Sunday, December 30, 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 would be available for direct consumer purchase.  We don’t permit patients to order a chest x-ray on themselves, but yet we will give them access to genetic testing results that many doctors like me won’t be able to skillfully interpret.  Make sense?

 “How much risk can there be if all you have do is to submit a saliva sample?” 

The risks come later once the results are in.  What is the value of discovering that you are at risk of developing a disease when there is no available treatment that can mitigate this risk?  If you learn that you have an increased risk of Alzheimer’s disease, would this knowledge improve your health?   Or would your life be filled with worry over a possible agonizing future.  Would you wonder when you misplace your keys if the beginning of the end is near?  If you knew now that Parkinson’s disease, an incurable and progressive neurologic disease, might be percolating within your brain, would your life be better?

Importantly, having an increased genetic risk does not mean that you will develop the condition.  You may very well live a long and happy life without ever developing the disease that you are at risk for. 
Of course, we should welcome genetic testing that can detect risks of conditions that we can prevent or influence, an entirely different issue from the one being discussed here.  Indeed, genetic testing has helped many of my patients and their families.

Will the public be able to resist the pitch from 23andMe and its competitors?  While physicians can educate our patients on the perils of these products, remember that patients are free to purchase them themselves.   It is likely that we physicians will be called upon only after the confusing and ominous results are in. 

Finally, the genetic risk industry’s true mission may be to sell genetic data to pharmaceutical companies and other institutions, a point not emphasized to the public. 

Sunday, December 23, 2018

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,

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 Booker
All Jumping into
The pressure cooker.

Who will emerge
From their Gang of Plenty
To take on His Highness
In 2020?

Joy and Peace!

Sunday, December 16, 2018

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 input.  I will illustrate this below.

“How is my patient doing?”

Yes, I ask them directly.  I’ve been doing it this way for 25 years and I will continue to do so. 

This Nurse Pleads for Documenation Relief

Patients also are signing reams of mindless forms in physicians’ offices and in hospitals at the time of admission.  Hospitalized patients sign multiple forms before they are taken to their wards, and often must sign additional forms giving permission for blood transfusions and various diagnostic tests or surgeries.  How carefully do most patients read this forms?  About as carefully as we read through a 10,000 word legal document when we are upgrading software on our phone or computer prior to clicking on ‘I Agree’.  Who has the time, interest or legal knowledge to read through all of the stuff that we have to sign?  I don’t. 

A few days before writing this, a patient related an amusing prank she perpetrated on her physician.  While in the waiting room, she was filling out a required form where she would list the presence or absence of various medical symptoms.  She found it annoying that her physician requires that the same form be filled out prior to every visit.  So, she wrote on the form that she had died last week.  Curiously, neither the physician nor any of the staff asked the patient about this medical development.  Perhaps, they didn’t think it was significant.  You don’t think that they simply didn’t read the form, do you?

Sunday, December 9, 2018

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 examples of individuals who stand their ground despite popular disapproval.  This might represent truly noble behavior and high principle when a person defies public opinion by doing the right thing.  This is called leadership.  More commonly, when a person lurches forward in defiance of the opinions and advice of experts and others, it is not leadership, but ignorance, hubris and arrogance. 

Recently, a Chinese researcher announced that a set of twins were born after altering their genes so that they would be protected against infection with the HIV virus.  The scientist announced that other births with gene alterations would be arriving soon.  I’ll not relate the scientific details, much of which is beyond my knowledge and understanding.  But, readers need to be aware that these genetic changes will not only affect the specific individuals but would be passed onto their offspring.  If true, it would constitute a permanent and heritable change in a person’s genetic code.  This is to be distinguished from utilizing genetic science to treat a single patient only, a more ethically palatable procedure.

I’ll leave aside the obvious fears that such a wanton ethical breach generates.  Even a lay person can appreciate the potential dangers at play here.  Scientists and ethicists could give us a fuller account of what is at risk.  And they themselves would admit: ‘Imagine what we don’t know’. 

The global ethical community, including in China, expressed opprobrium against this arrogant, dangerous and rogue action.   It is rare for any of us to witness an issue that unifies people, organizations and nations that are so often in conflict.  

The Chinese researcher in the face of worldwide outrage continues to defend his work.  In other words, the world is wrong. 

When there is responsible opposition to our own views and beliefs, shouldn’t we consider that we might be wrong?

Sunday, December 2, 2018

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 to bother us and it serves no useful function?

A minor change in a complex system can cause faraway effects. 

The human body is a supremely elegant, complex and integrated structure.  Tampering with one part of it may have wildly indirect consequences so far removed that we will not recognize the connection.  Consider these examples:
  • A certain class of antibiotics can cause rupture of the Achille’s tendon.
  • An anti-malarial medicine can cause nightmares.
  • Rotovirus vaccine can cause intestinal blockage.
There is science underlying the 3 examples above, but consider how implausible the causal connections between the drugs and the side-effects are?  Imagine what we don’t know.

This is why seasoned medical professionals prescribe new medicines sparingly.    A new vanguard of medicines has entered the arena.  Biologic medicines have stormed into the medical universe promising to stem the progression of many stubborn diseases such as Crohn’s disease, rheumatoid arthritis, psoriasis and ulcerative colitis.   We have all seen commercials for these agents on television, where the actors posing as patients are always fit and often engaged in some athletic activity.   These medicines, which tamper with the immune system by design, must be taken FOREVER.   The list of potential known side effects covers several pages in small print and range from life-threatening infections to cancer.  And, to repeat a line from this very post, imagine what we don’t know.  

The human body is a masterpiece of design and function.  When we pull on a thread, we may be distorting the far corners of the tapestry and never even realize that we were the culprit.

My advice to my colleagues and to my patients?  Be skeptical and humble always.

Sunday, November 25, 2018

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 tables?  Did you reach across the table in fellowship?  Was the table regarded as a politics-free zone?  Or, did you simply enjoy the experience as a needed oasis from the surrounding darkness and cacophony?

We have made the work of repairing the world harder than ever and harder than it has to be.  I truly believe it can commence 1 person at a time with the smallest of gestures.  Buy the person standing behind you in line at Dunkin' Donuts a cup of coffee.  You'll be rewarded by a sincere smile.  Smile back with a soft reply to 'pay it forward'.

Yes, I am very thankful for so many blessings and good fortune, much of it undeserved.  I truly hope that all of us found some joy that they could enjoy and share with others.

Sunday, November 18, 2018

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. 

“Absolutely not”, she responded. 

Now there were two strikes against proceeding with a colonic invasion.  Beyond the near cruelty of the laxative prep, if a cancer were found, then it would be left in place.  So, why subject the patient to the risk and indignity of a diagnostic test that would not help her?

Readers here with medical knowledge can offer hypothetical diagnoses for this patient where a colonoscopy or scope exam of the esophagus and stomach could make a difference. I acknowledge this.  But, medicine is not a pure discipline like mathematics.  There are always exceptions and we are never 100% sure of anything.  Regardless, I believe that the evidence against subjecting this patient to scope examinations is beyond a reasonable doubt. 

When a diagnostic test is being proposed to you, make sure that it will make a meaningful difference in your care.  Will it yield information that you and your physician want to know or need to know?   

Sunday, November 11, 2018

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 would not be reasonable for a patient who had access to network cardiologists to expect that a visit with an out-of-network cardiologist would be covered. 

Sometimes, the reason for a denial is absurd.  A physician prescribes a medication.  The insurance company denies coverage insisting that the medicine would be covered only if different medicines were tried first and were not effective.  The term for this is step therapy requirement and doctors despise it.  So, this is not a categorical denial, like with the cardiologist example above, but is a qualified denial.  The medicine is covered if the physician complies with insurance company edicts.  Here’s what the physician might tell his patient.

“I prescribed a medication to you that my training and experience informs me is the best choice for you.  Instead, let’s spend the next few months giving you some different medicines, just for fun.  I don’t think this medicine really makes sense in your case; that’s why I didn’t prescribe it.  Your insurance company, who always has your health and welfare as its highest priority, want us to wander off course for a while.  Who knows?  Miracles happen.  Maybe the stuff might work by accident.  No need to fret too much.   Eventually they will give in and you will ultimately get the right stuff covered.  And think of all the quality time the two of us will enjoy on our journey together!”

Here are some of the benefits of the qualified insurance company denial.
  • It wastes money.
  • It exposes patients to risks of side-effects from unnecessary medications.
  • Physicians and their staffs get to fill out lots of fun forms filled with ridiculous documentation requirements.  This is a welcome distraction for our staffs from the stress of their typical office responsibilities.
  • Some patients and physicians simply give up.  Do you think this might be one of the unstated goals of Big Insurance?
  • It delays the right medical treatment.
  • It pisses off patients.
  • It pisses off doctors.
  • It reinforces the narrative that insurance companies are self-serving corporate entities whose overriding mi$$ion is profit.
There are also many occasions when a denial is neither clearly reasonable nor unreasonable.  It can be difficult to determine if a recommended treatment is standard or experimental, especially if experts disagree on this point.  This is not a major issue if one is considering a treatment for acne.  But, what if an oncologist recommends a bone marrow transplant (BMT) for a desperately ill person, which some experts and institutions regard as experimental?   Does it matter if the F.D.A. has not approved the treatment?  What if other countries have decided that a BMT in the same circumstance is standard treatment?

These scenarios can be agonizing and vexing for patients, family members, physicians, insurance company personnel, the public and juries to sort out.   I have no easy formula to offer readers.

Just because a doctor recommends a treatment, doesn’t mean it is established care.  And, just because an insurance company denies a treatment, doesn’t mean the company is evil.  

If one of my loved ones was desperate for a medical treatment, and many doctors felt it was the right and reasonable choice, I know how I would feel.

Sunday, November 4, 2018

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 into this world.  His nurse, a Jew, attended to him.   A society and individuals are defined by their ability to show compassion – not when it is easy to do so – but when it is hard. 

Example of an Eternal Light in a Synagogue Hovering over the Holy Ark

There has been much chatter if other people and influences might bear some indirect responsibility in this tragedy.  In my view, this is not the time to introduce other agendas that distract us from what should be commanding all of our attention.   

I remarked above my amazement that the hate of a thousand men could be contained in one man.  At times, we see the opposite phenomenon.  From time to time, we encounter a person who exudes more love, faith, tolerance and compassion than we think one man can possess.  Mr. Rogers lived near the Tree of Life synagogue.   

“Mr. Rogers, you left us too soon.  We need you so desperately.  Can you find your way back here even for a day?” 

The wound is grievous and raw.  I cry inside for the families and the Squirrel Hill community.  Within the Tree of Life synagogue, as in all Jewish places of worship, is an eternal light, which is situated in the front of the sanctuary.   With this light which still burns today, and all of our own lights, we must strive to wash away the darkness.  The work will never be done. 

Sunday, October 28, 2018

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 with this fee, which is established by the insurance company.  He who collects the money must be at fault.
  • A patient arrives 45 minutes late and still expects to be seen.
  • A doctor arrives 45 minutes late and acts as if he is on time.
  • The insurance company denies a patient’s prescription.   Of course, these corporate folks deny that they deny anything.  They use phrases such as, ‘…the medicine your doctor prescribed is not a covered benefit.’  In other words, they are not technically forbidding the physician from prescribing anything.  If it’s the physician’s best medical judgment that his patient needs a $4,000 a month drug, then the insurance company would never block this.  They just won’t pay for it.
  • A patient is sent to see me who barely speaks English without a translator.   This is always fun for me and the staff. 
  • A patient is transferred to my office from a local nursing home.  The documentation explaining the reason for the visit is poor or absent and the patient may be demented or ill to provide meaningful details. This has happened repeatedly.  Each time it does, I make a phone call to the nursing home staff and offer a candid and pointed assessment of my view of this inexcusable conduct.  
  • A patient does not bring in a list of her 11 medications, as every patient is instructed to do.   
  • A patient asks me, the gastroenterologist, to refill the cardiac medicines.
  •  A patient wants a referral to a primary care physician.  She prefers a female physician.  I point out that I am a male.
  • A patient asks me how much a colonoscopy costs and is perplexed that I do not know the answer. 
I hope that you enjoyed Act I of this literary work in progress.  Interested to see Act II?

Sunday, October 21, 2018

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 gazillions of dollars from the system, much of which could be returned to patients to reduce their costs.
  • Medical students typically borrow a few hundred thousand dollars in loans.  This reality drives many of them into high earning medical specialties which ultimately cost the system more money.  We need more primary care physicians, not plastic surgeons.
  • There is an explosion of pricey medical technological health care with duplication of services among competing institutions which may be across the street from each other.   How many MRI machines does one city really need?   And, to justify the costs, each institution must aggressively market for patients.
  • Pharmaceutical ads, much of which is aimed directly to the public who cannot prescribe their own drugs, costs money.  Aren’t you sick of hearing, “Ask you doctor if _____ is right for you!”
  • There is a tsunami of overdiagnosis and overtreatment that is draining the system of zillions of dollars, while also exposing the public to the risks of unnecessary care.
It has always been my personal view that we could markedly increase medical quality and decrease costs simultaneously.   If we could cull the system of unnecessary care, costs would plummet and patients would be liberated from the medical labyrinth that is often the final destination of an unnecessary medical inquiry.  Patients can enter this maze easily, but struggle to find the exit.  Some are trapped inside for years.

So often, an unnecessary (or even necessary) medical test turns up ‘abnormalities’ unrelated to the issue at hand.  Every one of us has internal imperfections that mean nothing.  Once doctors discover them, however,  they then assume an attack mentality to prove that the accidental findings are innocent.   While the doctor may be relaxed during this exercise, the patient is anxious suddenly believing that he could be harboring a serious condition.  Physicians' reassurances may sound hollow to our vexed patients.   “Doctor, I know you said I shouldn’t worry, but then why do I need to repeat a CAT scan in 4 months?”

Why can’t we get to the end zone on controlling medical costs?  To do so would require some businesses and industries to disappear, some occupations to end and many incomes to decrease.  Think of your own profession.   Would you be willing to lose your job or take a 30% pay cut to reform your profession?  I have found that it’s easier to ask someone else to sacrifice for the greater good than to do so yourself.

Sunday, October 14, 2018

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

I had an out-of-body, or an out-of-wallet, experience a few weeks before writing this in a frame shop in downtown Willoughby, Ohio, not far from my office.  I brought in two large newspaper photographs that memorialized two amazing scenes after the Cleveland Cavaliers captured the NBA championships.  These were to be gifts for two of my kids who have been devoted fans of our basketball team.  I handed over the items to the owner who gave my project close and careful scrutiny.  He conferred with his wife to verify that his framing plan of action was the best option.  I asked how much of a deposit he would need, and he declined my offer.  I told him I had never in my life left an item for framing elsewhere without being asked for a deposit.  What if his frame shop did the work and the customer never returned or might balk against the agreed upon price?   Apparently, this couple trusted me or simply trusts all of their customers.  When I came to pick up the items, the credit card gizmo wasn’t working.  No worries, I was told. Just take the items and give a call in a week or so with my credit card information.

Who does business like this?  While I acknowledge that these folks are deviating from sound business practices, there was a warmth and humanity from this transaction that affected me.  I will surely return there.  

My mom and I regularly reminisce about these halcyon days of yore.  It was a wholesome life suffused with simplicity.  Customer service actually existed.  Proprietors knew us personally.  Utilizing technology meant using a rotary phone.  And, when we wanted to thank a friend, we did so in longhand using ink and paper. 

I wouldn't trade any of this for Alexa, but my voice on these issues has become increasingly lonely.

How 'bout dropping someone a note today?

Sunday, October 7, 2018

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 regarding an 87-year-old man with rectal bleeding.   He had never had a colonoscopy in his life and had only minimal contact with the medical profession.  (Maybe this is how he reached the age of 87!)   His bleeding developed a few months after he was started on a blood thinner prescribed because of an abnormal heart rhythm, in an effort to reduce his risk of a stroke.  A CAT scan was performed which strongly suggested that the bleeding was coming from a cancer in his colon.

If the patient had not developed a cardiac rhythm disturbance, then he would not have been prescribed a blood thinner.  And, without the blood thinner, he would not not have developed bleeding.   And, his colon cancer would have remained a stealth stowaway in his large intestine, unknown to the patient and the medical profession.  Perhaps, the cancer would have remained quiet and never posed a threat to him.  Now, however, he will undergo a colonoscopy which may be followed by major surgery to remove the invader.   One need not be a trained physician to appreciate that major surgery in a near nonagenarian with heart disease has risks.

I cannot tell readers the denouement as the case is in progress.  But, it reinforces how much in our lives is far beyond our control and comprehension.   An innocent experience can create an opening that leads to a path that reaches a tunnel that connects to a labyrinth that ends by a bridge that crosses a river…

We all think we are such assiduous planners.   We might be, but to me it seems that we are often just shooting dice.  

Sunday, September 30, 2018

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 diligence.  While there may be no presumed innocent standard in a judicial confirmation process, as this is not a trial, I would think that fairness and decency would instruct us to maintain some modicum of open mindedness.

Importantly, there remains a handful of senators from both parties that are still in play.  And with the GOP majority so shallow, one or two votes could be decisive.  

Sadly, this process has only served to reinforce the existing and widening fissure, or canyon, that is dividing this nation.  This has diminished the confirmation process, our legislators, the Supreme Court and the nation.   This is the overriding stark truth.   Do not let distractions about the loss of the filibuster, the shameless treatment of Merrick Garland, the relevance of a Supreme Court nominee’s high school and college drinking habits, the need for a formal FBI investigation, Diane Feinstein’s concealing Ford’s private letter from the Judiciary Committee, your residual anger over the Anita Hill hearing, your view on Roe vs Wade or the justifiable rise of the #MeToo movement, blind you to the horrible spectacle that is still ongoing.

I think that this has been a national embarrassment.   Who’s at fault?  It reminds me of Agatha Christie’s Murder on the Orient Express where everyone was guilty.

I am offering no opinion if Judge Kavanaugh should be confirmed or charged with a sexual crime.  I do not know what happened and neither do you.  The outcome of this debacle will make half the nation feel triumphant while the other half will seethe.  Does that sound unifying and healing?

Confirmation of Supreme Court nominees used to be an august demonstration of the majesty of our democracy.  Nominees were treated with respect by the senate and by the nation.  By and large, the process transcended politics.  No more.  Now, the partisan poison that has infected the executive and legislative branches has spread to the remaining branch.  

Whoever wins next in next week's vote, one thing is for certain.  We all have lost.  

Sunday, September 23, 2018

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? 

But, change is possible.

Here are some actions that many in the medical profession might seek atonement for.  I am judging no one here, and I admit that as I construct this list that I am not without sin.
  • A diagnosis is missed because a physician was not sufficiently diligent.
  • Privileged health information was inadvertently disclosed.
  • A physician is habitually late and is indifferent to his patients’ time.
  • A doctor disparages a colleague.
  • A physician fails to return phone calls from concerned patients.
  • A doctor berates one of his staff who made an error.
  • A doctor berates one of his staff who did not make an error.
  • A doctor modifies a medical record for the wrong reasons.
  • An impaired physician does not seek professional assistance.
  • A physician has a lapse in his bedside manner and doesn’t demonstrate the empathy the patient deserves.
  • A physician thinks of his own interest over the patient’s interest.

I don’t ask any reader to pay any heed to this post penned by a confessed imperfect and flawed man.

Sunday, September 16, 2018

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 11th 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 invade the medical arena?  The question is only how deeply it will invade.  The role of the traditional physician is at risk of being marginalized as computer software hits the profession hard.  Sure, computers cannot palpate an abdomen or perform a rectal exam – yet, but they can listen to heart sounds with much greater accuracy than a physician with a stethoscope can.  Additionally, as most practicing physicians know, the physical examination is much less useful than the patient’s medical history, although our medical school teachers and mentors always preached how critical the physicians’ eyes, ears and hands were.  Most doctors know what’s going on most of the time after carefully listening to the patient’s story, the medical history.

I know that sophisticated computer algorithms can synthesize an individual’s personal medical data and generate specific diagnoses, many of which might not have been considered by a human physician.  Of course, there’s a lot more to being a decent physician than spitting out a list of diagnoses, as we doctors know despite when empowered patients bring us lists of diseases they think they have after spending some time in the Google School of Medicine.

Although artificial intelligence is not a real doctor, it offers an incredible tool for the medical profession to serve the public.  For example, if a 50-year-old man who has just returned from rural Kenya comes to see me with diarrhea, a 7 pound weight loss, vision change, fever and a rash, I may not be able to provide an instantaneous diagnosis.  If I could plug the patient’s profile with his symptoms into a computer program, along with various laboratory features and photograph of the rash and the retina, it might alert me to diagnostic possibilities that are beyond my reach. 

Let’s say that a machine outperforms me on my medical board certification exam.  If you could only see one of us, which of us would you choose?

Sunday, September 9, 2018

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 referenced above.  I’m sure I am now blacklisted there.   My guess is that the minutes of commercial time would shock us all.   I’m surprised that the network hasn’t started introducing the commercials with Wolf howling ‘Breaking News! New Floor Cleaner Wipes the Competition!’

So many commercials are devoted to health issues.  Many of them are for prescription drugs.  Interesting how the pharmaceutical companies are flooding the airwaves, internet and print hawking products to a public who cannot purchase them by themselves, as they might do with a TV set or a mattress.  They are coaxing the public to lean on their health care providers, aka doctors.  Enter the phrase:  ‘ask your doctor if Proctobomb is right for you.'

General Ambrose Burnside
Hair in All the Wrong Places

I heard a commercial today about some kind of laser device that could sprout hair on a bald and desolate scalp.  I was struck that the ad touted 93% significant hair growth from users.  I admit that I did not read the study, but I am skeptical that it would be characterized as rigorous scientific inquiry.  Moreover, I wonder who funded the study, or if the physician investigators  benefited by participating.  Once again, I am not leveling actual allegations of conflicts of interest, only that I am suspicious they exist when a commercial product is championed in a single study for an incurable condition..

I’ve read thousands of medical studies, and a 93% benefit is nearly unheard of in conventional medical reports.  Even treatments that are established and proven therapies rarely reach such a high bar.  Such a stratospheric level of performance should arouse skepticism that the study is misleading and deceptive.

Most of us who are follicularly-challenged would walk through a minefield for the promise of 93% significant hair growth.   Here’s the catch.  Who defines what significant hair growth is?  Recognize that as the definition of significant hair growth is relaxed that the success rate increases. For example, if  significant hair growth is defined as a few new limp saplings, then the company can boast a success that will not be visible to the customer or anyone gazing at his pate.

Think of how success rates in medical reports can be massaged to lure physicians and patients.  If a drug or device company announces  a huge success rate, make sure that what they are measuring really matters to you.  Just because they claim it’s Breaking News, doesn’t make it so.

Sunday, September 2, 2018

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.

Sunday, August 26, 2018

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 if this could justify a 5-year delay.)

At this point, his wife interjected and expressed that ‘no one ever told him to get it done.’  I interpreted this as an effort to defend her husband’s delay and also to give a poke to the medical profession, who must have been derelict in its responsibility to advise him.

‘Not so fast’, I thought to myself.   Of course, I was going to be polite and respectful, but a push back was in order.

'My doctor never told me smoking was bad for me.'

While I agreed with her that his primary care physician should have made a timely recommendation to pursue colon cancer screening (which for all I know may have happened), surely her husband was aware himself that he needed a colonoscopy.   The medical profession and numerous health organizations have been diligent and effective over the past few decades educating the public about colon cancer prevention   Folks don’t need a doctor’s advice or reminder on this any more than they do to wear seat belts or bicycle helmets. 

Personal responsibility is a virtue and a responsibility.   I don’t expect my patients to know how to treat Crohn’s disease and Hepatitis C.   And, I do my best to make sure that their colons don’t escape my attention.  But, it not all on me.   Would it be reasonable for a smoker today to keep puffing away because a doctor didn’t counsel about cigarettes' health risks?

Sunday, August 19, 2018

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 sign and date the forms, there really are no requirements of the doctor, except to provide the prescription. The agreements basically catalogue a very long list of required behaviors that patients must agree to and be prepared to document.  Here’s a sampling.
  • I will agree to random drug testing.
  • I will agree to cancel any office visit at least 24 hours in advance.
  • Only 1 lost opioid prescription will be replaced annually.
  • I will agree to psychiatric care and counseling, if necessary.
  • I will treat the office staff respectfully.
  • I will store my medicines safely.
  • I agree to waive any right to privacy or confidentiality if any law enforcement agency is investigating alleged misuse of my opioid medicines. 
To begin, it is not clear to me why “agreeing to cancel any office visit at least 24 hours in advance” or treating “the office staff with respect” is so unique to opioid users that it is included in some OC’s.  Explain to me please the relevance with respect to the opioid issue.  Why shouldn't these terms apply to all patients?

Of course, I understand the rationale behind these contracts.  But, this coercive effort seems like OperationOVERKILL.  To me, it seems like a humiliating experience for patients and risks eroding trust and weakening the doctor-patient relationship.  I would think that preserving and enhancing this relationship would be particularly important in caring for these patients.

If these medical diktats are truly necessary for opioid users, then why shouldn't every patient sign an agreement promising to take all medicines as prescribed, never arrive to the office late, refrain from disparaging the practice, never request a refill on a night or a weekend and limit their phone calls to the office to one per month.   How would patients react to this?  One advantage of this approach is that it would clear out doctors' crowded waiting rooms.

I don’t object to the content of the agreements; but I think forcing a signature on a written 'contract' is unseemly and unnecessary.  Medical care should not be rendered as a transactional business matter.

Physicians often rightly complain that our work is treated as a business by insurance companies and others.  With regard to Opioid Contracts, who deserves the blame?

Sunday, August 12, 2018

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.

This case is a tragedy for all involved, as well as for the community at large.  I was so disturbed about reading the details about a desperately ill child with overlying tensions between parents, who I believe loved their child, and the medical and legal professionals. 

  Courts Practicing Medicine Guarantee Pain and Heartache

Yes, I believe that parents have rights over their children’s medical care including the right to refuse treatment, one of our bedrock medical ethical principles.  This is why we secure permission from parents before performing medical tests and treatments on their kids. 

But, I do not believe that this right is absolute, and there is no simple standard formula that we can rely on to guide us..

It depends upon the stakes.   Refusing Nexium for your child’s heartburn is not quite the same as refusing surgery for a burst appendix.   It also depends upon the age and maturity of the child.  A 17-year-old Jehovah’s Witness may be capable of making an informed decision to refuse a blood transfusion.  I doubt that a 3-year-old Witness has this capability.  Should Jehovah Witness parents of a 3-year old be permitted to refuse a blood transfusion that the doctors feel would save his life?   Can a parent refuse recommended vaccinations for their children believing them to be harmful?  If the child becomes infected with a vaccine-preventable condition, what about the health risks to others who might be exposed to them?   Where do the individual’s rights end and the community’s rights begin?

Do children who have not reached an age of maturity and understanding have innate rights that merit protection that may override their parents' rights to direct their children's medical care?    

While it’s best if the family and the medical team agree on a plan, I realize that this is not always possible.  When the stakes are life itself, the issues become raw and agonizing.  The sure sign of a system failure is when the courts become involved. 

Sunday, August 5, 2018

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 on passengers who are not under actual suspicion or been charged with a crime.   But, if we strip instinct and suspicion from the armamentarium of our security services, then what is it exactly that makes these folks actual professionals?  Do we want ‘box checkers’ or real pros?

Of course, most of the time suspicions will not be borne out.  This does not mean, however, that the tool is invalid or that the target should feel victimized.  Before, we cry ‘discrimination!”, let’s consider what the stakes are here.  This is not an improper search of your car trunk; it’s blowing up an airplane.

I related to this issue since seasoned physicians rely so often on our instincts and sixth senses about our patients.   Every physician has said or thought throughout his career, ‘something is not right here’, even if all of the objective data seem to line up.  I think patients understand this and want their doctors to use their intangible skills along with their stethoscopes.   Frankly, it is these skills, in my view, that are amply present in our very best physicians. 

While you can’t teach these skills, doctors over time do develop them.  While younger physicians have much to teach us experienced practitioners,  we have a few things to offer them, at least that’s what my instincts tell me.