In fact, failure to do so will frustrate our efforts to prevent various injurious addictions.   Physicians and others have heard the vignette when an alcoholic denies his addiction despite that every other person in his life feels otherwise.    “They are all wrong,” he states emphatically. 'I can quit anytime.' There are many ex

The Risks of Drug Side Effects - A Case for Caution and Humility

I prescribe heartburn medicines every day.    There’s a gaggle of them now – Prilosec, Nexium, Prevacid, Protonix – to name a few.   As far as experts know, their primary effect is to reduce the production of stomach acid.   This is why they are so effective at putting out your heartburn fire.   In simple terms: no acid, no heartburn. I am quite sure that well-meaning physicians like myself do not understand or will ever know all of the unintended effects of tampering with a digestive process that took a few million years or so to evolve.   Are we so arrogant that we believe that these drugs only target gastric acid production?   They are absorbed into the blood stream and course through every organ of the body.   Is it not conceivable that certain tissues might be sensitive to these foreign invaders?   Might there be unintended consequences that occur far downstream well beyond our horizon similar to a butterfly effect.     Do we really think that gastric acid is present just

Thanksgiving 2018 - Finding Joy in a Dark World

We are still recovering from the tragedies in Pittsburgh and Chicago.  Fires out west have roared over thousands of homes with more fatalities than have been yet accounted for.   Immigrants streaming toward our southern border in search of a better life are demonized and politicized.  Our nation's allies who have stood with us for a century are now reassessing their faith in our faithfulness.  Our free press, despite its lack of accountability and presence of bias, is under unfair attack.  Harvard's preferential admission policies have become exposed with other universities to follow.  Road rage had become the rage.  Facebook has exploited and deceived us. Truth has become an elastic concept.  Our political opponents are regarded as enemies.  I win if you fail.  The citizenry has deepened its disgust and cynicism.  An errant remark can lead to public vilification and loss of a job or reputation.  We have become an angry populace. What did you discuss at your Thanksgiving

Overdiagnosis Threatens Elderly Patient

Yesterday, a physician asked my opinion if a patient needed a colonoscopy.  My partner was already on the case and I was covering over the weekend.  The facts suggested that a colonoscopy was warranted.  The patient had a low blood count and had received blood transfusions.  Certainly, a bleeding site in the colon, such as a cancer, might be responsible.  We do colonoscopies to address similar circumstances on a regular basis.  Why did my partner and I demur in this case? We Placed this Sign on the Patient Because to us, our medical judgment trumped the medical facts.  First, the patient was elderly and extremely debilitated.  The challenge of having an individual in her state ingest the necessary laxatives is likely insurmountable.  If any readers have enjoyed the delight of guzzling down a colonoscopy prep, contemplate doing so as an elderly, ailing and bedbound individual. I asked the physician if the patient’s family would consent to surgery if a cancer was found.

The Agony of Insurance Company Denials

I just read of a a jury award in excess of $25 million against an insurance company who denied a recommended cancer treatment to a patient who ultimately died.   I do not wish to review here the particulars of this case, and admit that my knowledge is limited by one news report that I read earlier today.   While I will not invoke the ubiquitous phrase FAKE NEWS, I always bring some measure of skepticism to various news sources, even those who enjoy excellent reputations.   The Olde Town Crier Always Told the Truth But this jury case raises an issue that physicians and patients wrestle with regularly. The physician prescribes a medication or recommends a treatment. The insurance company denies coverage for the recommendation. Sometimes, the reason for the denial is entirely reasonable.   For example, if an insurance policy restricts a patient to a network of physicians, the company will deny coverage if the patient wants to seek care out of the network.   It

Light and Darkness in Pittsburgh

The lights went out in Pittsburgh 8 days ago.    The shade from this moral eclipse reached far beyond the Pennsylvania border and, indeed, extended throughout the nation and onto foreign lands.   I know Squirrel Hill well, having performed medical training in Pittsburgh a few decades ago.   I’ve been to the Tree of Life synagogue in the prior era when none of us were afraid to engage in the routine activities of life.   I am saddened and horrified to witness yet another momentary triumph of evil.   I wondered how it is possible that a person who was born pure could over time morph into a seething cauldron of hate, completely unmoored from the moral guideposts that keep us civilized.    The man who stormed the innocents, wounded by selfless law enforcement professionals, was taken to the hospital to receive medical care.   Yes, we cared for his health and his life, despite that he massacred others who were in synagogue to pray and to celebrate a new life that had recently come

Behind the Scenes in a Medical Office

Here is a potpourri of medical vignettes.   All are real life scenarios that I have experienced in my practice.  The absurdities of life also permeate the medical profession.  An insider’s view of medicine, as in any profession or industry, may be less sanitized than its public face.  Here are some Scenes from Scopesville, Ohio. Act I, Scene I Patients are routinely told that they should not eat or drink on the day of their colonoscopy.   Recently, a patient decided that these instructions did not prevent him from eating a full breakfast.  This is where the phrase, ‘you prepped for nothing’, applies. A patient comes to see me on the advice of his primary care physician.  He has no idea why he has been sent.  Let the sleuthing begin! A patient asks for a work excuse for the entire week following his colonoscopy. I am asked to fill out disability papers for a patient I saw once a year ago. A patient complains to me and my staff about a $20 copay.  We have nothing to do wit

How to Save Health Care Dollars

Health care costs in America are incinerating nearly 20% of the Gross National Product.    Can you say, non-sustainable?    Folks have been bloviating for decades about reforming the health care system with respect to quality, cost and access to care.   This is quite the quagmire.   If it were easily solved, then it would have been done during the Truman administration. He couldn't get it done.   Here are a few reasons why it has been so tough to crack this case. Cutting costs can threaten medical quality. I know of no player in the Medical Industrial Complex who is willing to sacrifice his own revenue to serve the greater good. Pharmaceutical companies receive federal research dollars but are not subject to reasonable governmental control on their opaque pricing schemes. The public expects every conceivable medical benefit, preferably for free. The fee-for-service model drives unnecessary medical care. Pharmacy Benefit Managers – huge middlemen – suck out

It Takes a Village - A Look Back...

I prefer to do business with small, privately owned establishments rather than patronize the big box centers that have pushed smaller stores to the margins or off the grid.  Of course, I do spend money at the large centers for the same reasons that all of us do.  But, I miss the personal attention and interest that a single proprietor and the staff can provide.  South Orange, the small town, or actually village, where I was raised was full of these stores where we bought hardware items, sandwiches, clothing, medicine, shoes and ice cream cones.  I would periodically stop into the bank, with my passbook, to deposit my accumulated cash from my paltry weekly allowance. (As a third grader, I received 10 cents per week.)  When I would pop into to one of these places, the owners knew me and my family, not quite the experience in some retail stores today where one guard has to admit me into the store and another must scan my receipt before I can exit.  Village Hall in South Orange, NJ

When Diagnosing Colon Cancer Might be a Mistake

So much of life depends upon timing.    Sure, we plan, but we know how much of our life’s events are unplanned and unexpected.   So often, our jobs and our mates – two of our most defining accomplishments – are the result of a chance encounter or a random act.   Life does not reliably proceed in an orderly manner. This is often true in the medical profession.    Here, physicians in our quest to seek out and squelch disease, often discover what would should have been left alone.   For example, is discovering prostate cancer in an older man a true benefit if the tumor would have remained silent throughout the man’s life?   Whenever possible, it is best to ask the question, ‘what will I do with the information?’, before recommending a diagnostic test to a patient.   There is a risk to disturbing the natural order of things. Are we really just shooting dice? Sometimes, medical events occur on their own without any prompting from a physician.   I was contacted by a physician

Kavanaugh versus Ford: Who Really Lost?

The nation was transfixed this past Thursday with the sequential testimonies of Christine Blasey Ford and Brett Kavanaugh.   It is rare that a judicial or quasi-judicial proceeding generates this stratospheric level of intensity and interest.   In my recollection, the O.J. Simpson murder trial and the Anita Hill hearing before the Senate Judiciary Committee both reached this level. I watched a good deal of the hearings and read about what I was unable to watch. Personally, I don’t think that minds were changed.     Nearly every U.S. senator’s mind was firmly decided at the moment that the judge was nominated months ago.   Many offered up their strident support or opposition within 24 hours of the announcement of the nomination, if not sooner.    I will let readers decide if such a response is the diligent and fair reaction that a nominee and the country deserve.   To me, it seems that this massive pre-judgement was offered up without necessary fact finding or standard due dil

When Should Your Doctor Say 'I'm Sorry'?

For many people throughout the world, this past week provided an opportunity to reflect on one’s life and to invest in one’s soul.    While self-examination should be an ongoing task,   the Day of Atonement is a singular opportunity to meditate deeply on this process.   While this day culminates a 10 day period of intense reflection – or so it should – once again, this does not relieve us of our obligation to pursue this task on all other days. Atonement is a tough business and I admit that I am no expert.   Consider how challenging this process is. Personal reflection. Acknowledging personal flaws and transgressions. Approaching those whom we have wronged to make it right. Forgiving those who seek our pardon with grace. Committing not to repeat our offenses if placed in the same circumstance again. Sounds easy?    Hardly.   Changing our traits and actions are very difficult.   Why do you think so many of us have the same list of New Year’s resolutions every year?  

Artificial Intelligence and Medicine - Is Your Doctor Obsolete?

I read about artificial intelligence software that can rival high school juniors armed with #2 pencils.  The program attacked SAT math questions and performed at the level of a typical 11 th grader.  The study was too complex for me to grasp. I guess I should ask an 11th grader for assistance.  Artificial intelligence is well beyond conventional computational exercises. It can ‘think’. Man vs Machine Increasingly, we see functions executed by machines that were formerly performed by living breathing human beings.  Examples range from the mundane to the preternatural.  Order food and drink from an iPad.  No server needed. Driverless auto travel.   This may lead to a resurgence in prayer. Pilotless air travel.  Hard times ahead for the Airline Pilots Association.  Making precision tools – from 3D printers. Gourmet meals created with a voice activated command. Theater and film productions starring faux actors created on keyboards. Will artificial intelligence i

Breaking News! A Cure for Baldness!

I have satellite radio in my car.  I listen to 2 or 3 stations.  I have a deluxe version of cable TV, giving me access to hundreds of channels.  I watch a handful of them.   There is no way, of course, that I could simply pay for the 7 stations I watch.   For example, if I want HBO so I can watch John Oliver’s uproarious Last Week Tonight on Sunday, I have to purchase some package of useless channels to secure my HBO spot. I listen to CNN often in the car.  This network blares out ‘Breaking News’ every 5 minutes or so.  I wrote to them demanding an explanation for these idiotic announcements, but they couldn’t break away from the avalanche of breaking news to respond to me.  In times past, ‘Breaking News’ meant that the Germans surrendered, Truman beat Dewey or that Neil Armstrong planted his feet firmly on the lunar landscape.  I also wrote twice to CNN asking how many minutes of commercials occupy Wolf Blitzer’s hour long ‘news’ show.   I got the same non-response as referen

Thoughts on Labor Day 2018

All work is honorable.     Sometimes, when I ask a patient what his occupation is, the response begins with, ‘I’m just a…”.   I’ll have none of it.   There is no ‘just’.    Most of the people who keep this country afloat are anonymous folks who put in an honest and decent day’s work.   Some use a keyboard and others use a hammer.   Some use a shovel and others use a colonoscope.   Some arise when we are still asleep and others start work after we have retired.   Some use their hands with skill and precision and others offer professional advice.    Some design a building and others build it.    Some create and others consume. But, why should these words matter here?   After all, I am just a blogger.

When Should You Have a A Screening Colonoscopy? Preventive Care and Personal Responsibility

A man I had not met came to my office prepared for one of life’s most joyful pursuits – a screening colonoscopy.    Perhaps, this experience gives truth to the adage, ‘it’s better to give than receive’. This man was 70-years-old and was about to undergo his first screening study of the colon, an exam that experts and others advise take place at age 50.   Let me do the math for you; he was 20 years too late.   I performed my task with diligence and removed a large polyp.    While I believe that the lesion was still benign, we gastroenterologists prefer to discover your polyps when they are small.    Smaller lesions are nearly always benign and are safer to remove. Afterwards, I chatted with the patient and his wife and I expressed some surprise that there had been a two decade delay of his colonoscopy.    (Readers would be amazed and amused at the creative excuses I’ve been offered over the years explaining delayed colonoscopies.   A popular one is “I’ve been so busy!”, as i

Opioid Contracts for Chronic Pain Patients Threaten the Doctor-Patient Relationship

A contract is an agreement stipulating the rights and obligations of the signatories.   In most cases, a contract is consulted when a dispute arises.   When all is proceeding swimmingly, the contract remains dormant in a file drawer or in a digital file.   In general, decent people resolve differences in the old fashioned way utilizing the twin arcane legal techniques of reasonableness and compromise.   Remember them?   Yes, it is possible to settle disputes without consulting an attorney. Settling a Dispute without a Lawyer I learned recently about the existence of Opioid Contracts, an 'agreement' between a patient and a physician regarding the use of opioids.    I have read through various OC templates and, although I have no law degree, they seem extremely lopsided in that one party seems coerced to accept numerous stipulations while the other – the doctor – serves as the enforcer.   Although many of these agreements require both the patient and the physician to

Refusing Medical Care for Children: Religious Freedom or Child Abuse?

I read yesterday in Cleveland’s main newspaper about the tragic passing of a 14-year-old girl.   She had cancer.    Why would this tragedy have been reported on Page 1?    As sad as a loss of a child is from a medical condition, this is generally not of interest beyond the family, friends and loved one.   This case was different.   The parents refused the chemotherapy that her doctors advised.   They wanted their daughter treated with herbs and feared that standard medication would worsen their daughter’s already precarious condition.    The parents believed that chemotherapy would violate their religious beliefs. The parents sought another medical opinion from Cleveland’s other premier tertiary care center, which affirmed the original medical advice. About 2 weeks ago, the parents received a court order mandating that their daughter receive chemotherapy.   Shortly afterwards, the daughter, who was already on a ventilator,   developed serious medical complications and died.

TSA Under Fire for Quiet Skies Program: A Lesson for Doctors?

Consider these behaviors.    A newborn calf nurses from his mother.    A robin places a worm into the gaping mouths of her offspring.    Cats know how to hunt. These behaviors are examples of instinct.   The creatures do not even understand why they engage in these acts.   They are inborn behaviors.   Animal Instinct Humans have instincts also.    Unlike most professional standards and qualifications, instincts cannot be easily quantified or tested.   But, under certain circumstances, they are invaluable assets.   We learned last week that the Transportation Security Administration (TSA) has been pursuing a program called Quiet Skies, when passengers who have met certain criteria are monitored for various behaviors that might suggest that closer scrutiny is warranted.    I am making no comment here on the merits of the program, but I am supportive of TSA using instincts of air marshals as a tool to evaluate threats.    Some have criticized this as an infringement