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Showing posts from 2019

Can a Doctor Do a Medical Procedure Without Consent?

Some time ago, I performed a colonoscopy on a patient who was having serious internal bleeding.   He had already received multiple transfusions since he was admitted to the hospital.   After obtaining informed consent for the procedure, I performed the colon exam.    I encountered blood throughout the entire colon, but saw no definite bleeding site, raising the possibility that the source of blood might be higher up than the colon, such as from the stomach.   I had not considered this possibility when I met the patient, but this was now plausible.   Can I proceed with the upper scope test, which the patient did not consent to, while the patient is still sedated from the colon exam? Could the Stomach be the Culprit? Seasoned gastroenterologists can usually predict the site of internal bleeding based on numerous medical facts, but there are times that we are surprised or misled.    Patients don’t always behave according to the textbook presentations we learned.   At t

Whistleblower Holiday Cheer 2019!

‘Twas the night before Christmas, And all through the House, All the creatures were plotting, Claiming Trump was a….RAT! We have Schiff and Nadler And, of course, Madame Speaker, Who are as transparent, As the Anonymous leaker! Our Democracy might fail, Our Dem statesmen teach, So what choice do they have But to hold hands and impeach. When Mueller fell flat, They all felt the pain, But, the Lord heard their prayers And POOF – came Ukraine! With so many versions How could we know If Trump really offered A quid pro quo. The witnesses swore Trump’s plan was – Extort! Jim Jordan responded With a loud bleating snort. And with all of this static Some can’t be heard, When the candidates speak, We hear nary a word. So Warren and Bernie, (And Blitzen and Dasher) Have been squelched and muzzled. By the Candidate Crashers. When it all ends And the Senate says, No! No minds will change. I told you so!

'Doctor, What Would You Do?'

There’s a phrase that every physician hears repeatedly from patients, that requires a nuanced response. Doctor, what would you do if you were me? There are variations on this inquiry, such as ‘what would you do if I were your father’, but they all are aiming at the same target.  The patient, or often the patient’s family, asks the doctor what advice the physician would choose if he were in the patient’s place.  For example, if the physician were the patient would he opt for: Surgery Chemotherapy Experimental treatment Watchful waiting A second opinion A third opinion Alternative medicine Acupuncture Hospice 'Doctor, what would you do? Patients erroneously believe that this form of inquiry is the magic bullet of finding out what the physician’s truly best advice is for a particular medical circumstance.  After all, if the doctor would recommend a treatment for his own mom, then surely this must be the best option. Except, it isn’t.  Here’s why. P

Are Female Gynecologists more Sensitive than Males?

Would you rather be right, wrong or interesting?   When I was a medical student rotating on the OB-GYN rotation, the issue arose if female OB-GYNs were more sympathetic to patients than their male colleagues were.  Before reading on, what's your opinion here? There was a view that females in this medical specialty would have more empathy for patients as they may have experienced menstrual cramps, pelvic pain and childbirth.  No man can relate to these symptoms and they might be expected to be more dismissive or distant over these ‘minor hormonal disturbances’.  In other words, men just don't get it. A discrete GYN exam 200 years ago It is true that one who has ‘walked the walk’ may connect more closely with one who hasn't.  For example, since I have never suffered from an addiction, I can never counsel a drug addict or alcoholic with the same street cred as one who has triumphed over these afflictions. The chief of the OB-GYN department at my medical

Is Everything Offensive?

I will digress from this blog’s medical quality theme to let off the gaseous form of H20, also known as steam.   I wouldn’t consider this to be a rant, a genre that I have offered previously.   But, it’s more than just venting to my readers.   So, it’s somewhere between a rant a and a vent.    In my world, I try hard to challenge myself and others.   It’s the way I’ve always been.   I love the debate, the argument and the rhetorical fencing.   I feel satisfied if I can change someone’s mind and I particularly relish when someone can change mine.   Let the better argument prevail.    Of course, contestants in this arena must be willing change their views and give an opposing argument a fair hearing.   There have been instances during these colloquies, and at other times, that I have inadvertently offended someone.  At times, this occurred because my words were clumsily selected.  On other occasions, the recipient may have been overly sensitive and had a low offense threshold

Thanksgiving 2019

Behold the denizen who has bravely entered our property so close to Thanksgiving! Wishing all of you a great holiday.

Why I Won't Prescribe You Antibiotics

At least a few times a year I am asked to prescribe antibiotics to people who are not my patients.  From my point of view, there is only one answer that makes sense here – no.   I have the same reaction when patients call me for a refill or advice when I have not seen them in a year or two.  The patient may feel that I will refill their heartburn medicine indefinitely without an office visit, but I won’t.  Once I hit the refill button, I am now totally responsible as the doctor.  Patient Gets Medication Refill in 14th Century The Patient’s Perspective I’ve been on the same medicine for 10 years and all I need is a refill.  I feel fine. I do not want to take time off work for an unnecessary appointment. Why should pay a copay when all I need is a refill?  Sounds like a rip off. The Physician’s Perspective No refill until I verify that there are no concerning symptoms. A routine ‘heartburn patient’ may have developed some swallowing difficulties which could signa

Why Doctors Won't Give Medical Advice

Doctors dispense medical advice.  That’s what we do.  Folks come to our office with various medical issues.  We talk to them.  We poke around some of their body parts.  Then, we exercise our medical judgement.  We might order a CAT scan.  We might prescribe stuff.  We might simply reassure them and send them on their way. This is a typical ‘day in the life’ of a health care provider, formerly known as a doctor.  From time to time, folks solicit my advice under different circumstances.  Despite my efforts to keep my medical specialty stealth, sometimes the secret seeps out when I am in a social setting. “Oh, you’re a gastro guy?  Would you mind if I asked you quick question about my husband?  He has a gas problem…” I get questions like this all the time, and I do my best to respond in way that sounds authoritative, yet dispenses no legitimate medical advice.  Here are some examples of how I might respond to the above inquiry on spousal flatulence. “Yeah, if I had a doll

What Makes a Good Doctor. You Be The Judge

I’ve delved into the issue of medical judgment more than once on this blog.  I have argued that sound judgment is more important than medical knowledge.  If one has a knowledge deficit, assuming he is aware of this, it is easily remedied.  A judgment deficiency, per contra, is more difficult to fix.  Who doesn’t think he has good judgment? For example, if a physician cannot recall if generalized itchiness can be a sign of serious liver disease, he can look this up.  If, however, a doctor is deciding if surgery for a patient is necessary, and when the operation should occur, this is not as easily determined.  Medical judgment is a murky issue and often creates controversies in patient care.  Competent physicians who are presented with the same set of medical facts may offer divergent recommendations because they judge the situation differently.  Each of their recommendations may be rationale and defensible, which can be bewildering for patients and their families.  This is one of t

Do You Really Need Plastic Surgery?

We live in an era where plastic surgery is routine.   Indeed, in many parts of the country, plastic surgery is an expected rite of passage.   Years ago, face lifts and ‘tummy tucks’ were done on those in middle age who were trying to experience a surgical time machine.  Now, folks in their 20’s are having all kinds of work done, not to recreate a prior image, but to create a new one. The traditional scalpel in only one of many tools used to perform body design work.  There is a smorgasbord of injectable fillers that plastic surgeons, dermatologists and other physicians provide to a public who is zealously combating every wrinkle.  Once a person is of the mindset that the only good wrinkle is a dead wrinkle, he will commit himself to a lifelong odyssey of cosmetic work.  These folks are generally never fully satisfied with how they look.  They are always finding imperfections that they target for correction. I enthusiastically recommend readers to read Nathaniel Hawthorne’s short

Physicians and the Art and Power of Observation - Has This Bird Flown?

Medicine is for the birds, or it should be.  Hear me out. A day before I wrote this, I was on the trail in northwest Ohio, binoculars in hand, trying to tell one warbler from another.  This was the final weekend of The Biggest Week of birding in Magee Marsh on the shore of Lake Erie.  Birders converged here from neighboring states and even from foreign countries to participate in this ornithological adventure.  My companion and I were new to the game.  Indeed, my birdwatching prowess had consisted of being able to successfully identify a blue jay at the feeder on our deck.  I had now entered a different universe. There were serious birders afoot equipped with photographic and telegraphic equipment that looked like stuff that James Bond might have used.  Birds flitted about that heretofore would have generated no interest on my part.  When a rare warbler was spotted, the excitement raced through the birders like a brushfire, causing a crowd to gather to view the feathered pheno

Colonic Hydrotherapy. Is it Time to Bend Over?

From time to time, patients asks my advice on colonic hydrotherapy, vigorous sessions of enemas that aim to cleanse the body of toxins that are reputed to cause a variety of ailments.   The logic sounds plausible to interested patients.  Over time, toxins accumulate and leech into the body wreaking havoc.  Indeed, using the label ‘toxins’ already suggests that these are noxious agents.  If one accepts this premise, it is entirely logical that cleansing the body of these injurious agents would have a salutary effect. Not surprisingly, the health benefits of hydrotherapy usually target very stubborn and vague symptoms and conditions that conventional medicine do not treat adequately.  It makes sense that if your own physician is not making sense of your chronic fatigue, for example, that you would entertain other options.  I get this.  Who wouldn’t want to enjoy having more energy, better concentration, an enhanced immune system or delayed aging?  But, in medicine and in life, just

Treatment for Diverticulitis Revisited

Is there stuff that you do just because that’s the way you’ve always done it?    I’ll answer for you – yes. In many circumstances, this makes sense.   For example, I stop my car at red lights just as I have always done.   I recommend that readers do the same as there is an underlying logic for this recommendation.   It is not simply a rote routine that has no rationale.    However, the particular order that we pour ingredients into a pot when making soup, may be more random than rational.    We follow the same order we always have, never pausing to wonder why or if there might be a better way. And, so it is with many practices and procedures in the medical profession. Let’s return to the medical condition of diverticulitis, which I presented on this blog recently.  Follow the link , if interested. For the last several decades, this disease has been treated in the same way – with antibiotics.   This means that physicians believe this to be an infectious disease – like st

Value-based Pricing and Reimbursement in Health Care

I am a conservative practitioner in my specialty of gastroenterology.   Compared to peers, I order fewer scope examinations, prescriptions and CAT scans.   I’ve always believed that a more parsimonious practice of medicine would protect my patients better than would a more aggressive approach.   Sure, this also means that I spend fewer health care dollars on my patients, but this is not my primary motivator.   I practice in this manner because I am convinced that in the medical profession, less is more. I am somewhat of an iconoclast as many of my colleagues for various reasons practice differently.   They might feel that my medical nihilism is depriving my patients of necessary testing and treatment. Patients over time tend to find physicians who share their philosophy.    Patients who believe that more testing and more medication is the pathway to better health will not be comfortable with a doctor like me. But, change is afoot!   I predict that within the next several year

Do I Have Diverticulitis?

I have been treating diverticulitis for 30 years the same way.   When I suspect that a patient has this diagnosis, I prescribe antibiotics.   This has been the standard treatment for this disorder for decades. I have found that diverticulitis is a slippery entity that has two trap doors waiting for physicians to fall through.   It is an easy task to miss the diagnosis.   Every physician has done this. The diagnosis can be erroneously assigned to a patient.   Every physician has done this. Recognize that the phrase ‘every physician has done this’ includes me. The diagnosis can be elusive as there is no diagnostic test that secures the diagnosis.   The technology tsunami has covered the medical landscape, as it has run over so many other spheres in our society.   Doctors and patients increasingly rely upon ‘the numbers’.    Want proof?   Do you think there are many physicians today who can actually plug a stethoscope into their ears and hear, let aloneunderstand all of

Should High Blood Pressure be Treated?

In last week's post, I promised an explanation why many screening and medical treatments offer so little benefit to individual patients.    If you invest the time to digest last week's post and the post before you now, then you will be equipped with new understanding that will enable you to make much better medical decisions.  In accordance with this blog's mission, this is truly a 'peek behind the curtain'.  I grant you that these 2 posts are a little wonky, but try to stay focused.   Here is the main reason that ordinary people – and even some medical personnel – become confused on this issue.   Studies that assess screening tests and medical treatments are often performed on very large groups of patients.   The reason for this is that smaller studies, for reasons I cannot fully explain here, are simply not felt to be sufficiently reliable.    This is why the Food and Drug Administration would never grant approval of a new medicine based on favorable resu

Does Mammography Save Lives?

I find that the public often exaggerates the benefits of many preventive health measures.   I don’t blame the public for this.   There are several forces conspiring to deceive the average patient into accepting exaggerated claims of various medical tests and strategies.    Of course, the Medical Industrial Complex is a gluttonous beast that must be fed massive quantities of medical testing and treatment if it is to survive. Most of the public thinks that medical interventions, including mammography, lowering cholesterol levels, blood pressure reduction and even colonoscopy are downright lifesaving. Recognize that I am in favor of all of these measures, but that the actual benefit to the individual is much smaller than most folks believe.   In the case of mammography, there is uncertainty as to whether it saves lives at all, a view readers can easily find with a rudimentary internet search.   Mammography experts all agree that any benefit of this screening test to the individu

Labor Day 2019

All work is honorable. Honor everyone's work. Work with honor.   The Whistleblower wishes all of you a meaningful Labor Day.

Do Patients Like Weekend and After Hours Medical Care?

I have previously expressed how physicianss feel about treating patients that they do not know in a prior post , which readers are invited to review.  This post is the other side of the story.    Nowadays, patients are used to seeing physicians who are not their doctors.  Often, patients may be seeing a nurse practitioner, a highly trained professional for their medical care, instead of a physician.  A generation ago, patients nearly always saw their own physician, including if a patient was hospitalized. Imagine that, your own primary care doctor sees you in the hospital, an event that occurred when dinosaurs roamed freely. The medical universe has changed.  Hospitalists care for most hospitalized patients, which in my view, has vastly improved the quality of hospital medical care.  It is commonplace for patients who need to be seen right away in the office, to see a doctor who is available, who may not be the physician of record.  Pregnant women today often see many obstetric

Should Doctors Offer a Money Back Guarantee?

It may seem odd that a gastroenterologist patronizes fast food establishments several times each week.  I’m in one right now as I write this.  I eschew the food items –though French fries will forever tempt me – and opt for a large sized beverage.  In truth, I am not primarily there for a thirst quenching experience, but more to ‘rent a table’ so I can bury myself in some reading.  Indeed, many thousands of New York Times issues have been devoured at these tables.  I saw a sign posted on the wall here that I had not seen before. Sorry, No Refunds Refunds?  How often can this happen in a place like this?  We all know that food items in these institutions are remarkably consistent, which is one of benefits that customers enjoy.  Your Big Mac or Whopper will taste the same in Pittsburgh as it does in Peoria.  I questioned the server on this new development and she explained that increasingly customers were demanding refunds for contrived reasons in an effort to bilk the restaur

Joining a Clinical Trial Helps Others

From time to time, I am asked by someone about participating in a medical research study.  These situations are usually when an individual, or someone close to them, has unmet medical needs.  Understandably, a patient with a condition who is not improving on standard treatment, would be amenable to participating in a clinical trial to receive experimental treatment. I find that most folks misunderstand and exaggerate the benefits they may receive as a medical study participant.  Sometimes, I feel their ‘misunderstanding’ is fueled by study investigators who may overtly or unconsciously sanitize their presentation to patients and their families.  There is no malice here.  Investigators have biases and likely believe that their experimental treatment actually works.  Their optimism is likely evident in their communications. Here’s what an investigator might say to a patient. I thought you would be interested in a new clinical trial testing a new medicine for your disease.  P

Transparency in Health Care Costs - New White House Proposal

Opaque:   adjective, not able to be seen through; not transparent Medical pricing is beyond opaque.   It’s a riddle wrapped in a mystery inside an enigma.   Many readers will recognize that this clever phrase is not my own. Throughout my career, I have been unable to provide an accurate answer to the perennial inquiry, how much does a colonoscopy cost?   Patients, of course, find this to be baffling.   This ignorance is certainly not restricted to my specialty of gastroenterology.   Does it make sense, for example, that the same medication may have wildly different pricing at different pharmacies or in different cities?    In contrast, we would expect to find a similar price for a gallon of milk among supermarkets.   My strong suspicion is that seemingly irrational, inflated and complex medical pricing is all by design to serve those on the billing end – hospitals, pharmaceutical companies and pharmacy benefit managers.   Before you accuse me leaving physicians off of thi