Sunday, March 28, 2021

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

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. 

Sunday, March 21, 2021

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. 


Sunday, March 14, 2021

Tolerating Uncertainty in Medicine

Uncertainty makes everyone anxious, although each of us has a unique threshold for uncertainty tolerance.  In other words, different folks may react quite differently if they are confronted with the same set of facts. 

Consider this hypothetical.  Two patients who are of similar age and enjoy excellent health undergo a CAT scan for a stomach ache.  By the time they follow-up with their physicians to review the results, their symptoms have resolved and they feel perfectly well.  A small spot is seen in the liver which the radiologist suspects is an innocent cyst, but he cannot state this definitively.  Each of the patient’s physicians explain that minor accidental findings like this are common and are very unlikely to pose any health threat.

Patient #1: “Ok, doc. I feel great and if you’re not worried, neither am I.”

Patient #2:  “Are you sure it couldn’t be serious, like a cancer?  Should I have it cut out just to be safe?”

First of all, let me give readers an inside tip on how to pose inquiries to your doctors.  If you begin your question with,  “Doctor, are you sure that…”, the physician’s response will be, “No, I can’t be 100% sure…”  If you begin your inquiry with, “Doctor, is is possible that…”, your doctor will answer, “Yes, anything is possible…”

Life is a casino.  We play the odds every day.

There are no guarantees in medicine or in life.  Uncertainty is everywhere and we all have our own uncertainty tolerance levels.  While there is no correct uncertainty threshold, your own level will determine if you spend most of your time at peace or on edge.  If you demand certainty, for example, then you will be forever seeking more testing and evaluation to eliminate doubt, and you may never reach your destination.  This principle may also apply when making investment choices , considering legal advice, buying a used car, eating street food abroad, considering an extended warrantee on an appliance as well as choosing among medical treatment options.   If I reassure a patient that his colonoscopy is normal and published data suggest that the chance that a lesion was missed is about 5%, will the patient accept the test’s inborn imperfections?  Will I?  Should everyone undergo 2 colonoscopies in order to decrease the miss rate?  How much effort and resources are worth achieving small incremental benefits?  I’m only posing the question here.

And individuals who have excessive risk tolerance may risk unfortunate outcomes.  Cashing in retirement funds for chips to place on the roulette wheel would make most folks uncomfortable. 

A patient I saw recently is eligible to receive the COVID-19 vaccine but does not wish to proceed.  He is aware of the safety and efficacy data but is concerned over potentially unknown adverse reactions that may emerge over time. This is not a right or wrong issue; it’s a matter of judgement.  He isn’t certain that he his making the right choice, but he is certain which option feels more comfortable at present.  Many others would decry his decision as a risky roll of the dice.  Remember, however, we’re all gamblers as we journey through life placing our daily bets and hoping at least most of them pay off.  


Sunday, March 7, 2021

Lockdowns and COVID-19 - Is the Cure Worse than the Disease?

 There’s been lots of talk about lockdowns lately.  This issue, like masks, has become politically contaminated.  It’s been one of the fascinating lessons of the Pandemic of 2020 – the recognition that issues that would seem to be ‘immune’ to political interference became instead potent partisan weapons.

Consider two rather distinct reactions to the recommendation to don a mask when frolicking about in public.

Citizen #1:  Of course, I will mask up.  This will keep me and others safer.  In a small way, I feel I’m doing my part on the journey to the other side.

Citizen #2:  Mask?  Hell no!  Just more encroachment by the government to rule our lives.  

Similarly, locking down the economy, both here and abroad, has provoked bitter reactions from all sides.

'No mask for this patriot!'

As I have written, I feel awful about the hundreds of thousands of businesses who have closed or are barely hanging on.  I also feel that their plight has not been given the attention it merits from the national press.  We have been regularly informed – as we should be – about the health risks of the virus and the need for all of us to behave responsibly.  But I do not think we have been as fully informed about the economic pain and irrevocable consequences that the nation is enduring.   Additionally, the press tends to villainize political leaders who argue for loosening up on their lockdowns and laud those who call for tight control.  Many businesses who have faced stringent restrictions have been infuriated as other businesses in their communities have been permitted greater latitude for reasons that defy common sense. 

There is a balance between maximizing public health and mitigating economic catastrophe and good people can disagree on where to draw the line.  While I don’t pretend to know how to thread this needle in motion, I do think that both sides deserve consideration and respect.  For example, if hypothetically we were to adopt a total national lockdown, we might stifle the virus much faster but have little to return to afterwards with a nation facing collective bankruptcy.  And the converse is also true.

I also feel that if all of us had uniformly adopted the public health measures advocated by medical experts a year ago, that many lockdowns could have been avoided or have been less onerous  That’s on us.  If folks are packing into bars and clubs at night, what do we expect local and state authorities to do?

Texas and Mississippi have recently opened up their economies in a big way with bravado.  They have been vilified and I share the concern of the critics.  If the COVID-19 cases rise, as many expect, then these political leaders will deserve all the vicious incoming they will receive.  But if no viral surge develops and an economic surge results, will the critics and the press admit they were wrong and celebrate the success?