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.

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?   

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.

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.