Sunday, October 10, 2021

Doctors Spreading COVID-19 Vaccine Misinformation

(As published recently in cleveland.com)

Should a physician who spreads misinformation on coronavirus vaccines lose his medical license?  Would this violate the doctor’s right to free speech?  Shouldn’t physicians be able to offer their patients counsel and advice that differs from mainstream medical thought? 

Every profession has ethical and legal requirements to maintain the integrity of the profession as well as the public trust.

·      If an attorney lies to a judge, then this lawyer can expect to be severely sanctioned. 

·      If a public-school teacher instructs science students that the world was created exactly as recorded in the Book of Genesis, then professional repercussions are expected.

·      If a police officer is discovered to have planted evidence to justify an arrest, then the officer will likely face criminal penalties.

In the medical profession, there are also professional and ethical boundaries that practitioners must respect.  Consider these flagrant violations.

·      A doctor falsifies a medical record to buttress his legal defense in a medical malpractice case.

·      A physician accepts a kickback for sending referrals to a colleague.

·      A physician performs unnecessary procedures to make money.

·      A doctor submits false documentation when applying for hospital privileges.

Such breaches may very well jeopardize the doctor’s professional standing and even his personal liberty. 

This past July, the Federation of State Medical Boards (FSMB) stated that doctors who spread misinformation on Covid-19 vaccines risk disciplinary action which could include revocation of their medical licenses.  The FSMB instructs that physicians are obligated to share medical advice that accords with sound science and medical judgment.

The State Medical Board of Ohio requires every licensed physician to report misconduct which includes, among other behaviors, a colleague practicing below minimal standards.  Indeed, a physician who fails to report suspected misconduct to the Board may face disciplinary actions.


                         

Hippocrates, remember him?


One would expect that physicians who promote false information regarding Covid-19 vaccines would be ripe for sanction.  Remember the Ohio physician who testified before a House Health Committee hearing this past June that coronavirus vaccines magnetize recipients?  In the doctor’s own words, “… they can put a key on their forehead. It sticks.  They can put spoons and forks all over them and they can stick...”  The Plain Dealer recently reported that her medical license was just renewed by the State Medical Board of Ohio for 2 years, an automated process that does not mean she is not also under a confidential disciplinary investigation.  Let’s hope that the Board does the right thing.

Her testimony might make for a compelling Twilight Zone script, but it has no place in the medical landscape.  This is not a free speech issue. It’s a competency issue.  

Governing bodies of professions have rules and standards that must be enforced if they are to mean anything. 

Scientific support for coronavirus vaccines is overwhelming - much more solid than for many other standard medical treatments that physicians prescribe every day.  I wish that my own advice to patients was in the range of >90% effective with almost zero risk of serious complications. 

Millions of Americans have become ill and hundreds of thousands have died from this virus.  And there will be more to come.  If a medical practitioner is advising against coronavirus vaccines on medical grounds, or recommends ivermectin as a treatment or promotes misinformation that risks the health of patients and the community, then please sell your snake oil elsewhere.  You took an oath upon becoming a doctor.  And if you willfully violate it, as well as the medical profession’s clear standards, then you should be called to account.  We physicians must denounce anyone who purveys deception and misinformation that threatens everyone’s health, even if it is one of our own.  





 

 

Sunday, September 26, 2021

I won’t take the COVID-19 vaccine!

 Recently, I faced 3 patients who had chosen not to receive a COVID-19 vaccine.  Interestingly, each had a different reason underlying their hesitancy. 

The first patient gave an adamant refusal that there is no way he would ever submit to the vaccine.  He didn’t trust the government.  The second patient offered the canard that the approval process was rushed.  The third patient had simply procrastinated.  Her family members had all been vaccinated and she has received many other vaccinations.  She was simply perched on the fence and hadn’t moved.

I offered counsel to Patients #2 and #3 as I felt there was a chance I might have impact with them.  I hope that I did.



Stop Vaccine Tyranny!

The walls are closing in on the unvaccinated.  With the recent formal Food and Drug Administration (FDA) approval of the Pfizer vaccine, and the increasing number of businesses, organizations and venues that will only admit the vaccinated, the vast space that the unvaccinated have inhabited is fast shrinking.  Will the unvaccinated be able to function if they cannot attend a concert, visit a museum, dine at a restaurant, take ground or air transportation, attend theater or even their place of employment?

Some will submit to the vaccine because rising inconveniences would be unbearable.  Others may belatedly decide on the merits that the vaccines make sense.  And yes, there will be some diehards who will continue to reject reason and science.   For them, rolling up their sleeves or donning a mask is to surrender.  We saw during Hurricane Ida, as we do in all prior deadly storms, when some folks reject all of the repeated dire warnings to evacuate and hunker down instead.

 It’s hard to understand how some folks place themselves in avoidable danger just to prove a point. I have a different understanding of what they are actually proving to the rest of us. 

Sunday, September 19, 2021

TSA Fails to Protect Passengers from COVID-19

We are taught from a young age to finish the entire job.  I confess that I still need reminding on this virtue.

I suspect that all of us must plead guilty to partial task completion from time to time.  Have you ever washed some of the dishes remaining in the sink?  How about cleaning out part of the garage and rationalizing that this is enough work for one day.  How many of us have projects around the house that are waiting patiently for our attention as they sit frozen in time?

There are more stark examples  when stopping short if the finish line is downright absurd.

Consider some examples extracted from my imagination.

  • An artist paints only on one side of the canvas, and I don’t mean for artistic reasons.
  • A car wash cleans only the rear section of automobiles.
  • A publisher distributes books that are 100 pages short of their true length.

Silly, right?

It’s easy to conjure up similar examples regarding the medical universe.

  • A surgeon washes only one hand prior to surgery.
  • A doctor prescribes antibiotics for only half of the standard number of days.
  • A hospital housekeeper cleans half of a patient’s room after discharge.
  • A gastroenterologist begins a colonoscopy and decides to end the procedure at the halfway mark.

In these examples, the medical interventions are all pointing in the right direction, but they are simply insufficient. 

Half measures are called that for a reason.



We're Half Safe on Airplanes Today


Recently, the Transportation Security Administration (TSA) extended its mask requirement for travelers using air and ground transportation from September 13th to January 18,2022.

This is the Mother of All Half Measures.  Yes, we know that masks have impact and I have been wearing one more often since the Delta variant has taken off.  But the better response – which every responsible public health expert (or even novice) endorses - is vaccination.  If COVID-19 vaccine has incredible safety and efficacy data, far superior to masking, then why doesn’t the TSA require this?  Technically, it wouldn’t be a vaccine mandate since the individual is still free to forego travel. But I suspect it would make vaccination more attractive for those that wish to use public transportation and air travel. 

In addition, masked travelers are permitted to demask when taking food or drink, which markedly decreases the masks’ effectiveness. 

If we are wheeled into the surgical suite to hear the scrub nurse in the operating room announce that half the instruments have been sterilized, wouldn’t we be sprinting out of there like a race horse?

Why then are we satisfied traveling if we are only half protected?

 

 

Sunday, September 12, 2021

Religious Exemptions to the COVID-19 Vaccine

We have all been counseled to avoid discussing religion and politics in order to reduce the risk of a hostile encounter.  I recall being reminded of this maxim when dining with a new acquaintance many years ago.  My response?  ‘That’s all I like to talk about!’

I am writing this at 9:30 a.m. on a Saturday and I’ve already had multiple conversations – both directly and electronically – with people in my life on both of these radioactive subjects.  As far as I know, all of the friendships remain whole.  Indeed, these debates and exchanges serve to fortify our friendships rather than to threaten them.

I recognized that discussing religion can be fraught for many individuals and might be best avoided for them.  Same with politics.  Many a thanksgiving dinner has been sullied by someone who decides to serve as the family turkey 

Look at the national response when a Colorado baker refused to bake a wedding cake for gay couple in 2012.  The cake shop owner claimed this violated his religious beliefs at a time that the state did not recognize same-sex marriage.



Praying for Wisdom

The COVID-19 pandemic has provided fuel for some to argue that the vaccine encroaches on their religious freedom.  Indeed, federal law provides for a vaccine exemption for a sincerely held religious belief.  (Individuals can also claim a medical disability exemption under the Americans with Disability Act.)  If the exemption claims are legitimate, then the employee is entitled to receive a reasonable accommodation at the workplace so long as this would not pose undue hardship on the employer.

While defining a medical disability can be somewhat objective, how does one define a religion?  This is murky terrain.  Try to do this yourself before reading further and you’ll see what I mean.

Here’s a summary statement on the definition of religion taken from the Equal Employment Opportunity Commission (EEOC).

The presence of a deity or deities is not necessary for a religion to receive protection under Title VII.  Religious beliefs can include unique beliefs held by a few or even one individual; however, mere personal preferences are not religious beliefs.  Individuals who do not practice any religion are also protected from discrimination on the basis of religion or lack thereof.  

Seems rather a broad definition to me.  The courts will be charged with defining religion and they will need Solomonic wisdom to achieve this.  Might veganism or vegetarianism be religions?  Satanism?  Atheism? One man’s religion is another man’s cult.  All of this will be good news for discrimination lawyers whose prayers for prosperity have been answered.  

 

Sunday, September 5, 2021

The Meaning of Labor Day 2021

Labor Day, which honors American workers, was established well over a century ago in 1894. The holiday emerged from a cauldron of worker unrest protesting against harsh, unfair and unsafe working conditions.  Indeed, there were strikes and even violence in the early years of the fight for workers’ rights.  Over the ensuing decades, organized labor gained membership and power as increasing numbers of workers sought out union protections.   Those numbers have declined over time for several reasons.  Currently, about 11% of workers belong to unions.




While I have not always supported organized labor’s positions and actions, I certainly agree that every employee -union or non-union - is entitled to a fair wage and safe working conditions.

It’s been a very tough year for labor and for the rest of us.  When a company or a business is forced to close by an enemy that we can’t see or touch, toxic ripples spread out far and wide.   When a restaurant shuts down, for example, imagine how many people are impacted directly and indirectly.

Many important holidays seem to have lost their meaning.  Labor Day for many has become a day to purchase sale items or to throw burgers on the grill.  Memorial Day’s significance has similarly dimmed.

Let's honor all those who have built this country, fought for fairness and are still laboring to lead us forward.

Sunday, August 29, 2021

Politics and the Pandemic - Progress Denied

Over the course of this pandemic, we have learned a lot about the country, our leaders and ourselves – and not all of it has been good.  One thing we have learned is that anything can be politicized.  Will anyone be shocked, for example, if a protest movement develops demanding that that Mother’s Day either be abolished or renamed?  

Overall, Governor Mike DeWine has provided sober guidance and directives here in Ohio.  I think that his performance during the pandemic will be an important reason why he will be reelected in 2022.  Interestingly, although he is a bonafide conservative, he will face primary threats from the right in a state that Trump handily won in the past 2 presidential elections.  As we all have learned in November 2016, anything can happen.

But, DeWine, like every other political leader considered the political impact of public health decisions.


Governor DeWine Understands the Pandemic and Politics.

In April 2020, he issued a mask mandate for customers and employees in newly opened retail establishments and businesses.  The slogan was ‘no mask, no work, no service, no exception.’  The governor issued this recommendation after consulting with public health experts.  Although I have only rudimentary public health knowledge, this measure seemed very rationale to me. 

What a difference a day makes.  Within 24 hours, the governor did a political back flip and reversed the requirement that customers must be masked.  This abrupt U-turn resulted after howls of protest from mask opponents.  The public health facts certainly didn’t change, but the politics did. 

We have seen repeatedly our political leaders caving to serve political concerns. I am not suggesting that public health experts are the only ones wearing white hats.  Because their mission is to protect the entire population, I think some of them have been overzealous to protect the public at the expense of our economic health, the education of our kids and mental health consequences of mitigation strategies.  It’s easier to recommend that someone else lose his job to serve the greater good.  It’s easier to support extending the eviction moratorium if you are not a landlord.   It’s easier for teachers to support cancelling classroom learning for ‘safety’s sake, than it is for parents who must quit their jobs so that they can become homeschool teachers. 

I don’t claim to know where to establish the balance between public health protection and society’s other needs.  Of course, this is not a mathematical query that has a single correct solution.  Experts will disagree as they face a moving target with insufficient data.  But, had politics been stripped from the process, then we would be a lot farther along than we are now. 

 

  

Sunday, August 22, 2021

Biden Botches Afghanistan - Where Does the Buck Stop?

 We have all witnessed the debacle from our clumsy and precipitous withdrawal of our military from Afghanistan.  The humanitarian and moral disaster was as astonishing as it was avoidable.  Not only do our allies and our adversaries correctly point out our incompetence, but so do members of the the president’s own political party and administration.  Perhaps, this is an issue that might unite the Democrats and the GOP. 

Indeed, the record contradicts President Biden’s claim that no military experts warned him that his plan risked chaos and catastrophe.  All of us certainly heard the president reassure us only weeks ago that the Taliban were unlikely to prevail in the short term and there would certainly not be a ‘Saigon moment’, recalling an iconic and humiliating scene from 1975.

The president also claimed that he was handcuffed to withdraw troops as he needed to honor the prior agreement between the Taliban and the former administration.  This is malarkey!  First of all, President Biden already broke the prior deal by extending the withdrawal deadline from May 1st to August 31st.  And Biden’s fidelity to Trump’s Taliban agreement seems inconsistent as he readily and enthusiastically reversed many other Trump actions with regard to the Paris Climate Agreement, the World Health Organization and the Iran nuclear deal. 

Of course, the president and his minions tried to deflect by arguing that we needed to extricate ourselves from this ‘forever war’, a point that most of us agreed with but was not the actual point. The withdrawal was botched even if the strategy to disengage was sound.

We also heard the president argue that he didn’t want a 5th president to inherit this war as if the next presidential election were only days away. 



'Joe, take a lesson from Harry.'

But, here’s the point of this post.  I find Biden’s reaction and explanation to this colossal failure to be deeply disappointing and contrary to his repeated pledge to be straight with us.  In his initial explanation to the nation on 8/16/2021, he stated that ‘the buck stops with me’, while his remarks were largely devoted to blaming everyone else (except the Taliban) for what transpired.  And during subsequent remarks and interviews, he continued to deny any personal responsibility.  We didn’t even hear the typical passive voice construction that ‘mistakes were made’. 

While it may have been painful and difficult, the president should have admitted to what we all saw with our own eyes.  And in the same speech, he would promise to do all he could to make the situation right.  Isn't this what we try to teach to our kids?

Not only would such a course be the right thing to do, but it would also serve the president’s interest.  It would reinforce to all of us that his promise to give it to us straight is still true.

 

 

Sunday, August 15, 2021

How Much Do You Know About Covid? Test Your Knowledge!

 There isn’t a person, a pet or a plant in this country who is not aware of COVID-19.  With regret, but not surprisingly, the pandemic has struck back as it successfully targets the unvaccinated community.  We have to hope that this outbreak will be the last gasp of the pandemic and not that of many ailing Americans.

The nation has been deluged with information, misinformation and disinformation.  We confront facts and alternative facts.  Even legitimate public health experts are not consistently singing from the same hymnal.

So, I thought this was an apt opportunity to test your knowledge on the novel coronavirus with ten True or False questions – no multiple choice or essay.  What could be easier?  And there is no penalty for guessing.  Answers appear at the foot of this post. 

Good luck.  Let the games begin.



How Much Do You Know?

 

The Delta variant is so named since this strain was brought in from overseas by a Delta airline pilot.

CNN, a leading cable news station, stands for Coronavirus News Network.

Masks offer superior protection than vaccines since they directly block virus from entering the respiratory passages. 

Employees cannot be legally required to get vaccinated against COVID-19.

An employer who asks if an employee has been vaccinated against COVID-19 has violated HIPAA rules and risks government sanctions.

The two-shot Moderna and Pfizer vaccines are twice as effective as the one-shot Johnson and Johnson vaccine.

‘Long Covid’ is caused by a long sausage shaped virus rather than the typical spherical viral particle.

The N-95 mask gets its name from Lab 95 at the National Institutes of Health where the mask was designed. 

A newly described Baldo variant has no spikes on the viral surface and can therefore slide more easily into the lungs. 

Vigorous handwashing with designated soap and very warm water kills the COVID-19 virus. 


I hope that you found this quiz to be enlightening and amusing.  Feel free to share the post with family and friends who might enjoy this diversionary challenge. 

The answer key?  The correct answer to every question is False!

 

Sunday, August 8, 2021

How Do We Reach Herd Immunity Against COVID-19?

Last week I conjectured that the Center for Disease Control and Prevention (CDC) obfuscated when they recently recommended that vaccinated individuals resume indoor masking under certain circumstances.  My speculation was that the policy was justified but that the CDC was not forthcoming in explaining the rationale for the policy revision.

The revised re-masking recommendation, as with every other aspect in this pandemic, has only further polarized a nation that seems to be trying very hard not to heal itself literally and politically.  I predict that our collective political affliction will long outlast the coronavirus plague. 

I routinely ask patients if they have received the COVID-19 vaccine.  Recently, a patient replied that has not received one.  I asked what his concerns were and he firmly responded that he would never get vaccinated against the coronavirus.  Not much space for dialogue here.

The CDC and public health experts admit that masks are not the antidote.  The shortest and surest pathway to the other side is for the unvaccinated to vax up. The government hasn’t yet figured out a strategy of how to get this done.


Trying to Crack the Herd Immunity Code


Here are 3 options.

Educate the public so they will voluntarily accept the vaccine to protect themselves and rest of us. Highlight the rather incredible safety and efficacy statistics.  Begging, pleading and downright bribing may be incorporated into this policy.   This has been our current policy which thus far has failed rather spectacularly.

Mandate vaccinations for every eligible person, either immediately or when official Food and Drug Administration (FDA) approval for the vaccines is granted, which is anticipated in the near term.  While you might be tempted to choose this option with zeal and enthusiasm, you may wish to consider what may follow the vaccination edict.  One of the pandemic’s lessons is that Americans, unlike many other countries, are individualists who are not swayed by serving the greater good.  A mandate would fuel protests and refusals to succumb to governmental tyranny.  Politicians and candidates would pander to this aggrieved group which might serve to elect and re-elect anti-vaxxer officials.  The nation might end up being further divided and not much closer to herd immunity. 

Discomfit the unvaccinated sufficiently such that the voluntarily accept the vaccine.  If concert venues, airlines, restaurants, public transportation, hotels, employers and retail establishments increasing required proof of vaccination for entry, it might serve to induce vaccination compliance.

What have I left out here?  What would you suggest?  Give it a shot. 

 

Sunday, August 1, 2021

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. 

Sunday, July 25, 2021

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?

 

Sunday, July 18, 2021

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.

Sunday, July 11, 2021

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?

Sunday, July 4, 2021

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


Sunday, June 27, 2021

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. 

Sunday, June 20, 2021

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.


Sunday, June 13, 2021

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.

Sunday, June 6, 2021

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.

 

 

 

 

 

  

Sunday, May 30, 2021

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.




Sunday, May 23, 2021

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.

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