Sunday, January 27, 2019

Diagnosing Sleep Apnea - Leave it to the Amateurs!

It seems that there is an epidemic of obstructive sleep apnea (OSA) out there.  Snoring, a harbinger of OSA, seems to have captured the national attention, at least judging by the ubiquitous ads I am subjected to hourly on the radio.  Gastroenterologists routinely inquire about the presence of OSA in our patients as this may increase the risks of sedation and anesthesia. 

Most patients with OSA are undiagnosed.  Many of them are not aware that the condition troubles them, but experts warn of potential long term consequences if the condition is not treated.  The diagnosis is classically made after an overnight sleep study when the patient is monitored.  I have equal confidence in the diagnostic skills of those who sleep in the same room as the individual at home.  For example, if a patient’s wife tells me that her husband regularly (and fortunately temporarily!) stops breathing during sleep, I think that the diagnosis has been securely made.  In these cases, I am unsure how an overnight sleep study would alter the treatment plan, but I suspect that most sleep physicians would still recommend it.

Why is everyone so tired?

The usual treatment is for the patient to don a clumsy and noisy helmet apparatus called CPAP while sleeping.  Many patients find this remedy to be worse than the disease and have eschewed this recommendation.   I expect that technological innovation will make progress on this front.

I offer readers an interesting side note on one of the warning signs of OSA – snoring.  I find that patients often regard snoring as if it were a moral failing.  For example, if I ask a patient if he snores, he may point to his wife in the exam room exclaiming, “you should hear how loud she snores!.   This scenario has repeated itself over the years and always amuses me.   Snoring isn’t a vice that needs to be minimized by pointing to a fellow sufferer.

Sleep is important and most of us don’t get enough of it.  Wouldn’t life be better if an afternoon siesta became a daily routine in our culture?  

Sunday, January 20, 2019

Physician Weight Loss Tips

Although I have confessed that I am not a seasoned expert in this field, here are some tips and pointers I’ve gleaned over the years.

Slow and Steady Wins the Race!

  • Avoid gimmicks.  We’ve all seen ads and telemarketing pitches that promise to melt off pounds by the hour.   These products are very effective for the companies, but not for you.  They don’t work.  Yes, you may enjoy some short term weight loss for as long (or short) as you can stay motivated, but the chance of keeping the weight off is vanishingly small. 
  • You don’t have to be perfect.  Allow yourself some backsliding and seek continued motivation from these events.  The path to your successful destination may include some zigzagging.
  • Weight loss medications don’t work well.  Of course, the notion of a pill solving any medical problem is seductive, but the history of weight loss medications includes an array of side effects and relatively modest results. 
  • Bariatric surgery, including gastric bypass procedures, has made great strides in recent years.  I have seen many successes and failures in my practice.  These procedures will not work unless the individuals have made the difficult mental commitment to a profound life changing procedure that will be present every day of their lives.  In my view, these procedures should not be casually or prematurely entertained.  Is a candidate for surgery unable to lose sufficient weight in any other way?   If the candidate couldn’t stay motivated to stay on a diet, will they have the motivation to make surgery a success?
  • I recommend partnering with a professional, such as a dietician, to offer guidance, support and accountability.  If not, recruit a family member or a friend to serve as your coach.
  • You will not exercise the weight off.  Patients lament to me all the time they can’t understand why their weight stays the same or even creeps up despite their walking and exercise routines.  To burn off serious weight, a person would have to intensely exercise for hours and hours each week – far beyond the capacity and willingness of almost all of us.  From a weight loss perspective, a more successful strategy is to restrict the calories that are coming in rather than burn them off after they have been swallowed.  In other words, eat less. 
  • Set reasonable and achievable goals for yourself.  
Achieving sustained weight loss is hard.  If it were easy, all of us would be skinny.

Sunday, January 13, 2019

Memorial Sloan Kettering in Bed With Industry

Is there corruption in the medical profession?  Recall Captain Renault’s iconic rejoinder to Rick in Casablanca.

“I’m shocked, shocked to find there is gambling going on in here!”

In any enterprise with billions of dollars at stake, and when different players have competing interests which may not coincide with the public’s interests, there will be skullduggery.  How do you think our Defense Department and its relationships with vendors would look if we were able to shine a bright light on all its faces?  Do you think it’s possible that a weapons manufacturer might argue, through lobbyists and salesmen, that its weapons are essential to national security and superior to those of a competitor?   How about when a congressman argues for the continued purchase of military equipment manufactured in his district that military experts state is no longer needed?  And, there’s the quintessential and craven corruption of legislators refusing to close military bases in their districts that the military want to close down.

And, so it is with the Medical Industrial Complex where the arena is filled with jousting pharmaceutical execs, hospital administrators, insurance companies, the government, medical device companies, physicians, pharmacy benefit managers, politicians and the public – all competing to protect their interests.  Does this system seem optimal to achieve a greater good for society?

Recently, the Chief Medical Officer of the Memorial Sloan Kettering Cancer Center in New York City ‘resigned’ in the wake of disclosures that he failed to disclose financial relationships with outside health care companies.  In other words, it was a failure to disclose that ousted him, not the conflict.
Here’s my riposte to this.  The obvious weakness in our current disclosure policy is that the emphasis is on the disclosure and not the conflict.  Following nearly every medical article that I read, appears a long list of disclosures, often in small font, listing the various business relationships that the authors have with various companies.  Apparently, in the authors’ and the editors’ minds, the disclosures have provided them with adequate ethical insulation.  They argue that readers can weigh the disclosures when they assess the authors’ credibility. For example, if an article is extolling a new diagnostic test, readers may be informed that the author is a paid speaker for the company that manufacturers the test.  The actual conflict, however, remains. 

Over the past 10 years or so, practicing physicians and scientists have been so deluged with disclosures in our journals and at our professional meetings that we have become numb to them.  (How carefully do we listen to the safety presentation given by flight attendants prior to take off?)  The ongoing tsunami of medical disclosures have vitiated their potency, and as I stated above, do not address the actual conflicts. 

The connections between medical science and medical industry can create great benefits for humanity.  I accept and encourage this.  And, I’m all for full disclosure.   But, personal and institutional integrity must be paramount.  Oftentimes, the conflict itself should be disqualifying and no simple disclosure should be permitted to cure it.

Addendum:  The Chief Medical Officer who 'resigned' was immediately hired by... yes, you guessed it, a pharmaceutical company!  And, Sloan Kettering (SK) now prohibits its leaders from serving on corporate boards.   Can we assume this to be an admission that SK now recognizes that such business relationships are improper or did they simply feel the optics were uncomfortable.

Comments, confessions, and disclosures welcome. 

Sunday, January 6, 2019

Medical Device Sales Rep Kills the Sale

A few weeks before writing this, two device salesmen came unannounced to our small private gastroenterology practice.  They were hawking a product that could quickly and non-invasively determine how much scar tissue had formed in a patient’s liver, a useful tool for assessing patients with hepatitis and many other liver conditions. 

We are physicians, not entrepreneurs.  We do not regard the colonoscope as a capitalist tool.  Yet, these two salesmen were barraging us with facts and figures on how much money we could make off their product.  They knew the insurance reimbursement rates and could quickly calculate our practice’s return on investment depending upon our projected volume.  They recognized that the cost of their device would be beyond our reach and offered to sell us a ‘refurbished’ product at a huge discount.

Liver Sales Reps Ignored the Liver!

For a host of reasons, we were not interested in acquiring the device, which we could not afford.
Here’s what was so striking.  Not once did either of them mention, even by accident, that their product was a device that might help a human being.   These guys were so clumsy and so transparent that they weren’t even adept enough to feign an interest in contributing to the health of liver patients.  Of course, we would have seen right through this pretense anyway, but at least they would have gone through the motions with the hope that we might not have recognized their charade.

Afterwards, our office manager was deluged with e-mails beseeching us to reconsider our refusal, offering ‘new and improved’ calculations that promised us profitability.  And, borrowing a technique from late night infomercials, they now offered an even steeper discount on a newly discovered refurbished product that was a deal they advised that we should not pass on.

We have many sales folks who come to see us.  Of course, we understand that they are selling products.  But a true sales professional understands his customer, and these guys massively misfired.  We are physicians, not hedge fund managers who regard income generation as our primary objective.  How should salesmen sell to doctors?  When device or pharmaceutical representatives come to see us, they are best poised to sell us on how their wares can help our patients improve their lives.  The product that can sell itself, sells best.