CDC Reverses Indoor Mask Policy - Are We Getting the Whole Truth?

Depending upon your politics, the Center for Disease Control and Prevention (CDC) has either shamelessly reversed course or simply issued a new guideline in response to new medical evidence. Indeed, many are hostile to the agency’s recent 'new & improved' recommendation that those who have been vaccinated against COVID-19 mask up when indoors in regions where the Delta variant is highly prevalent. The dissenters point out that this directly contradicts very recent CDC and public health expert advice that clearly stated that those vaccinated could be safely liberated from their face masks.  In fact, this demasking was offered as a direct incentive to those who remained hesitant to roll up their sleeves.  The CDC and its supporters maintain that their new policy on masking the vaccinated is based on a sound review of recent data, which they tarried in releasing. 

I am a rationalist who practices gastroenterology guided by medical evidence.  Despite some missteps, I have largely supported the CDC and have heeded and disseminated their advice.  But, in this instance, I don’t think they are being straight with us.

Making a comeback!

Here are some facts. The vaccines are performing very well including protecting against the Delta variant.  The overwhelming majority of COVID-19 cases, hospitalizations and deaths are occurring in those who have not been vaccinated.  It is within this population – not among the vaccinated – where the pandemic now lives.

We also know that ‘breakthrough infections’ in vaccinated individual is extremely rare, a fact that the CDC admits.  For example, breakthrough rate is estimated to be 0.098% for symptomatic infections, in other words, very close to zero.  The CDC now argues for vaccinated folks to mask up to prevent them from transmitting the virus if they become infected, although this seems like overkill considering that the breakthrough rate is about zero.  What is the quality of evidence that suggests that the few infected vaccinated individuals can transmit the infection?  What does make sense, of course, is for unvaccinated folks to don a mask since this is how the disease is being perpetuated. 

Since there is no way to enforce the more rational strategy that unvaccinated people wear a mask indoors, the CDC is asking all of us to do so in order to capture the unvaccinated within the new policy.  Otherwise, how could a retail store, for example, know that some unmasked customers were vaccinated or not?  They couldn’t.  In my view, the CDC has unnecessarily rolled the vaccinated into the new mask group to eliminate this conundrum.  If all of us are masked, then we know that the unvaccinated are also masked.  If I am correct about the CDC’s motives and strategy, shouldn’t they have told us the truth rather than exaggerate and mislead us about how dangerous vaccinated individuals might be?  It’s the CDC’s explanation that needs to be unmasked.

And masks won’t end the pandemic anyway.  This is a half measure at best.  The right approach is to increase vaccination rates and I anticipate that the government, employers, schools and others will be leaning hard in this direction in the near term. 

Should COVID-19 Vaccines be Mandatory?

 I think we’re headed in that direction.  There are various angles and positions to consider.  But, as in so many disputes, it’s not a matter of right and wrong but an issue of which side has the better argument. When a judge rules for one party in a dispute, this does not mean that the other side had no legitimate position.  If means that the judge concluded that an analysis of the facts and the law tilted toward one side.

We must acknowledge that an individual has a right not to be forced to accept a vaccine or any medical treatment.  The doctrines of informed consent and patient autonomy are bedrock pillars in American medical care.  If, for example, I recommend a colonoscopy to a patient with symptoms highly suggestive of a serious colon condition, the patient is free to decline my advice.  While I may feel strongly that this decision – referred to as informed refusal – is unwise, no medical practitioner or ethicist would argue that I should be able to compel compliance with my advice. 

Patient autonomy and the right to refuse medical treatment becomes murky when there is a public health dimension to the issue.  The patient cited above who declines a colonoscopy may be incurring personal risk but his decision does not threaten the community.  In contrast, an individual who refuses a vaccine threatens others and is a direct obstacle to public health efforts to protect the citizenry.  So, while the individual has rights so does the community.  The issue then become which side’s rights should prevail?

In America, there has been great reluctance to mandate COVID-19 vaccinations for various reasons.  The vaccines have still not been granted formal approval from the Food and Drug Administration. Initially, there was not sufficient vaccine supply to meet demand.  Employers were concerned over legal exposure to mandate the vaccine for employers.   And, just as we saw with face masks, the vaccines became highly politicized. 

The hope was that Americans would achieve the task voluntarily.  But we haven’t.  Even now, less than half of all Americans have been fully vaccinated.  Does this fact astonish you?

The calculus regarding mandating vaccines is changing.  The Equal Employment Opportunity Commission (EEOC) has concluded that employers may mandate vaccines providing that there are exceptions for medical disability and religious reasons.   This gives cover to businesses and organizations who are ready to take the next step. Increasingly Republican political leaders and conservative commentators – after months of silence or actual support for anti-vaxxers – are now advocating for the vaccine.  And most importantly, we are now seeing a sharp spike across the country with rising cases that are filling up hospital and intensive care unit beds in nearly all 50 states.  And it’s going to get worse.  And we know why it’s happening.  The vast majority of these cases are occurring in unvaccinated individuals.  All of this was preventable.

So, which side do you think has the better argument?

 

A New Kind of Stress Test

Readers of this blog, and those with whom I have shared my philosophy of medical practice, know that I am a conservative practitioner.   I rail against overdiagnosis and overtreatment.  Less medicine results in more healing and protection.  In an example, I have explained previously why I advise patients not to undergo total body scans, despite the lure that they offer a cancerophobic public. 

I’ve never undergone a CXR in my life.   I’ve never entered medicine’s Tunnel of Adventure, also known as a CAT scan.  My fear would be that the scan would show various internal imperfections of no meaning that would generate anxiety, expense and a cascade of medical tests to follow up on the ‘abnormalities’.  Any real patient reading this who has been around the block once or twice, will validate my scanophobia.   Not a week goes by in my practice, that I am not facing a worried patient who was found to have some trivial finding on a scan that nearly always is entirely innocent.  Often, the scan was not necessary in the first place.

Not surprisingly, I have never had a stress test.  I should say that I have never had a cardiac stress test.  As a living breathing human being, I face stress tests every day.  Not sure what I mean here?  Consider the last time you called an airline’s customer service representative.   If you have done so and have not suffered angina during process, then you are likely to have no significant coronary artery disease.  You have passed the stress test.

As I write this, I am seated in the Detroit airport, waiting for my connecting flight to take me to Boston.   Every aspect of air travel is a stress test; from the moment that I book tickets on line to the time that I sink into the plush and spacious seat that can comfortably accommodate a skinny gerbil. 

I have just discovered that my flight is delayed 50 minutes, or so they say.  I fear that the dreaded Delay Creep (DC) might set in here.  Here’s how this works.  They announce a 50 minute delay.  Forty minutes later, the delay is extended 35 minutes.  A half hour later, an announcement advises the smiling passengers that an update will be forthcoming at a time of their choosing.   DC in its purest form ends hours later with the flight’s cancellation.   My mom had this exact experience  on her way to visit me in Cleveland.  Did the $14.00 food voucher make her whole?

Air Travel is Stressful

The Wright Brothers - 1903

Patients have complained long before I earned a medical degree about unreasonable waits to see their doctor.  We do our best to run an on time shop, but there are times that we miss the mark.  Sometimes, it is our fault.  We come to the office late.  We squeeze patients into the schedule rather than add them on at the end of the day or tomorrow.  We don’t build in ‘firebreaks’ into the schedule knowing that every day brings delays that are not anticipated.  For example, if at the conclusion of a patient’s office visit, the patient’s tells me that her husband has cancer, should my response be, “Our time is up today, but please give him my best wishes”?

Sometimes, patients cause delays by arriving late or not doing the paperwork that we request to be done in advance.   Additionally, some of our elderly need extra time at home to get ready and need transportation to get to our office.  For the most obvious reasons, sometimes they just don’t make it on time despite their intentions to do so.  When this happens, which of the following responses do readers advise?

“Glad you made it!  Take a few deep breaths in the waiting room and we’ll be with you as soon as we can.”

“Back of the line, Granny!”

Some emergency rooms are using Twitter and other means to update their patients on the wait time.

Can physicians improve in their on-time performance?  We have seen in recent years that there is a potent force that can influences physician behavior.  Reimbursement.  If payment is linked to how long you have to wait for us, then our schedules will run like a Swiss chronometer.

Everyone’s time is valuable.   The next time you’re in the waiting room, consider any extra waiting time to be a gift.  This is your opportunity to collect your thoughts, read another chapter or two of a gripping novel, write a thank you note to someone in longhand or consider buying a gift for a special person for no reason.   Don’t make it a stress test.

Why I Cancelled a Colonoscopy

This morning, as I wrote this some time ago, a patient came to my office for a colonoscopy.  I sent her packing.  Here’s what happened.

In our Ambulatory Surgery Center (ASC), in my prior private practice, we introduce light into dark spaces every day.  This is where we perform colonoscopies and upper endoscopies.  We have a program in place where referring physicians can have their patients contact our ASC and schedule a procedure without seeing us first in the office for a consultation.  Obviously, we have to have a vigorous screening process in place  We do not want to meet a person for the first time for a colonoscopy and discover that he has complicated medical issues and is dragging an oxygen tank behind him.

Our screening system works extremely well, but it is not perfect.  On occasion, it misfires  The patient arrived at our office at 7:00 a.m. after a 45 minute drive.   She had ingested the required purge,  often the highlight of the experience.  I hadn’t seen her for years.  She was suffering from severe pulmonary disease, smoked cigarettes and used supplemental oxygen at night.  Clearly, this was not an appropriate patient for our out-patient facility.  Our nurse anesthetist and I conferred and agreed that we should not proceed because of safety concerns.

I explained to the patient, her husband and her daughter our reasons for cancelling the case.  It was a long conversation.  At first, she was disappointed for all of the obvious reasons.  She had endured a day of a clear liquid diet followed by ingesting our prescribed liquid dynamite to cleanse her colon.  She and her family had taken an early and long drive.  After she had ventilated her transient exasperation, she quickly came to understand that our sole objective was to protect her.

Why am I sharing this vignette?  Every doctor could relate similar anecdotes.  I share this typical scene from our practice, which I offer as an example of sound medical judgement.  We did the right thing and protected a patient’s health.  We considered the risks and benefits of the procedure and sedation, and chose safety.  Doctors (or patient) shouldn’t try to get away with stuff.

When the Medical Quality Police evaluate me, as is being done by our hospitals, insurance companies and the government, how will they measure our performance this morning?  They won’t and they can’t. So much of the good work that a doctor, a policeman or a teacher does, can’t be measured.  I work with great nurses every day, but there is no formula that exists that can measure what they do.  What has happened is that these professions are now assessed by box-checking bureaucrats who are charged with measuring all kinds of silly stuff that doesn’t matter.   Do I get any credit, for example, when I advise a patient that he doesn’t need a colonoscopy or a CAT scan?  Ask your doctor about this issue during your next appointment, but bring some Maalox with you because your physician’s esophagus will start sizzling.

Medical Quality Measuring Device

Look up Pay for Performance on this blog and elsewhere to find out more about this scam.

Incidentally, there’s happy ending to the woman whose case we cancelled.  Since she was prepped for a colonoscopy, we sent her to the hospital where I did the case safely later in the day. 

How do you define a high quality physician?  If you are able to define it, how would you measure it?

Independence Day 2021

 We have nearly emerged from the pandemic's abyss, but we have not yet reached the other side.

The wily virus tries daily to morph into other variants to slide past our defenses.

The politics of division and personal destruction have not yet been set aside.

The surreal scenes of January 6th are seared onto our memories.  

The recent horrors in Surfside, Florida leave us all gasping.

We are still a divided nation.

I want to believe that there is an ache and a hunger to come closer together.

July 4th is upon us.  Might this be an occasion when we might begin the process?

”I am apt to believe that it will be celebrated, by succeeding Generations, as the great anniversary Festival. It ought to be commemorated, as the Day of Deliverance by solemn Acts of Devotion to God Almighty. It ought to be solemnized with Pomp and Parade, with Shews, Games, Sports, Guns, Bells, Bonfires and Illuminations from one End of this Continent to the other from this Time forward forever more.”

John Adams

Transitioning to a New Doctor - Challenge or Opportunity?

 Over the past few weeks, several patients I saw faced a common challenge.  This is a situation I have confronted in the past, but what was unique recently is that multiple patients in a short period of time were in the same situation.

This was not a medical issue.  In fact, many of the individuals were feeling perfectly well.  This was not a financial issue, such as the patients were in the dreaded ‘doughnut’ or their particular medications were not covered by their insurance companies.  This was not a second opinion request from patients who suspected that their gastroenterologist (GI) of record may have missed something.

Here’s what happened.  A gastroenterology practice that had been in the community for decades closed down.  Suddenly, tens of thousands of patients with an array of digestive maladies were let loose to find a new digestive nest to occupy.  I’m sure that every GI within 20 miles of my office has been affected.  Many of them have landed on my schedule and I expect this will continue over the weeks and months to come.

Finding a new nest

This is a challenge both for the patients and the new GI specialists.  The patients I have seen all loved their prior GI some of whom were treated by their practice for decades.   These were not dissatisfied patients who were seeking advice elsewhere.  They were happy and satisfied where they were.  And now they were forced to sit across from a new doctor – a perfect stranger – who faced the task of trying to lay out a pathway to a new relationship.

This isn’t easy and both parties must contribute to the success of the effort. The physician must be mindful of how disruptive and anxious this process is for the patients and their families.  Patients must recognize that the physician cannot be expected to quickly replicate a rapport that may have taken years to establish.  Additionally, physicians, as individual human beings, cannot be expected to have similar personality trains and practice philosophy.  Patients and physicians need to exhibit some understanding and flexibility as they both enter the new nest.

Change is always challenging and particularly so when it is unexpected.  There may also be some unexpected upside.  The new physician, who brings no bias to the case, may offer some fresh insights on some old and stubborn medical issues. 

The doctor-patient relationship is the foundational unit of medical care.  Like all relationships, it needs to be cultivated and nourished from time to time.  Both sides need to give the other some space to maneuver and shift a position when necessary in order to make progress together.  So, if life conspires to put you in front of a new doctor, consider it an opportunity rather than a challenge. 

Changing Physician Behavior - A Difficult Challenge

How many actions do we take in our lives simply because this is how we and others have always done them?   In these instances, shouldn’t we at least pose the question if there might be a superior alternative?   I admire innovators who view the world through a prism that aims to shake up and disrupt the status quo.  You know who I mean; the folks who hear the music in between the notes.  

Medicine is riddled with practices that have remained in place for decades and are, therefore, hard to change. 

• Acute appendicitis is treated with surgery.  Why aren’t antibiotics an option here as they are for other similar infections in the large intestine?
• Diverticulitis has been treated for decades with antibiotics?  Only recently, have experts wondered if this treatment should be reexamined.
• For a generation, children with red eardrums received antibiotics presuming that this was a bacterial infection.   Ultimately, a skeptic started asking questions, and most of these kids are now left to heal on their own.
• During my earlier years of medical practice, we would obtain liver biopsies – an invasive procedure – on patients with unexplained abnormal liver blood tests.  We did this because this is how it was done.   Why has it become rare now?  Because folks who challenged the status quo recognized that the liver biopsy result only rarely changed our medical advice or patient outcomes. 

Of course, this phenomenon is not restricted to the medical profession.  There are many ossified policies and procedures throughout society that are simply left in place.  Has our public school educational system, for example, truly evolved responding to new research?  Seems to me that the high school experience today isn't that different from mine a few decades ago.  In general, we need disrupters who lead us to contemplate other pathways.

Sometimes, we need someone to crack through the concrete.

We physicians try to rely upon sound scientific advice when we are advising you.  But  often there are no medical studies on your specific medical issue.  Or experts may be in conflict on which course of action is preferred.  When the science is absent or in dispute, then we rely upon our judgment and experience.  This is as it should be. This is not the same as practicing by rote as we glide along a groove that has been carved by our predecessors and never challenged. 

Why for so many decades did patients and the medical profession endorse a yearly physical examination with all the trimmings?  Where's the evidence?

Maybe doing something the way it’s always been done works well.  But, if we are to make progress, then we need to take heed of the medical dissenters who are blowing the whistle from time to time.

Where's the Civility in Everyday Life?

Here follows a true vignette from a few years ago.  After giving a patient the pleasure of a colonoscopy, I left the hospital and headed for my office.  As there was 45 minutes until my first office patient was due to arrive, I stopped at a coffee shop for my default hot beverage - café mocha.  I strongly prefer independent coffee shops and routinely will take a long drive to reach one. 

I approached the counter and discovered that my phone, always holstered in the inside pocket of my sport jacket, was AWOL.  For many folks, especially physicians, their smart phones are beyond essential.  It serves as my pager, my appointment calendar and my communication nexus.  It is a portal to the medical site that we doctors consult for difficult cases – Wikipedia!  It is my lifeline to my offices and the hospitals I serve.  Sure, my brain may still be functioning even when I am phoneless, but the phone  supplies the fuel and power to make it all happen.  Your auto mechanic may be a knowledgeable professional, but without his toolbox…

Here's How Gastroenterologists Keep Up.

I asked the teenager behind the counter if I might borrow the phone to verify that my own phone was safe and secure.  I did not identify myself as a doctor – which I never do – as this was not relevant.  She seemed slightly hesitant with respect to this innocent request, which I attributed to her youth and inexperience in life.  By her expression, one might have thought that I had asked her to empty the cash register and place all the paper money in a brown paper bag.  Clearly, this issue was above her pay grade so she consulted with the proprietor.  Request denied!  The phone was for the business only.  I was shocked.  A slow burn started to simmer within me.

I asked the customer behind me in line if I might borrow his phone.  With no hesitation, he ran out to his truck and brought me his device.  After my 10 second call, I returned his phone with my thanks.

That’s the last café mocha, or any other beverage, that I will purchase in this establishment.  I contemplated expressing my displeasure to the owner, but decided against it. 

Where’s the civility?  Where’s the kindness?  Even if he were not inclined to do the right thing for the right reason, one would think he would fake it in order to please a paying customer.  Loaning a stranger a phone isn’t an act deserving of great praise.  Refusing to do so, however, is more newsworthy.

I have always felt that small vignettes give a wide view into someone’s character, especially when the person doesn’t know he is being watched. 

I’m not suggesting that I am more civil or generous or charitable than anyone else.  Of course, there have been many times that people have seen me miss the mark.  I think and hope that my aim has improved somewhat over the years.   Or, maybe a kind person has simply set up a bigger target for me to shoot at.

Why Won't My Doctor Give Me A Medication Refill?

One of the perennial patient gripes I confront is why on some occasions I refuse to refill a patient’s medication that I have previously prescribed.  Usually, but not always, when I offer my explanation for this roadblock, the patient understands why I advise a face-to-face meeting.

Here is a sampling of patient feedback I’ve received over the years.

Why do I need to come in?  I’ve been on the same prescription for years?

Why should I have to pay a copay when all I need is a refill?

I live 45 minutes away.

The doctor doesn’t have an appointment for 2 months and I only have 4 pills left!

I don’t drive anymore and I can’t get a ride.

This doesn’t happen with any of my other doctors.

Here’s how I see it.  Of course, I understand the sentiments expressed above from the patients’ perspective.  Certainly, when a patient I know whom I have been in regular contact with asks for a refill, I send it right through.  If, however, I feel that too much time has lapsed since I’ve had personal contact, then I will request an office visit so that I may determine that the refill still makes sense or if there are other digestive issues to address.  In general, I’ll ask refill seekers who haven’t seen me in a year to make the trek to my office, but I admit that my 1 year interval is arbitrary and that other capable physicians may have a different standard. 

Patient Getting Refill in the 14th Century

Here's a sampling of what might transpire at the yearly refill appointment.

Let’s try a lower dosage of your medicine which might be just as effective.

I’m not sure you need the medicine anymore.  Let’s hold on the refill and see how you do.

The medicine you want refilled hasn’t been working as well as it used to?  Perhaps, something else is going on.  I think we should look into it.

Since you were here last year, a new medicine is available that might give better results than your current medicine.

Since your visit last year, your brother developed colon cancer.  I’m glad that he is doing well. This new family history means that your next colonoscopy is due now, not in 5 years as we originally planned.

The yearly refill visit isn’t to hassle or inconvenience you.  And often, this will be a quick visit where I send the refills through.  But not always.  Many times, these seemingly routine yearly visits can really be time well spent.

 

 

 

 

 

  

Memorial Day and America First

 I’ve never served in the armed forces.  Therefore, I can’t possibly grasp the depth of meaning that Memorial Day holds for families who know what service and sacrifice really mean.

My father served for 39 months during World War II, but was fortunate to have been kept from harm’s way.  He was part of a generation, perhaps the greatest generation, that was not preoccupied with self.  The trite phrase, ‘we are all in this together’, was a touchstone of that time.  No more.  Back then we crossed oceans to serve not only our nation’s interests, but also to preserve world peace.  Now, we have become much more self-oriented, both as a nation and as individuals.  America First has captured the sensibilities of tens of millions of Americans, a phrase that harkens back to Charles Lindbergh who was a speaker and supporter for the America First Committee.  Lindbergh was an American hero who was also an anti-Semite who received the Service Cross of the German Eagle by Hitler’s government.  

Charles Lindbergh - Champion of America First

I’ve thought a lot about freedom this past year. I’ve seen it championed and exploited and attacked and misunderstood.  Indeed, it has been downright weaponized.  Heretofore, it has been a unique and unifying American concept that has bound us together.  I fear now that it is often wielded to strike and divide us. Consider a few examples.

No mask for me.  I won’t let you attack my freedom.

Freedom of speech?  We found your tweet from 10 years ago.  The security guards will now escort you to your car.

You expressed a contrary view on college admission processes with the intent of engaging in civil discourse.  Our response?  You are a racist.

A free nation accepts the results of fair elections.  Consider the conspiratorial chaos we have witnessed since Election Day 2020.  Is this coming attractions?

A new interpretation of Freedom of Assembly is to storm the Capitol wreaking destruction and death.

Freedom of the press does not support tendentious and slanted coverage in print and on the airways.  I have seen too much of this and lament the lack of accountability and contrition by the journalism profession.

There is no conscription now which was a patriotic and unifying experience for young citizens.  If today's generation faced the existential challenge that my dad's generation faced, what would we do?  While I do not advocate for a return of the draft, I do wish there were a year or two of required national service.  I can think of a dozen reasons why it’s a great idea.  Why haven’t we done this?

To those of you who have served, and to your families, I honor you all.  Continue to set an example for the rest of us of what freedom truly means and why we must so zealously protect it.

Job Interviewing Techniques in Medicine and Beyond

It would seem self-evident that an applicant for a job should be scrupulously honest.  First, it is the right thing to do.  Secondly, in our digital era, one’s academic record can be accessed back to kindergarten.  Yet, many applicants will embellish their credentials or claim a skill level that may exceed reality.  Thirty years ago, I was applying for my first job in New Jersey after completing my 2 year gastroenterology (GI) fellowship.  I was not competent to perform ERCP, a complex scope examination that GI practices desperately still want to add to their practices' skill sets.  Yet, I was advised by a practicing GI physician to simply claim that I could do the procedure.  Otherwise, he said, they would simply pass me by.  I queried the practitioner on my proposed course of action after being hired if I were summoned to perform an ERCP.  Decades later, I do not recall his response.   I can imagine what my new employer’s response might have been upon discovering that I had misrepresented my skills.. 

Should Applicants or Employers Take a Polygraph?

How honest should an interviewer be with a job applicant?   On the day that I wrote this, I read of a technique where an interviewer who is meeting a job applicant at a restaurant, secretly arranges for the applicant’s meal to be messed up in some way.  The justification is to see how the applicant reacts in real time to an unforeseen and unfavorable event.   It reminds me of my initial interview at NYU School of Medicine, when the interviewer, among other slippery questions, asked me “what is the death rate?”   The correct answer, which I luckily knew, is 100%.  Perhaps, this demonstration of my nimble intellect explains why they accepted me. 

I do not support subterfuge in a job interview to gauge applicants’ behaviors.   It’s certainly fair game to present hypotheticals, but outright trickery should be out of bounds.  And, if an interviewer is overtly dishonest, can this person be trusted after the hire?  If we sanction employer legerdemain, then should we not permit the applicant to play tricks on the interviewer to gauge his or her behavior and the company’s culture? 

I’ve always played it straight.  It’s all I know.  As for the position in New Jersey referenced above,  I didn't get the job.  And, so my life in Cleveland began.

Is Your Physician a 'Spin Doctor"?

Recently, I read about a judge’s decision on a legal dispute.  The facts aren’t important here.  As I read my newspaper’s summary of the decision, it was clear to me that one side won and the other side lost.  Yet, both sides claimed victory.  This is commonplace in the public square where a clear loser boasts of a victory that even a casual observer recognizes to be magical thinking.  In the case above, the loser who claimed victory wasn’t a corporate PR spinner, but was the county prosecutor.

Folks seem to have such a difficult time admitting error, poor judgment or failure. 

Here’s a hypothetical.  A man sues a company alleging wrongful termination.  In addition to demanding that he be re-hired, he has asked for an apology, a public clearing of his name in boldface on the weekly company newsletter, back pay with benefits, and $5,000 to cover medical and psychological expenses incurred as a direct result of his firing.

The judge awards the man all of his demands, but reduced the $5.000 demand to $3,500 as he felt that the larger amount was excessive.

Is there any doubt here who won this case?  Yet, here’s what we might expect the company’s PR magpie to crow in a press release.

All of us at Termination Enterprises are delighted with the judge’s decision to reject a disgruntled former employee’s demand for excessive payment.  In the spirit of reconciliation, we have decided to rehire the worker in accordance with the values of our company.

Magpie

Spin is everywhere.  If a politician is queried about sagging poll numbers, here is what you won’t hear.

My poll numbers are down because my policies stink.

You are more likely to hear bromides such as the following:

• I don’t pay attention to the polls.  Polls go up and down every day.
• Considering how we are being outspent, it’s amazing how well we’re doing.
• We’re exactly where we expected to be.
• Our campaign doesn’t want to peak too early.
• The only poll that matters is Election Day.

How does my profession handle the truth?  Now, I don’t regard myself and my medical colleagues to be liars, but we have been known to massage a phrase from time to time, as I have written in a prior post.   Similar to the hypothetical company referenced at the top of this post, physicians sometimes claim victory with irrational enthusiasm.

Claim: We are very pleased that the tumor has decreased in size. 

Truth:  This result will not change your life expectancy.

Claim: I recommend fiber supplements for your irritable bowel syndrome.

Truth:  Every doctor does this despite no proof of benefit.

Claim: I agree with you that an antibiotic makes sense here..

Truth: Antibiotics do nothing for colds except risk complications and cost money.

Claim: I’m sorry I’m late.  Something came up at the hospital.

Truth: I overslept.

Just because something is not true does not make it an outright lie.  Nevertheless, when your doctor makes a recommendation to you, ask about the medical evidence that supports the advice.  If the evidence is beyond a reasonable doubt, then you may decide the case accordingly.  If the evidence falls short, then you may decline the advice and claim victory.

Taking a Moment to Say Thanks

 

If we are lucky, then we have someone in our lives who loves us no matter what, who makes us feel a little smarter than we are, who sees a resemblance between us and some swashbuckling actor who looks nothing like us, who laughs at our jokes, who delights when we call or visit, who takes great pride in our accomplishments, who overlooks our flaws and who reassures us that the obstacle that has unexpectedly confronted us can be overcome. 

Thanks, Mom!

(And to moms everywhere.)

Happy Mother's Day!

Choosing the Right Doctor for You.

As my readers know, I have been a parsimonious practitioner during my entire career.  By this, I mean that I believe that less medical care leads to superior medical outcomes.  I have devoted several dozens of posts on this subject within this blog.  This is my medical philosophy.   Other physicians who see the world differently would challenge me suggesting that I deny patients necessary diagnostic tests and treatments.  Personally, I think that I have the better argument, but so do they.

Interestingly, over time patients tend to select and stay with physicians who share similar philosophies.  For example, a patient who believes that regular diagnostic testing, frequent labs, a CAT scan now and then, prescriptions for various symptoms is unlikely to remain my patient because of a philosophical gulf between us.   If that individual, for example, expects antibiotics – as his former physician obediently provided – for what the patient believes is ‘diverticulitis’, and I demur, then this patient will be dissatisfied.  Assuming that I am correct that antibiotics are not needed, it remains a difficult task to disabuse such a patient from his belief.   First of all, many patients want medication despite the absence of supportive medical evidence.  And, if a previous physician has prescribed medicine for the very same symptoms, it stands to reason that the patient expects a similar response from me.   What I regard to be overdiagnosis and overtreatment, is described by these patients as thorough and appropriate medical care.  

Sir William Osler

Physician, Teacher, Philosopher and Parsimonious Practitioner 

Conversely, if a patient is circumspect about exposing himself to the medical industrial complex – subjected to diagnostic tests, medications and specialist consultations – then he will not mesh with a doctor who uses the medical accelerator more than the brake.

These philosophical distinctions I raise can also cause tension within the medical team.  A gastroenterologist may believe that his patient should have surgery the next morning.  The gastroenterologist’s partner sees the same patient the next morning and has a different view, even though the patient’s status has not changed.  And, just add some seasoning to this stew, the surgeon on the case may disagree with both of them.

Individuals need to consider philosophy when hiring a physician, an attorney or a financial planner.   How comfortable are you with risk?   Are you action-oriented or more deliberative preferring to see how events play out?   Do you worry that failure to act risks a worse outcome?  How many opinions do you need to feel secure?    Do you prefer advisers who mirror your own view or do you welcome a challenge?

It takes time to gauge your doctor's medical philosophy and your comfort with it.  But it is an essential element of the doctor-patient relationship.  Most patients have accepted, with great assistance from the medical profession, that more tests and treatments define higher quality care.  I've spent a career trying to explain to my patients why I disagree so passionately.

One of the first duties of the physician is to educate the masses not to take medicine.

Sir William Osler, 1910.

Was the J & J Vaccine Pause Necessary?

 I am not a public health expert.  But I have learned this past year that one need not have any public health knowledge in order issue advice and opinions.  How ‘bout some hydroxychloroquine with a bleach chaser?

I trust our public health experts and have largely hewed to their advice, although I’m not sure that they have hit the bullseye every time.  As expected, they have modified their advice over time in response to new knowledge.  This is not a flip-flop – this is how science works.

And millions of folks have completely rejected their advice for all kinds of reasons.  We’ve all seen photos of patrons who were piled into bars or kids on spring break who were recklessly partying on.  Masks optional.

Others, in contrast, were pushing back on the Center for Disease Control and Prevention (CDC) arguing that the rules were not strict enough.  We’ve seen the teachers’ unions refuse to return to classrooms despite CDC guidance assuring that it was safe to do so, as long as proper mitigation strategies were in place.   It seemed that teachers were not satisfied with the prospect of low risk; they wanted no risk.

The Johnson & Johnson vaccine was placed on pause after a handful of recipients developed serious blood clots in the brain.  As of this writing there have been 15 cases out of nearly 8 million people who were vaccinated.  You can do the basic math and calculate what the odds of suffering this serious event would be.  I’ll give you a hint.  It’s about 1 in 500,000.

First, there is yet no conclusive proof that the vaccine is responsible for these blood clots.

Danger!

J & J Vaccines Can Kill!

I think that pausing the vaccine, which was heralded by highly charged public health expert warnings which were further heightened by the media, was disproportionate to the facts.  This issue was not reported in proper perspective.  Even if the vaccine were directly responsible for the blood clots, this risk is miniscule compared to the known benefits of the vaccine.  The J & J vaccine is extremely effective and reduces the risk of COVID-19 infection, hospitalization and death.  

We need some rationality here.  If we pull back from an activity that has a 1 in 500,000 chance of a catastrophe, does it make sense if we still engage in so many other activities that have similar odds? Feel free to research your risk of a serious car accident, getting struck by lightning, taking a new medication, undergoing routine surgery, traveling abroad, participating in high school or college athletics, riding a motorcycle, camping in the wilderness, swimming in the ocean and various other activities that we all routinely engage in.

A dose of perspective and proportionality if you please?

Couldn’t our health experts have simply announced that they were rigorously monitoring an extremely rare and unproven side effect of the J & J vaccine, but that all of the evidence overwhelmingly showed that the benefits far outweighed the risks?  Instead, they announced a ‘pause’ which may have cost lives and scared everyone.  Was this a pause in good judgment?

 

 

 

 

 

 

 

Is My New Doctor Qualified?

When one applies for a job or a position, it is expected that the interviewer will assess if the applicant has the necessary skill set and experience. Doesn’t this make sense?  Consider these examples.

A clarinetist applies for a position in a symphony orchestra.  While many criteria will be assessed, he will surely need to audition to demonstrate his musicianship.  Would he ever be hired without playing a note?

A college student wants to join the swim team.  The applicant can expect to show off her speed and technique as she cuts across the pool.  Would any coach accept a new swim team member without watching her swim?

A journalist for a town paper applies for a job at a large metropolitan newspaper.  The interviewing editor will surely review the applicant’s prior work product to gauge his competence and suitability for the new position.  Would an editor bring on a new reporter without ever reviewing his writings?

A college graduates applies to the State Department as a translator.  Would such a hire ever occur without determining if the applicant has the requisite language skills?

Want the job?  

You'll have to show you know how to use this.

So how does the medical profession hire on new medical professionals?  I should certainly know this since I’ve been in the trade for 3 decades and have had enough job interviews to know how the process works.  I’ll ask readers to peruse the following 5 sample gastroenterologist applicant questions. Can you spot the ones I was asked during my prior job interviews?   

Which antibiotics do you typically prescribe for diverticulitis?

What is your age cutoff for offering screening colonoscopies?

What is your complication rate for colonoscopy and other medical procedures?

When is the right time to prescribe steroids in Crohn’s disease?

Does a patient who is having a gallstone attack and a fever need to be hospitalized?

Which ones were I asked?  None of the above.  For reasons I cannot easily explain, I have never been asked any medical question during any prior job interview.  Similarly, when I have interviewed job applicants myself, I have never queried them on any medical issue.  The profession, at least in my experience, assumes that physician applicants have all of the necessary medical skills and knowledge, even though this does not seem to make much sense.  Shouldn’t the applicant at the very least be asked to review case histories of assorted patients and to comment?  It seems it’s a lot tougher to get a job as a clarinetist than as a gastroenterologist.  Does this put your mind at ease?

 

 

 

 

Overutilization of Colonoscopy - An Unusual Suspect

A week or so before writing this post, a patient came to my office requesting a colonoscopy.  Nothing newsworthy so far.  An individual wanted a service that our practice routinely provides.  Yet, I was reluctant to accede to her seemingly reasonable request.   She wanted a screening examination of her colon in search of a benefit that humans have pursued for as long as humans have existed – peace of mind. 

I have found that ordinary folks are often confused by the meaning of the term screening.  Screening exams can be performed on various organs of the body.  When a physician uses the term screening, it means that the patient is not having any symptoms whatsoever.  For example, if I advise a colonoscopy on a patient who is having rectal bleeding or diarrhea, this is considered a diagnostic exam, not a screening test.   

"You're paying the bill?  I'll have the steak!"

Why does this matter?  Insurance companies often reimburse screening and diagnostic exams differently.  Often, but not always, a patient’s financial obligation is higher for a diagnostic exam, when symptoms are present.   There have been occasions when a patient had contacted us after receiving the insurance company bill for a diagnostic colonoscopy, asking if we will ‘revise’ our documentation stating that the test was a screening exam.   Even an infrequent Whistleblower reader would know our response to such a request.

The patient who wanted a screening colonoscopy felt entirely well.  Her bowel pattern was unchanged.  She had no special risk factors for developing colon cancer.  My review of her record indicated that she was due for a screening colonoscopy in 3 years, not now.  I advised her of this, but she wanted to proceed anyway.

We have freedom of commerce in this country.  I can purchase goods and services according to need, desire or even whim.   If a person wishes to buy a meal, a vehicle, an appliance or a vacation, the seller’s role is not to discourage the transaction or point out that the buyer is making a foolish or unnecessary purchase.   Isn’t an individual who wants a colonoscopy, and is properly informed of the risks and benefits of the test, and is made aware that she is not yet due, entitled to the exam?

I thought that she was.  But, I didn’t think that her insurance company should pay her bill.  I explained to her that I would schedule her for the requested exam, but that she should expect that her insurance company would hold her financially responsible for the entire bill.  

Once the patient understood that the cost would be hers, she elected to wait an additional 3 years, as I originally advised.   The lesson?  When folks have skin in the game, they make different decisions.  In my view, this concept needs to be systemically incorporated into our health care system.  

If you are out to dinner at an upscale restaurant, and an insurance company would be paying the bill, would you order differently?

Are We Ready for the Next Pandemic?

 While most of us prefer order and routine, life can turn course unexpectedly and randomly.  Of course, we all know this.  For many of us, our occupation, our choice of mates or where we live are the result of some chance occurrence, not the product of diligent planning.   Indeed, this reality adds some excitement and wonder into our existences.  Would we really want to live according to a prescribed routine like a train schedule?   For me, I am most satisfied when my days include my daily routine pleasures seasoned with some spontaneity.  I suspect that this is true for most of us.  However, we differ in the ratio of random/routine that we prefer.   Some of us plan a trip, for example, with each day carefully planned while others prefer to simply land in their destination and explore untethered to a guidebook or a rigid schedule.

And no force can set order aside more forcefully than nature.  Here is the scene from our window earlier this week.  Does this look like a typical spring day?  Apparently, Mother Nature has her own order of things.

Is Mother Nature Out of Order?

There are certain tasks for which a specified order is the optimal option.  When an airline pilot is preparing for take off or when a surgeon is preparing for surgery, each of these professionals proceeds through a check list of requirements to verify that all safety protocols have been followed so that the risk of a misadventure is minimized.  These safety checks have been devised over time with revisions performed as necessary.  They are born from experience.  Each item on the list is to prevent a specific adverse reaction which was at higher risk of occurrence prior the check list era.  For example, prior to a medical procedure, it is now mandatory for the medical team to verify the identity of the patient.  Any idea why this ID verification came about?

We don’t want airline pilots simply to bring spontaneity to their flights letting them ‘wing it’.  “Maybe today will fly this bird right over the coast so the folks can get a great view.” 

We are still trying wrest ourselves free from the gripping tentacles of the pandemic.  And one of the lessons, which we still haven’t learned is that there is a specific order of measures and mitigation that must be followed to prevail.  As we look around the world, we see that some nations are much closer to the end zone than are others.  Europe is behind the U.S. and we should be much farther ahead than we are.   If we had followed public health directives early and consistently, opening up the economy and schools according to science, rejected distracting political interference, where might we be today?   Has this experience persuaded to use the pandemic check list next time?

 

Should Doctors Pay Patients When We Are Late?

Some time ago, I flew with my youngest kid, then a high school senior, on a college visit.  He’s the last of 5 youngsters, so I’ve had my share of these visits to various centers of knowledge where young minds are molded to face uncertain and unknown futures.   While I’ve never found these visits to be substantively valuable, they were of great value to me as it was fun to be with them on these exciting excursions.

The Hallowed Halls of Higher Learning

Photo Credit

The formats of the school presentations are superimposable.  There’s an information session, which serves as an infomercial that tries to draw students to apply.  Schools favor receiving large volumes of applicants so that their acceptance rate will be lower and they will appear to more selective than they actually are.   How cynical of me to suggest that there are forces in academia that might be pursuing a self-serving agenda!

These sessions are led by effervescent young cheerleaders who present a power point of smiling students who are having fun, doing world class research and shaking hands with world leaders.  Parents are reassured that the only criminal activity within the past 5 years in this urban campus was pick-pocketing. 

Afterwards, prospective students proceed on a tour where they are given critical data they will need when making their ultimate education decision.

“Here’s the cafeteria.”

“Here’s the chem building.”

“Here’s where we play Frisbee.”

In case any of my kids read this post, which is as likely as any of them admitting to being a Republican, I want them to know that I loved every minute of these visits with them. 

When my last kid and I flew on a college visit, we enjoyed the joy and relaxation of air travel, a subject that has crept onto this blog previously.   Was there a flight delay?  Ok, stop laughing now.   I asked my son if he felt that airlines should provide some form of compensation for delays of certain specified time intervals.  For example, if a flight is delayed 30 minutes, possible remedies might include:

• 2 bags of honey roasted peanuts
• Handshake with the pilot
• Special 1-800 customer service phone number which states on the record that ‘your call is important to us…”
• Guaranteed middle seat so you can enjoy a lively conversation with 2 happy travelers.
• Travel voucher for $30 (one dollar per minute of delay) that may be used for any First Class non-refundable ticket that is booked within 36 hours of your plane landing at your destination.

My son did not think that the airlines would endorse the concept that travel delays were compensable.

For a generation or two, patients have lamented that their doctors keep them waiting habitually.  How many times can our staff explain to them that we were saving 7 folks’ lives simultaneously?  What is our patients’ time worth?  Aren’t they often missing work or making special arrangements to see us?  Even if they are retired and have open schedules, doesn’t their time have value?

Should physicians compensate patients when their appointments are delayed?  If so, what remedy would you suggest from a gastroenterologist?

• Extra lube on the next colonoscopy?
• Buy One-Get-One-Free hemorrhoid cream?
• Waiting room magazines that were published sometime in the past decade?

Seriously, do we doctors owe you something when we keep you waiting?

Don’t be too harsh here.  We should also address how you should compensate us when you are late or don’t even show up.  I beseech you to be ‘fair and balanced’, a cable news network’s motto that all of you should know well. 

Why I Don't Advise Patients to Quit Smoking

I don’t advise patients to quit smoking.

I don’t exhort alcoholics to stop drinking.

I don’t preach to my obese clientele to slim down.

And I don’t lecture patients to get the COVID-19 vaccine.

This may be the point were some readers are wondering, “What kind of doctor are you?”

For the record, I do not endorse or advise cigarette smoking, alcohol addiction, obesity or careless behavior during the pandemic.  I favor temperance in my own life.  I exercise.  I am attentive to my BMI. And I wear a mask and have received my COVID-19 injections with enthusiasm.

But it has never been my style, either professionally or beyond the office, to tell people what to do.  Once folks reach a certain age, which for many are the teenage years, you just can’t make them do stuff.  Every parent understands this. This does not mean that I don’t have influence over people who trust me.  I do and I use it.  However, it’s a process issue.  How best can we help individuals make sound decisions?  Are issuing edicts and threats our best weapons?  Are lecturing and hectoring our most effective tools?  Should we devise a reward incentive to motivate folks?  Cash for pounds lost? 

         

Who is stronger, the sun or the wind?

I am more comfortable laying out the facts – the cold hard truth without judgement – and allowing folks to make their own decisions.  Sometimes, multiple conversations are necessary.  When any of us ultimately makes our own decisions freely, they are more likely to be durable.  It just works better if folks are vested with their own choices.  Achieving ‘buy-in’ is critical to maximize the chance of success.  Don’t you feel better when you have made a decision yourself rather than have been directed to act?   I certainly do.

Do you really think that my smoking patients are not aware that this habit poses serious health risks? Do they not know that quitting would likely deliver major medical benefits?  Will a finger-wagging doctor accomplish anything?  Can you imagine a smoker who is advised to quit responding, "Really, doctor?  I had no idea that cigarettes are bad for you!"

Recall Aesop’s fable when the sun and the wind competed as to which of them could separate a man from his cloak.  The wind unleashed all of its strength and fury, but the traveler managed to hold on to his covering.  Then the sun poured down heat to the point that the man removed his cloak and sought shade to get some relief. 

Gentleness and persuasion win against force and coercion.