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.