Sunday, December 29, 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 this point, which of the following options are most reasonable?
  • Do not scope the stomach now as the patient is still sedated from the colonoscopy and cannot give consent.  Once the patient has awakened and recovered, discuss the new diagnostic hypothesis and obtain informed consent to examine the stomach to look for a bleeding site.
  • Forge ahead with the stomach scope exam while the patient is still sedated.  Assume informed consent and proceed.
I opted for the latter option.  Ethically, I felt that I was on terra firma as the patient had already consented to a colon exam to evaluate the bleeding.  It seemed absurd that he would have consented for a colonoscopy but withhold consent for a stomach exam that was now deemed essential to pursue the same diagnostic mission.   Moreover, the patient had received multiple transfusions so there was clearly a medical urgency to identify the bleeding site.

Assuming consent for a subsequent procedure that was not initially anticipated is rational and defensible if the test is clearly in parallel with the medical evaluation and there is a medical exigency present.  Presuming informed consent, however, is an exceptional event.  Physicians are not permitted to go rogue. 

The blood in the colon didn’t come from the colon, as I had wrongly suspected.  It came from a duodenal ulcer just beyond the stomach, which I easily spotted with the stomach scope exam. 

This patient didn’t go by the book.  Sometimes, we physicians need to deviate from established policies also. 

Sunday, December 22, 2019

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!

While the republic survives,
And impeachment will fail,
This won’t be the end
Of this harrowing tale. 

It’s easy to break
And harder to build
Has hope for our healing
Already been killed?

Let’s join together
In this land of plenty,
As we strive to get through

Joy and Peace!

Sunday, December 15, 2019

'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.

Physicians, as members of the human species, cannot be as objective with regard their own families or themselves as they are with their own patients.  This is why wise physicians do not treat family members.  Indeed, every physician has heard vignettes of inferior care that was rendered by a doctor to a close family member.   The reasons for this are beyond what I can express here, but the core of the explanation is tainted physician judgement resulting in delayed diagnoses and incorrect treatments.  When a close relative recently approached me to discuss recurrent stomach aches, I gave her good advice.  Make an appointment with a doctor.

Another circumstance when physicians are known to provide inferior care secondary to judgement lapses is when the doctor is treating a celebrity or VIP.

If you ask your doctor what he would do if he were you, the doctor’s response should be an explanation of why he can’t give you the answer you seek.

Sunday, December 8, 2019

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 school was sitting with us students as this discussion unfolded.  The chief was a veteran physician and had trained several scores of OB-GYN physicians.  While this is not a scientific study, in this physician’s opinion, male gynecologists and obstetricians in the training program were consistently kinder and more understanding to patients than female physicians were.  The chief speculated that females, contrary to prevailing intuition, might be less empathic as they’ve had menstrual cramps, etc., and' they’re not that bad’.  Men, in contrast, might be more sympathetic to female pains and conditions as they tended to be spooked by symptoms that they will never have.

I am not offering an opinion on the issue, but am simply relating one chief's view.

Do you think the chief was male or female?  Might this have influenced the chief’s conclusion?

Is the chief right or wrong?   Can’t say, but it was interesting and I’ve never forgotten it, even 30 years later.

Sunday, December 1, 2019

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.  I have also had the experience where my seemingly innocent words hurt someone as I was not aware of some personal experience that rendered the individual understandably sensitive.   For example, if someone recently lost a loved one, they may not find a cemetery joke to be amusing.

But, do you agree that it seems easier than ever to offend folks these days? 

I am growing tired of Offensomania, an epidemic of offenses being perceived in nearly every corner of our society.  Folks are now ‘deeply offended’ after reading a newspaper article, attending a lecture, seeing a TV advertisement, witnessing a claim of intolerance, watching cable news, reading about educational curricula, viewing artwork and hearing normative political discourse.

'You have offended me.  En garde!'

Reasonable disagreement on the issues of the day should be expected and welcome, but why does every little think provoke claims of offense?

Does a day go by without some person or organization threatening a protest or a boycott?  A corporate executive can lose his or her job over an utterance or a tweet from years back in order to mollify the offended 'victims'.  Think about that, losing your job because of some silly stuff you said or did years back, particularly when standards may have been different?  I wonder if Al Franken agrees with me on this point?

I’ve read thousands of newspaper columns and I never recall feeling offended by any of them, though  I’ve certainly disagreed with many of them.  I’ve read hateful and ignorant words, especially in the past 2 years.  Sadly, I expect to read more of them in the next year.  But, they won’t offend me.  That’s not to suggest that contemptible views don’t merit a vigorous response – they do and I hope to be part of that voice.  But, I won’t claim to have been personally offended. 

I truly believe there are folks out there who are contriving offense to serve some other interest.  Think this over the next time - which will probably be today or tomorrow - that someone is professing some great offense over some item or event.  Do you really believe the offense is real?

There was a joke back in my college days.  A young student sees a protest on campus.  “Hey, I’m joining with you guys.  Whatever you’re protesting, I’m against it too!”

I know that true offenses occur because I’ve been a perpetrator and a recipient. But there’s a false epidemic that is fueling many agendas, careers, campaigns and organizations.  And, yes, this deeply offends me. 

Sunday, November 24, 2019

Thanksgiving 2019

Behold the denizen who has bravely entered our property so close to Thanksgiving!

Wishing all of you a great holiday.

Sunday, November 17, 2019

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 signal a serious medical condition.
  • Pt may not need the same dosage of the medicine.
  • Pt may not need the medicine at all.
  • Pt may be on new medications which might impact on the decision to refill the heartburn drug.
  • Pt may be overdue for a screening colonoscopy.
  • Pt may have general medical issues and needs to be encouraged to follow up with the primary care physician.

It might be tempting for one of our staff to ask me for antibiotics because ‘I have another UTI’.  My secretary might hope that with one phone call, I can save her time and money.  While she may be an able secretary, she may be a lackluster diagnostician.  Many of my own patients come to my office ‘because their diverticulitis is back’.  While their symptoms may remind them of their first episode of ‘diverticulitis’ last year, often the actual medical evidence supporting the original diagnosis is rather thin.  I can’t count how many of these patients have never had diverticulitis. 

Prescribing you medication is a serious responsibility.  It’s not an act that should be casually done with a stroke of a pen, or these days, with a stroke of a key.  Wouldn’t you want all the odds to be in your favor? 

Sunday, November 10, 2019

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 dollar for every time someone asked me about their gas…”
  • “Hmmm.  Sounds interesting.  Do you have any corks at home?”
  • “Call the gas company.  When we had a gas leak in our house, they simply fixed the pipe with a blowtorch.  Maybe your husband has the same problem.”
  • “I would call your husband’s doctor.  I suggest around midnight when you know he’ll be available.  Much better than calling during office hours and dealing with that office rat race.”
  • “Are you sure it’s gas?  Have you heard about the light-a-match gas test?”
  • “Your say your husband has gas?   You should hear what he told me about you!”
Cows pass methane orally and rectally

The point is that physicians generally defer from giving medical advice to folks who are not our patients.  Even a seemingly innocent query can have serious ramifications.  I would not want to give casual advice to non-patients who have questions about last month’s chest pain or if it’s safe to travel to South America before a cardiac stress test next month. 

This is not just true for doctors.  Try asking a financial planner you meet at a party if you should unload your stocks based on the market’s behavior that day.  Ask an attorney who does not represent you if he thinks you are better off settling your case or proceeding to trial. 

Professionals cannot be flip about rendering advice, particularly to strangers.  Consider this hypothetical.  I’m out to dinner and my friend’s wife, who is not my patient, asks if she should double up on her Nexium because she’s still getting heartburn.  I say yes.  But what she thinks is heartburn is really angina.  My casual remark may make me an accomplice to a catastrophe. 

So, don’t ask me about your husband’s flatulence if he’s not my patient.  Bring him and his gas to my office and we will do our best to deflate the situation.

Sunday, November 3, 2019

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 the dangers of seeking a second opinion, as this opinion may be different, but not superior to the first one.  Patients have a bias favoring second opinions as they harbor dissatisfaction, or at least skepticism, with the original medical advice.  

Whose Advice Carries More Weight?

Here are some scenarios which should be governed by medical judgment.
  • A 60-year-old woman with severe emphysema uses an oxygen tank.  She has never had a screening colonoscopy.  Professional guidelines suggest that screening begin at age 50.  Does a screening colonoscopy make sense for her considering her impaired health?
  • A 40-year-old man has had 1 week of stomach pain.  This started 10 days after he took daily ibuprofen for a sprained knee.  The physician suspects that he might have an ulcer.  Should this patient undergo a scope examination to make a definite diagnosis?  Should the doctor prescribe anti-ulcer medication without determining if an ulcer is present?  Should the ibuprofen be stopped if the patient states he has significant pain if he does not take it? 
  • An 80-year-old woman had some recent dizziness and nearly fainted.  The doctor sees her in the office two days later and questions her carefully.  He suspects that the patient was simply dehydrated.  Should the doctor simply reassure the patient or arrange for a neurologic evaluation to make sure that a more serious condition is lurking? 
Of course, you want your doctor to know a lot of stuff.  More importantly, you need a physician who can give you sound and sober advice.  Knowledge and scholarship are important physician attributes, but practicing medicine demands more.  At least, that’s my judgment.  What do you think?

Sunday, October 27, 2019

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 yourself 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 story, The Birthmark, which speaks so elegantly to this issue, despite that it was published in 1843.

There is an important role for plastic surgery in the medical arena.  These talented professionals perform amazing work in reconstructing folks who have suffered trauma and accidents.  I also recognize that cosmetic surgery provides significant benefits to many patients.  However, it is beyond dispute that our society is preoccupied with physical appearance and is striving for an idealized an unrealistic level of beauty.   Many folks blame Barbie who convinced generations of girls and women that she was the paragon of beauty and attractiveness.   

Ladies, slip into these comfy slippers!

A few days before I penned this post, I read about women who bring designer shoes to podiatrists so they can have surgery that will permit them to wear their choice of stylish footwear.   Indeed, there are foot surgeons who specialize in these procedures.   My reaction?  Outrageous.   We’re not referring here to correcting podiatric deformities.   Can a doctor defend performing surgery on healthy feet so that a pair of shoes, probably not designed for a human, can fit in?  I am sure that there are analogous absurd examples of surgeries and procedures involving other body parts that should embarrass the medical profession.

Patient demand doesn’t justify medical excess.   Physicians need to call out abuses in our own house.  I expect that those practitioners who are bringing disrepute to the profession will claim that they are fulfilling an important medical function.  I say, if the shoe fits…

Sunday, October 20, 2019

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 phenom.  And, there were polite disputes among experts who were debating the true identity of the creature before them.  All in all, this was good clean fun.

Birders need knowledge and patience.  In addition, the most accomplished among them must have discerning powers of observation.  Here’s how I spotted a bird.  I simply came upon real birders who were all aiming their scopes and binoculars in one direction, and then tried to spy their target.  The skilled birder, the first on the scene, does not have this advantage.  He carefully scans the trees and foliage trying to find small birds, which are obscured by leaves and branches or camouflaged.  This looks easy, but it isn’t.  Many times, I had trouble finding the bird even when several birders next to me were staring at it.  This didn’t ruffle my feathers as I knew I was a few rungs below the beginner class.

You have to know what to look for, which is the distinguishing skill.  The pro knows the flora and which birds are likely to hang out there.  He sees the subtle moving of a small branch and knows this is not from the wind.  He knows the birds’ voices as individual arias, not as idle whistling.  He tunes out the visual and auditory static.

Easy to Spot 

Not so Easy

The power of observation used to be a honed skill of the medical profession.  Prior to the takeover of the profession by medical technology, physicians could deduce much simply by carefully observing the patient.  While medical educators may state that this skill is still valued, taught and practiced, this quixotic view isn’t part of the reality of medical practice today.  During my days in medical school, I recall learning from experts who could ascertain important medical information by examining a patient’s fingernails.  Palpating the pulse, and appreciating its nuances and subtleties, was an art, and not simply a means of determining the heart rate.  As a medical student, I watched Proctor Harvey, a giant in cardiology, use a stethoscope to hear sounds and make accurate diagnoses that are beyond the skills of nearly all of today’s physicians.   A patient’s speech, gait and skin often held important clinical clues for the physician detective.

I don’t’ think that medical quality is worse today because today’s physicians are not trained to observe.  Instead of observing, we test.   Nearly every heart murmur is subjected to echocardiography, as but one example.  The consequences of overtesting has been overblogged here at MDWhistleblower.  Readers know my serious concerns about overdiagnosis andovertreatment. Technology has both raised and lowered medical quality in this country.

I am wistful when I recall physicians and teachers from two generations ago, who could solve a case with their eyes and ears.  They would have been incredible birdwatchers. 

Sunday, October 13, 2019

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 because one pathway seems blocked, doesn’t mean that an alternative pathway will be a better avenue. 

Let the Cleansing Begin!

The reason that I do no actively recommend hydrotherapy is because there is absolutely no persuasive and credible medical evidence that it is effective.  While their advertising materials may boast of ‘clinical studies’, there is no firm scientific basis for their claims.  And, these sessions can be costly as patients are often advised that several visits are necessary to address years of toxin build up.

If gastroenterologists did believe that the treatment works, we would be offering it in our ambulatory surgery centers along with our standard endoscopic amusement activities.  (A cynic might suggest here that if medical insurance covered these treatments, then we would!) 

It may very well be that practitioners of this treatment believe in the therapy and genuinely want to provide healing.  And, I have no doubt that many who undergo hydrotherapy feel better.  I’ll never talk a patient out of success from my or anyone’s treatment.  If a hydrotherapy patient were to tell me that his depression has eased, I would express great satisfaction over this.

I admit readily that I, along with every other breathing physician, prescribe treatments and remedies for which no supportive medical evidence exists.   We physicians may sanitize this fact by claiming that our action is an example of ‘the art of medicine’, but we are more likely hoping for the placebo effect.  

Physicians who deviate from evidence-based medicine shouldn’t casually criticize other practitioners who practice off the grid, particularly when patients have great faith in complimentary and integrative medicine.

However, all of us who claim to be healers should aspire for supportive scientific evidence for our recommendations, and we should admit to patients when such evidence is lacking. 

If you opt for periodic colonic cleanses, and you perceive a personal benefit, then be aware that you are engaging in an ‘art’, and not a science.  

Sunday, October 6, 2019

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 strep throat – caused by bacteria.  But, the real reason I think that physicians like me prescribe antibiotics for this condition as because that’s the way we’ve always done it.

Changing established medical practices is like having an ocean liner make a U-turn.  It’s not easy.  For example, when I was a medical student, kids with red ear drums, or otitis, were routinely given antibiotics, assuming that this was a bacterial infection.  But, after a few decades, experts concluded otherwise.

Not Easy to Make a U-Turn

Similarly, I have a strong sense that the established treatment for diverticulitis may be revised.   The classic understanding of this disease was that this was a bacterial infection in the wall of the colon.  The theory was that a tiny puncture would develop in one of the diverticula, which are pouches that are weak points in the colon.  Germs from inside the colon would travel through the puncture site to the outside wall of the colon, which is usually sterile, and an infection would start.  We prescribe antibiotics and the patients generally recover well. 

But, should the antibiotics really get the credit?  What if these patients would have recovered anyway on their own?  I believe many of them would have.   In fact, many patients who have had diverticulitis, often have had episodes that recovered spontaneously without having seen a physician. 

In fact, a prominent gastroenterology professional society recently issued guidelines that expressed that not every case of diverticulitis requires antibiotic treatment.   It may take another 10 years for this recommendation to gain traction. 

I’m not abandoning antibiotics for diverticulitis in my practice yet.  But, I am following the issue closely in the journals.  There needs to be a better reason to do stuff than simple habit and routine – and that includes reading this blog.

Sunday, September 29, 2019

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 years, if not sooner, that my practice style will become normative.  Why would this occur?   Why would physicians who were heavy on the medical utilization gas pedal suddenly be pumping the brakes?  

It’s the reimbursement, stupid.   Soon, physicians and hospitals will be paid differently.  Value based pricing will become the means of reimbursing health care providers and institutions.   So long, fee-for-service, a system that rewarded the medical profession for excessive and unnecessary care.  Payers will reward physicians and health care systems that deliver favorable outcomes that are cost-effective.   Not surprisingly, when physicians and hospitals have a financial stake in how they practice, the practice style arc bends.   It’s a law of economics that folks spend other people’s money faster than they would their own.   Do you order differently off the menu when someone else is picking up the tab?

I think I'll order the steak tonight.

Changing the reimbursement policies will make sausage making seem appealing.  Remember, every example of excessive medical care is someone else’s income.  It is unlikely that those who will lose out will champion an effort that might cost them money. 

No system is perfect.  Every reform proposal poses conflicts that need to be exposed and addressed.  We all want high quality medicine that is delivered efficiently.  If, however, there is too much zeal in achieving cost savings, then this could adversely affect quality.   We need to ensure that we remain true to our primary mission which is to protect the health of those whom we serve.   The current system desperately needs to be reformed.  But, we want what emerges to be a step forward on a journey that may take a decade or longer to reach the destination.  If we simply exchange one set of problems for another, then we have traded quicksand for falling off a cliff. 

So, let’s look for the pharmaceutical companies, physicians, hospitals, insurance companies, the government, medical device companies, extended care facilities and the public to join hands as they sway in a Kumbayesque moment all pledged to serve the greater good. 

Sunday, September 22, 2019

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 those clickety-clackety heart sounds?  And, if they do, they order an echocardiogram anyway. 

Hey, what's this new fangled contraption?

The medical community and those we serve are hyperfocused on objective data - stuff that can be measured.  Here are 3 examples of seemingly reasonable questions that I believe often miss the mark.  

What did the CAT scan show?  
Did the tumor marker decrease?   
Is my carotid arteries screening test normal?  

A more relevant question, such as, how is the patient doing?, is ignored or relegated to a lower priority status.  Who cares if the tumor marker goes down if the patient doesn’t feel any better? 

So, when diverticulitis is a consideration, a physician actually has to act like a doctor.  Sure, a CAT scan can be consistent with diverticulitis, but many other conditions can precisely mimic this CAT scan appearance.  So, the physician has to make a ‘clinical diagnosis’ of diverticulitis.  This means that the doctor must analyze all of the data – your symptoms, the labs, radiology results – and then make a judgment.  A common error is when the diagnosis is prematurely made based primarily on the CAT scan, without weighing other factors.  A clinical diagnosis of diverticulitis can also be made without a CAT scan or laboratory data.  Yes, the doctor can actually perform old fashion doctoring, which has become rather quaint these days.

In my practice, many patients who come to me complaining that they are experiencing a ‘flare’ of their diverticulitis are mistaken.  There is some other explanation for their stomach pain.  Or, the patient may state that the pain is identical to a prior episode of diverticulitis, but often the original diagnosis of diverticulitis was incorrect or uncertain.  Yes, I admit again there is always the chance the patient is right and I am wrong, but hopefully my decades of training and experience are worth something. 

My points above are certainly not restricted to diverticulitis.  They cross into every medical specialty.   Technology and objective data too often are wag the dog.  Who do you want evaluating your medical symptoms, a physician or Alexa?

Sunday, September 15, 2019

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 results from small studies.   If a benefit or a failure is shown in a high quality study with hundreds or thousands of participants, the results will be highly credible.   It was large studies, for example that demonstrated that blood pressure control prevented serious complications. 

Here is the key point.  When a medical benefit is established in a large study, this benefit applies to a large population of people.   When this medical test or treatment is later applied to an individual patient in a doctor’s office, the benefit that this person receives may be miniscule.   This reality is not appreciated by nearly all patients I have treated in nearly 3 decades.  If a patient reads about a study that concludes that losing excess weight will cut the risk of stroke by 30%, the patient is likely to make 2 false assumptions:

He overestimates his risk of stroke.

He overestimates the true risk reduction of losing 10 lbs.

If his risk of stroke is already very low, then reducing it by 30% offers almost no benefit.  Follow the next example.

Will Lowering My BP Save My Life?

Assume a study of 5000 patients with high blood pressure demonstrates that lowering blood pressure 10%, can halve the risk of developing a heart attack.  This sounds like a game changer, but not to an individual patient, such as any person reading this.  The benefit is derived from studying a large population.   Assume that without treatment that 100 patients of the 5000, or 2%, would suffer a heart attack in 10 years.  With blood pressure treatment, only 50 patients would suffer this outcome, a 50% decrease in the adverse event.   Wouldn’t it be true that an individual patient would also have a 50% risk of developing a heart attack?  Yes, but let’s play this out.

A patient comes to the doctor with modest high blood pressure and no other cardiac risks. The patient has read about the landmark study that concludes that treatment would halve his heart attack rate.  Let’s assume, that this person’s risk of developing a heart attack in 10 years is 3%.  That means that this individual already has a 97% chance of staying well without any treatment.  Treating this patient would lower his risk of a heart attack from 3% to 1.5%, representing the 50% benefit we have been discussing.  So, with treatment, he now has a 98.5% probability of avoiding a heart attack.  Would someone enthusiastically take lifelong blood pressure medicine for an additional 1.5% protection when he already was 97% in the clear?   Would most of us welcome this return on investment?  I am not even considering the costs of many of these treatments and the potential side effects.   

When large studies’ benefits are applied to individuals, the benefits calculate out very differently. However, treating hundreds of thousands, or millions of people with elevated blood pressure would save many of them simply because we are dealing with large numbers of people.  A percentage point or two of a million people is a respectable number.  That’s why it makes sense to treat many diseases from a public policy standpoint.  The point is that each individual only enjoys a very modest benefit. 

I hope that readers have found this post – and the blog overall – to offer a very high return on investment.   Your comments are always welcome. 

Sunday, September 8, 2019

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 individual patient is very modest.  This is not my opinion; it is a fact.  And yet, most women, including the women in my life, believe that this test offers them solid protection.

Mammography - True Lifesaver?

If I am correct that the individual enjoys only very modest benefit from these routine medical interventions, then how did they gain a permanent foothold in the medical landscape?

Why would physicians zealously recommend tests that were of such limited value?

Why would insurance companies and the government pay for such testing?

Why would patients submit to tests or lifelong medications that offered a very limited benefit?

Why are so many of us unaware of this issue?

As I do not want this post to be double my usual word count, I will provide you next week with a detailed response on this issue.  I strongly urge you to check back here next Sunday for an opportunity to inform and empower yourselves.   I’m not against screening tests or established medical treatments.  I’m for the truth. 

Sunday, September 1, 2019

Labor Day 2019

All work is honorable.

Honor everyone's work.

Work with honor.  

The Whistleblower wishes all of you a meaningful Labor Day.

Sunday, August 25, 2019

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 obstetricians in the group since it is unlikely that the patient’s designated obstetrician will be on-call on D-day.  One of Cleveland’s corporate medical giants boasts that they offer ‘same day appointments’, which is true if a patient is willing to see a medical professional several zip codes away, not the patient's actual doctor.

In the olden days, one doctor did it all.

Understandably, if you call your physician after hours or on the weekend, you will most likely connect with one of your doctor’s partners.  This is why it is not advisable to call the emergency on-call physician 9 pm for a conversation about your chronic arthritis.

Patients are now used to seeing strangers prescribing their medications and ordering their diagnostic tests.  Hospitalized patients may be treated by several physicians they do not know. They have adjusted as best they can, but there are obstacles and drawbacks to this medical care paradigm.
  • It is unsettling for patients to be confronting several medical professionals for their care.  Similarly, if you are reading 4 or 5 books at once, are you really able to keep the separate stories straight in your mind?
  • There is unavoidable loss of continuity when there are multiple physicians at the table.  Hospitalists do a great job.  But, do we really think that all of the nuanced knowledge and objective data can be seamlessly transmitted to your primary care physician whom you will see after you are discharged?
  • What if different primary care physicians who are seeing the same patient have different opinions?  Who does the patient believe?
  • Even in the computerized era, it’s astonishing how often new physicians do not have easy access other physician’s medical records.  Does the weekend physician consultant who is seeing you in the hospital know that another doctor already ordered an ultrasound of the gallbladder a few months ago across town?
  • When there are too many physicians involved in a single patient’s care, medical testing and costs tend to increase, which does not increase medical quality.  In my experience, a new doctor is more inclined to order a medical tes, than to advise watchful waiting, a strategy that the doctor who knows the patient well would more likely rely on.  For example, if I see a patient I know for years with the same stomach pain, I may react differently than another gastroenterologist seeing him for the first time. 
Oftentimes, patients and physicians meet as strangers.  This reality creates many challenges.  Both sides need to be understanding.

Sunday, August 18, 2019

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 restaurant.  At some point, the restaurant decided to put an end to this practice. 

Refund Free Zone!

I wonder how my patients would react to being greeted by such a sign in my office?  Of course, physicians do not offer refunds or a money back guarantee for our services, as other industries boast.  Nearly every infomercial includes the tag, “and if you don’t agree that these _____  are the best you’ve ever used, simply return it for a full refund – no questions asked!”  Not so in the medical profession.   We are paid regardless of the outcome or your satisfaction.  It is true that physician reimbursement policy is evolving away from fee-for-service (FFS) toward a value-based system.  In other words, physicians won’t be paid separately for every medical service we provide you, but for the overall ‘value’ we provide, which is a somewhat amorphous concept.  FFS clearly incentivizes the medical profession to overtreat patients because we are paid more for doing more, even if such care may not be truly necessary.   It remains to be seen if the value-based payment approach will protect patients and be fair to physicians. I have my doubts.

Many professionals are paid regardless of how their clients fare.  It you lose your case in court, your lawyer will still be paid.  If a judge is overruled on appeal, his wages aren’t reduced.  If your investment underperforms, your financial planner doesn’t return his fee to you.  Tradesmen, on the other hand, make a commitment to satisfy us as a condition for getting paid.  If we hire a plumber to unclog a sink, for example, he understands that if he doesn’t deliver, then we won’t either. 

What if all of us were paid on results rather than on time expended?  Would this lead to higher quality goods and services?  Could it really apply to the medical profession?  If a patient comes to see me with abdominal pain, which often defies explanation even after a thorough medical evaluation, is it fair that I wouldn’t be paid if the patient’s pain persists?

None of this applies to Whistleblower readers.  These posts are free so don't ask me for refund.  

Sunday, August 11, 2019

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.  Preliminary data show promising results. 

If you were a patient, wouldn’t you infer that the drug might help you?

Patients, I have found, are of the mistaken belief that they may directly benefit from the drug being tested.  Of course, this makes sense to them.  Their rheumatoid arthritis drug isn’t working.  They are informed of a clinical trial of a new treatment for patients who do not respond to conventional treatment.  Obviously, they enter this trial with the hope that their condition will improve.  Unfortunately, this is the wrong way to approach a medical study.

Louis Pasteur - Legendary Medical Researcher

Clinical trials are not designed to benefit the participants.  They are performed to generate new knowledge that may help future patients.  This is the key point that so many study participants are not fully aware of, and they should be.  The investigators do not know important data about safety, efficacy and dosing.  These are among the fundamental data that the study – and future studies – will determine.  If medical investigators knew that the drug actually worked, then there would be no need for a clinical trial.  There’s a reason behind the term experimental treatment.

If you want to enter a clinical trial, know that you are doing so to help others who will come after you.  This is a selfless and praiseworthy event.   Indeed, we have all benefited from the sacrifice and altruism of prior patients who agreed to create new knowledge to help us.   If we enter a study we may not personally receive a return on investment for our efforts, but we are paying it forward to others.

Sunday, August 4, 2019

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 this list of Greed & Shame, may I remind you that we physicians do not set our own prices; they are all dictated by the payors.  When we send you a crazy bill, it is all according to your insurance company requirements and policies - not us.  Same for the copays patients fork over when they come to see us.  While we are the target of griping and sniping, these cash extractions are mandated by your insurance companies.

The medical arena is unique.  It does not allow consumers to utilize price comparison as they do when purchasing appliances, vacations, private schools,  apartment rentals or an apple.  It is unlikely that one would sign an apartment lease without being told what the monthly rent charge would be.   But, we will proceed to a CAT scan examination without knowing the cost or if a nearby competitor can provide the same service for less.

Fairly Easy to Determine the Cost Before the First Bite

Recently the White House launched an initiative to require physicians and hospitals and insurance companies to inform patients of the costs of medical care in advance.   Of course, this concept should be welcomed and applauded.  Push back against it was locked and loaded before the new policy was announced.   Who’s against price transparency?  Hospitals and insurance companies and drug companies are united in their opposition.  They claim, among other things, that they would be forced to surrender proprietary information,  that medical prices would actually increase and that the public would not be well served.   I am not an economist, but I surmise that exposing the buried secrets of medical pricing will empower the rest of us in making better choices.  Real and open competition will bring prices down, as is true in all other spheres of commerce.

Some economists are warning that this issue is extremely complex and that the outcomes may be paradoxical.  I'm willing to take a chance.

My goal before I retire years from now is to be able to tell a patient how much their colonoscopy will cost.  

Transparent: adjective, allowing light to pass through so that objects behind can be distinctly seen.