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