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.