Sunday, September 18, 2022

Doctors Performing Unnecessary Medical Procedures

If a patient wants a colonoscopy done, and it’s not medically indicated, should the doctor still do it?

If the physician complies with this request, has he or she committed an ethical breach?  Should the medical board or some other disciplinary agency be notified to investigate?

Of course, in a perfect world every medical procedure or prescription would be advised only if it is medically indicated.  But the world is not perfect and there are instances when good physicians may deviate from established medical dogma.


Doctors Performing Unnecessary Medical Procedures

We Inhabit an Imperfect World

Consider these examples and whether you think that a disciplinary response is appropriate.

  • A patient is due for his next screening colonoscopy in 2 years, which would be 10 years since his last exam.  He approaches his doctor with anxiety because his coworker was just diagnosed with colon cancer.  He asks that a colonoscopy be scheduled now.  The doctor agrees.
  • A patient wants his colonoscopy performed in December, after his deductible has been satisfied, rather than wait until July of the following year when he is officially due for his next exam.  The physician accedes to this request.
  • A referring patient requests that his patient undergoes a screening colonoscopy earlier than advised because he feels that the published guidelines from screening are too lenient.  The gastroenterologist complies.
  • A frail, elderly patient has some modest bowel concerns.  The gastroenterologist does not suspect that these symptoms portend a serious issue.  The patient is accompanied by her two children who are firm in their desire that their mother undergoes a colonoscopy to assure that all is well.  The patient grudgingly agrees to proceed.  The doctor schedules the procedure.

So, should these ‘rogue doctors’ be reined in and disciplined?  Or are these simply examples of imperfect practitioners functioning in an imperfect world trying to satisfy imperfect patients?  Do you agree that strict medical criteria should not be the sole criteria that physicians use?

 

Sunday, September 11, 2022

What are the 10 Most Important Things in Life?

Our favorite restaurant has closed.

A child’s toy is left behind on a trip.

Our dog ran away.

We have all observed that the value of something in our lives becomes well known to us when it is missing.  The loss of a job, a friendship, financial security or one’s health are cold reminders of the worth of these items in our lives.  How important are the people in our lives?  We’ve all been taught this lesson the hard way.  Of course, it is human nature to take one’s advantages and blessings for granted.  I do my best to pause from time to time to meditate on the gifts that have fallen my way, many of which are undeserved.  I certainly need to do this more often. In fact, I don’t think one can do this often enough.



Do Flowers Really Matter?


I think most of us would agree that life is richer when we appreciate what we have while we still have it.  In the course of a long medical career, I have met so many inspiring individuals – happy and content with their lot in life.  They are grateful for what they can do which may be different from what they were able to do in the past. These are special people.  They seem to know what really matters and prioritize  accordingly.  They are great role models.  For those of us who take too much for granted, we routinely allow items of lesser value to ascend higher than deserved on the priority ladder.  I certainly struggle with this issue.  The first step in this challenge, I think, is to give life to this struggle and to engage in it.

Think of the 10 items in your life that you value most.  (Not 10 items that sound like the right answers but the 10 items and activities that truly command most of your time and attention.)  Are you satisfied with your list?   Are your top list entries deserving of this status?  What has been devalued and left off the list?  Does performing this simple list-making exercise seem like worthwhile endeavor or is it more like a banal classroom exercise that would only burn up your time?  Or, is it worthwhile just to check in with yourself from time to time?

Somewhere on my own list (can't say for sure if it's top 10 material)  is the joy and satisfaction I receive from writing this blog, still in full force since 2009. It gives me the opportunity to think, craft an argument, assess an opposing viewpoint and put it out in the public square.  I've often criticized the government and others, activities that could land a blogger in jail in many parts of the world. And when readers engage on a post, especially when they disagree with me, it fulfills the blog’s purpose.  I hope that this is a place where readers and myself can be open to other points of views and might even engage in a rare event these days. Changing one's mind.

Sunday, September 4, 2022

Labor Day 2022

Labor Day became a federal holiday in 1894, during the presidency of the only chief executive who served two non-consecutive terms. (Have I tempted you to look up this piece of presidential trivia?)  This holiday emerged from an overheating crucible containing worker exploitation and worker unrest. All of this let to labor reform.  Change so often requires disruption, discomfort, protest and even violence.  Clearly, the antebellum conflict between the northern and southern states, for example, was not to be resolved peacefully.



He served 2 non-consecutive terms.

There are still, of course, unfair labor practices and worker exploitation.  Are Uber drivers employees or independent contractors?  Did Starbucks retaliate against employees who wanted to organize?   But to be fair, we must acknowledge that great progress has been made that is still ongoing.  Oftentimes, when a particular struggle has not yet achieved its full mission, folks point out the distance remaining rather than the distance traveled.  Acknowledging progress should be readily and enthusiastically expressed even if the destination has not yet been reached.  'But we still have a long way to go' is often give as a default statement.  And for many of these struggles, complete success is aspirational.

Labor Day honors the working men and women of this country, those who do the blocking and tackling to keep this nation moving downfield.  Without their contributions, this nation would be but a shell and a shadow of what we are today.  I salute you all. 

Sunday, August 28, 2022

Why Won't My Doctor Refill My Prescription?

Medical care has various tiers of service with differential quality levels.   Each level is designed to meet a specific level of need.  Physicians and patients do not always agree on what level of service is appropriate.  Sometimes a patient feels that a higher level of service is necessary and other times the physician has a similar view.  Consider the listing below of potential medical encounters. 

  • Physician and patient dialogue through the Electronic Medical Record (EMR) portal
  • Physician and patient phone call to discuss a medical issue.
  • Telemedicine visit with audiovisual capability.
  • Traditional office visit with a physician or medical professional.
  • Emergency Room (ER) Visit.

Each one of the above encounters has value, but clearly they are not equal experiences.  The objective is to match the level of the encounter with the medical need.  For example, if you are uncertain if your recently prescribed erythromycin should be taken with food, then an ER visit would seem a step or two too far.  Conversely, if you have developed fever, vomiting and abdominal pain, and haven’t seen your doctor in a year, then leaving your physician a voice mail message seems like a misfire.  

What is the best way to communicate with your doctor?

It's important to know the best way to communicate with your doctor.

I have found that patients tend to inappropriately use lower tier encounters when seeking medical advice. Over the years, thousands of patients have phoned me or 'portaled' me with medical issues that clearly needed face-to-face visits.  These patients often felt that their request for antibiotics or a CAT scan could be easily handled on a phone call.  In general, I ask these patients to see me (or another physician) in the office for a fuller airing of the issues.  After these visits, patients readily appreciate that this higher level of service was essential, particularly when my advice differs from their original request. These patients were utilizing a lower quality platform for convenience which would have been at the expense of quality.  

As always, there are exceptions to everything. Medical judgment is required on how intense the medical encounter level needs to be.  Different physicians have different views and practices on this. Some doctors are more comfortable handling issues over than phone than others.  

Phone medicine can be murky terrain for physicians.  For instance, if you call a doctor after hours who does not know you complaining of chest pain, do you really expect him to simply refill your heartburn medicine?  .  

 

 

Sunday, August 21, 2022

Do Patients Know Their Medications?

Do you know what medicines you are taking?  Do you know the doses?  Do you know the purpose of each of the medications? 

These seem like rather basic inquiries and yet you would be surprised how many patients cannot respond accurately to these 3 simple questions.  The medical profession needs to emphasize the importance of patients achieving an adequate level of medical literacy.  Knowing their medications is an important element of this mission.  It is much easier for doctors to care for informed patients.

When a patient is unsure, for example, why he is on Lipitor, we can easily explain this.  It is more challenging, however, for doctors and other medical professionals when patients do not know the specific dose of a drug or if a drug was omitted from the medication list.  This happens all the time.



Now here's a guy who knows how to make a list!


Electronic medical records (EMR) have the current medication list available for the medical staff to review. But, not surprisingly, it is not reliable 100% of the time.  Sometimes, the patient’s written medication list (assuming he has one) conflicts with the EMR’s list.  Or, the EMR may still be including medicines on the list that were stopped months or years ago.  I have also seen EMR lists that include 2 or 3 heartburn medicines and yet the patient tells me his is only taking one of them.  This makes the visit fun when we try to guess together which medicine is real and which are impostors!

I am not faulting patients here.  Many of them are on several medicines with changes in medications and dosages being made regularly.  It is hard to keep track of all this.  Imagine how challenging it is for a patient who is taking 8-10 medicines every day, with dosing ranging from once daily to four times daily, to keep it all straight.

And, if a patient is hospitalized, there’s a good chance that the medication list on discharge will be quite different from the initial one.  It’s understandable that such a patient who is still recovering from illness and may also be facing employment and familial challenges, might not prioritize studying his new drug list. But it is absolutely critical that he or a caretaker do so.

My plea?  Keep an accurate list of all medications – including over-the-counter agents and any other supplements – with the correct doses.  If your regimen is changed, then revise your list.  Bring it with you to every medical encounter.

Remember, the holiday song that contained the phrase, ‘he’s making a list and checking it twice’?  You might have been taught that this was Santa preparing for Christmas.  Actually, it was Dr Santa setting an example for his own patients.

Sunday, August 14, 2022

The Right to Refuse Medical Care - Saying 'No' to a Colonoscopy

An 85-year-old woman was referred to me because she was anemic.  She was accompanied by her son.  Anemia, meaning a decreased blood count, is a common reason that patients are sent to gastroenterologists.  The reason for this is that internal bleeding in the gastrointestinal tract – even silent bleeding – can cause anemia.  Gastroenterologists are always locked and loaded with our arsenal of scopes ready to probe into your digestive system in search of a bleeding lesion that would explain anemia.  While we are always hopeful that any discovery will be benign, at times the news is more serious. 

Just after I entered the exam room, the patient offered this declaration.

“I am not having a colonoscopy!”

I had not yet even introduced myself to her and her son, but she was determined to set the ground rules.  Of course, it should be the patient who determines her own future, but generally this occurs after some dialogue with a medical professional.  After all, this is why patients come to see us.  However, this octogenarian had managed to reach the age of 85 years intact, so clearly her personal ‘owner’s manual’ has guided her well.  You have to respect success.

I suggested to her wryly that she might at least have waited for me to recommend a colonoscopy before refusing one, but she clearly wanted to assert her autonomy and authority. I reassured her that if she persisted in refusing any recommended testing that I would support her decision. This response relaxed her as intended.  While she may have been prepared to scrap with me, I communicated my own ground rules that I would not be her adversary. 

My professional task is to educate, inform and to prioritize the options for my patients.  I am not the decision maker.  I do my best to equip patients with sufficient information so that they can make truly informed choices, even if I may personally disagree with the decision from a medical standpoint.

                                                  The Right to Refuse Medical Care - Saying 'No' to a Colonoscopy

                                                      A very clear message from my patient.


After reviewing this patient’s medical history and data, it was clear that a colonoscopy was medically necessary as I had concern that a malignancy – which could be curable – might be the culprit.  As part of the informed consent discussion, I also candidly with her the risks of declining diagnostic tests

With unwavering confidence, this woman expressed that she intended to be left alone.  No scope would be permitted to approach her.   We shook hands and I wished her well.

Over the years, I have come to appreciate more deeply how many elderly folks use different medical playbooks than younger people do.  Many times I have seen an elderly patient decline testing while her child who is present tries to change her mind.   In this example, two different playbooks are being used.

I did counsel the woman and her son that she needs to be a peace with her decision, regardless of unknown future medical developments.  Of course, she already knew this.  It’s in her playbook.  






Sunday, August 7, 2022

Prescribing Antibiotics Over the Phone

Recently, a gastroenterologist in our group left our practice.  Of course, the remaining physicians must do our best to provide ongoing care as best we can for her patients.  Ongoing care does not mean seamless care even though some patients expect that a new covering physician will simply assume the reins without so much as a hiccough or a speed bump.  More realistically, there will be a transition period and some inconvenience to the patients and to the covering gastroenterologists.  I was assigned to cover her patients immediately after her departure when the volume of incoming laboratory and procedure results would be heaviest.  Even normal laboratory and radiology results require more work than usual for a covering medical professional.  We can’t simply shoot off a message ‘your biopsy result was benign’ and consider the case to be closed.  There may be many other lingering active medical issues to address.  A modest laboratory abnormality, which would be expeditiously handled in one of my own patients, took much more time as I had to review the chart to make sure I was informed on the patient’s medical history.  For example, perhaps the patient is overdue for a screening colonoscopy or has another gastro condition that needs to be followed?  

Let’s face it.  A doctor who knows a patient well is more likely to give better medical advice with much less effort.  Patients understand this also.  This is why when a patient calls after hours, he hopes that his own doctor answers rather than a partner who does not know him.   


If your doctor is not available, expect speed bumps.

Here's an example of a patient who contacted me expecting seamless care when I was the covering doctor.

My diverticulitis is flaring again.  I need antibiotics right away.

Let me admit from the outset that this patient’s diagnosis and proposed therapy might be spot on.  She knows her body and her medical history.  Perhaps, she and the prior gastroenterologist were in a tight rhythm such that the doctor was comfortable prescribing antibiotics by phone for this patient she knew well.  The chance, however, that I – a covering doctor - would comply with her antibiotic request was zero.  Indeed, I am reluctant to prescribe antibiotics by phone even on my own patients, but I have done so in selected instances.  In the case at hand, this is a patient I have never seen.   Do I acquiesce to her request and risk missing an alternative diagnosis?  What if it’s not truly diverticulitis?   Suppose it’s appendicitis or an inflamed gallbladder, two mimics of diverticulitis which may require urgent surgery?  Perhaps, she is just constipated?  What if it is diverticulitis but is too severe to be managed as an out-patient?   How would she and I feel if I prescribed the requested antibiotics and 3 days later she is admitted to a hospital severely ill?

I directed the patient to be seen that day at one of the area urgent care facilities or by her PCP.  Yes, in a perfect world, I would have had clinic hours that day and availability to accommodate her.

Providing medical coverage for other doctors isn’t easy.  And it may inconvenience patients, as the vignette above illustrates.  But the risks associated with bypassing sound medical judgement are unacceptable and avoidable. 

 

 

 

Sunday, July 31, 2022

Were You Discharged from the Hospital Too Early?

You sent my father home from the hospital too soon.  Three days later, he was worse than ever and needed surgery!

I’ve heard similar lamentations from patients and their families over decades.  Every doctor and hospital nurse has also.  And I acknowledge that sometimes families are correct; folks were sent home too soon. However, in my long experience, most patients are not sent to the street too soon despite some folks feeling otherwise, usually after the fact.  

First, let’s all agree that the medical profession – like your own occupation – is a human endeavor which means that perfection is aspirational.  An imperfect outcome or a catastrophic development does not mean that medical carelessness or negligence has occurred.  Medical malpractice is a real issue, but that is distinct from adverse medical outcomes, which is what I am focusing on in this post

Medicine is not mathematics.  There is no formula or set of proofs that will reliably bring us the desired result with a calculation.  If you disagree, kindly send me the formulas so I can improve my performance. Medicine is an art where judgments are rendered based on moving targets and incomplete data.  When a sick patient is before us today, we must make decisions and recommendations without knowing the future.  Should we prescribe antibiotics to a patient with a cough even if the chest x-ray doesn’t clearly show that a pneumonia is present?  Perhaps, the patient will recover on her own without any treatment?  Should I wait a day or two and simply monitor the patient?  What if I withhold antibiotics and she ends up in the intensive care unit 3 days later?  Will the patient and the family understand if I prescribe an antibiotic, which I am not completely certain she needs, and she develops a severe side-effect from it? Would I be accused then of reckless over-treatment?



'I should have known it was going to rain.'


If you present the above patient vignette to 10 experienced clinicians, there will be no consensus.  The conservative practitioners may hold their fire while more aggressive physicians will pull the treatment trigger. Physicians with divergent recommendations may all be correct, a fact that is mystifying to the public who tend to believe that there is one best answer to a medical issue. 

We cannot foretell the future.  If you leave your home on a sunny day to walk in the park, and it starts raining later, is it really your fault that you didn’t bring an umbrella with you?

When I am wallowing in the medical gray area, a daily occurrence, I do my best to convey the vagaries of medical science and judgment to patients and their families.  I review the options with their respective advantages and drawbacks. But I emphasize that we all have to be at peace once the informed decision has been made.  If a patient makes a considered and informed decision to proceed with surgery, and a post-operative complication ensues, we should not challenge the original decision ex post facto.  The time to debate, question and challenge is best timed prior to the decision, not afterwards. 

Physicians are also mindful of the risks of keeping folks in the hospital -a building full of germs and other demons - a minute longer than is necessary.   Families, however, rarely gripe that we are keeping granny in too long, as they are less aware of these risks which may include. falling, an infection or a medication reaction.  

If we could foretell the future we would make better decisions.  (Think stock market or Las Vegas!) Might this futuristic objective be in the realm of artificial intelligence?  

Sunday, July 24, 2022

Why This Doctor Gave Up Telemedicine

During the pandemic, I engaged in telemedicine with my patients out of necessity.  This platform was already destined to become part of the medical landscape even prior to the pandemic.  COVID-19 accelerated the process.  The appeal is obvious.  Patients can have medical visits from their own homes without driving to the office, parking, checking in, finding their way to the office, biding time in the waiting room and then driving out afterwards.  And patients could consult physicians from far distances, even across state lines.  Most of the time invested in traditional office visits occurs before and after the actual visits.  So much time wasted! Indeed, telemedicine has answered the prayers of time management enthusiasts.

At first, I was also intoxicated treating patients via cyberspace, or telemedically, if I may invent a term.  I could comfortably sink into my own couch in sweatpants as I guided patients through the heartbreak of hemorrhoids and the distress of diarrhea.  Clearly, there was not much of a physical exam that could be performed virtually, but as I have opined elsewhere on this blog, in most cases the physical exam is not essential.  I felt that the quality of my virtual care approached the level that I performed in my traditional office visits.  There were instances, however, when a virtual visit was inappropriate and I advised a face-to-face meeting with me.

But the novelty of the experience wore off after a few months.  Many of my patients are chronologically advanced but technically limited.  A recurrent frustration for many participants was when they couldn’t connect to the platform or activate the audio.  Those lucky enough to have a 12-year-old grandchild nearby could be easily rescued.  For the rest, my staff would be calling the patients to try to guide them toward cyber success, an exercise that burned up staff time and burned out my patients.  This demographic rapidly became disenchanted with this experience. And so did I.


Remember this?


From my standpoint, telemedicine was simply less fun.  I realize that the work of doctoring is serious business, but the personal rapport and interactions I have with patients contributes greatly to the reward of what I do.  I found that this could not be replicated with two of us staring into our computer screens.  Virtual visits are transactional experiences.  Similarly, much of America soon tired of zoom meetings recognizing that efficiency has costs.  Ever heard of the term ‘zoom fatigue’?

But telemedicine won’t be deterred as the forces favoring it are overpowering.

Wonder what the patient experience will be when conventional medical care is replaced by artificial intelligence?  How important will the human physician be then?

There is already too much technology separating patients from medical professionals.  How much time do patients watch us pecking on our keyboards during their visits?  Do you think that telemedicine and the next technological frontiers will bring patients and physicians closer together?  As technology advances, our health may be much better and we will reminisce about doctors of yore as we do today about typewriters, pay phones and the Kodak Instamatic camera.

Sunday, July 17, 2022

The Overuse of Heartburn Drugs

Stomach acid must be Public Enemy #1 for gastroenterologists and primary care physicians.  Why else would more than 10 million Americans swallow proton pump inhibitor (PPI) medicines each day? These medicines are potent stomach acid blockers.  Common examples of these medicines include Prilosec (omeprazole), Nexium (esomeprazole) and Protonix (pantoprazole).  PPI medicines have generated tens of billions of dollars for pharmaceutical companies.  And several of these medicines are available over-the-counter (OTC), which permits the public to self-prescribe for a variety of ailments.

Are ordinary folks selecting these medicines appropriately when they purchase OTC?  I have my doubts particularly since medical professionals often prescribe these agents very liberally going beyond the boundaries of medical evidence.  I have also been culpable of the transgression of PPI mission creep.  Indeed, studies have shown that physicians prescribe these acid blockers for the wrong reason and also maintain patients on them for too long, which may be indefinitely.  I have taken on new patients, for example who have been on these medicines for so long that they cannot even recall their purpose or their efficacy.  Often, these medicines are started during a hospitalization and are continued after discharge and then may be granted eternal life.

These drugs are life-changing for patients with frequent heartburn and gastroesophageal reflux disease, known as GERD.  They are also extremely effective in treating peptic ulcers.  And they are an important component of treating or even preventing acute internal bleeding in hospitalized patients.  But PPI use, or overuse, has reached far beyond these drugs’ established indications.

Stomach Ulcers Heal with PPI Treatment

Stomach Ulcers Heal with PPI Treatment

Why has this happened?  The phenomena of drug overuse is much less common in hypertension or diabetes, for example.  Here’s the difference.  Abdominal pain, indigestion, upset stomach, abdominal cramps, nausea, and bloating are among the most common symptoms that patients suffer from.  The reality is that at a huge percentage of these individuals will not be found to a have a specific diagnostic explanation, such as an ulcer or gallstones or appendicitis.  Many will be told that their symptoms are ‘functional’ or the effects of irritable bowel syndrome, a stubborn syndrome associated with a variety of chronic intestinal distress.  And modern medicine doesn’t have very effective drugs for these conditions.  Medical professionals, therefore, often prescribe PPIs in these instances hoping to bring patients a measure of relief. 

But is this practice good medicine?  Should well meaning medical professionals like me prescribe drugs outside of the drugs' reach because there are no effective drugs available? What would the medical profession look like if all medicines were prescribed this loosely?

 

 

 

Sunday, July 10, 2022

Treating the Medically Uninsured

Imagine that you are a physician and the patient sitting before you has no medical insurance. This means, of course, that this individual will have to pay personally for the costs of blood tests, radiology studies, consults with medical specialists, prescriptions, diagnostic tests and even surgeries.  What do you think it might cost your patient if he is suffering from issues such as chest pain, weight loss, abdominal pain or dizziness?  Standard evaluations for these medical symptoms can cost many thousands of dollars. 

Treating the medically uninsured

Medical Care Ain't Cheap

So, assuming you are the doctor, how would you modify your advice to be sensitive to your patient’s sober financial realities? 

Which of the following modifications would you support for a patient who has no insurance?
  • Instead of ordering a stress test for chest pain, prescribe heart medicine to see if this resolves the issue.
  • Instead of sending the patient to the Emergency Room for a question of appendicitis, prescribe an antibiotic and have the patient see you in the office in 24-48 hours to reassess him.
  • Instead of referring the patient for a colonoscopy to evaluate rectal bleeding, prescribe medicine for hemorrhoids to see if this controls the bleeding.
I recognize that compassionate folks – Whistleblower readers – would be tempted to bend their medical advice to spare a patient from financial hardship.  However, if any reader believes that any of the above 3 hypothetical actions are acceptable, then permit me to respectfully point you in a different direction. All 3 responses are entirely unacceptable and unethical.  Here’s why.

A patient’s financial status should have no bearing on the medical advice.  Indeed, to modify it would be a breach of medical ethics and professionalism.   Every patient is entitled to the physician’s best medical advice, regardless of cost or ability to pay.  Sympathy for a patient’s personal circumstances, while understandable, must not taint the medical advice.

The patient, however, may opt to decline the doctor’s recommendation for cost reasons.  This is perfectly acceptable and understandable.

So, if a millionaire or an uninsured person comes to me for advice, I can’t guarantee that my recommendation will be perfect, but I assure you that the advice for each would be the same.


Sunday, July 3, 2022

Independence Day 2022

We are not, thank the Almighty, engaged in a civil war.  But it does seem that we are waging a war on civility.  Rage, anger, violence, division, hate and fear have crept into every corner.  Politics is increasingly regarded as a zero sum game.  Compromise and accommodation are considered by many to be signs of weakness.  If I can't get everything I want, then you will get nothing.  Should this be our modus operandi?

And the country is in pain.  We are still suffering from the aftershocks of a horrendous pandemic.  Our kids lost a year of education.  Inflation is roaring ahead with no clear end in sight.  A recession with rising unemployment may be just around the corner.  Folks are scared.   A war in Europe reminds us that democracy is at risk. Political campaigns have taken on a coarse vulgarity that mirrors the erosion of etiquette and decorum at large.  The January 6th hearings, while necessary, are only further dividing a fractured nation.  And as all of this was boiling over, the Roe decision was handed down by the Supreme Court.

Tomorrow is Independence Day.  Can we pause for a few hours and collectively reflect on the birth of this nation and what it has meant to us and the world?   There were spirited disagreements among the colonies who had competing priorities and interests.  They knew that the greater good was worth the compromises that would be necessary to achieve it.  How would we fare if we faced such a challenge today?

Independence Day


”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 26, 2022

The Difference Between a Screening and Diagnostic Colonoscopy.

Many patients are confused by the difference between a screening and a diagnostic colonoscopy.  While the actual procedure is the same, the distinction between the two depends on why the colonoscopy is being done.  While you might think that I am wading into a sea of nonsense and absurdity, I am offering you a glimpse of the rational and reasonable world of medical insurance!  Try to follow along.

Here’s a primer.

A screening exam means that you have no symptoms or relevant laboratory or x-ray abnormalities that justify a colonoscopy.  Consider this to be a simple check-up for your colon.  You are being screened to determine if you have a hidden abnormality or lesion.  Get it? 

A diagnostic exam means that the doctor is investigating an existing or suspected abnormality. A medical condition is under consideration and a colonoscopy is advised to investigate.   For example, if you have bowel symptoms, weight loss, blood in the stool, a personal history of colon polyps or a CAT scan that shows an abnormal intestine, then your colonoscopy will be considered diagnostic, not screening.   Get it? 

Large Intestinal in diameters

Diagnostic or Screening?
It's a Question of Motive.

Why does this even matter?   Do not expect that my response will make sense to you, since it makes no sense to me, and I’ve been in the business for a few decades.

In general, most insurance companies will cover screening colonoscopies fully, but most diagnostic colonoscopies will be subject to deductibles and co-insurance.  In other words, even though a diagnostic colonoscopy is the exact same test in every way as a screening exam, the diagnostic version may cost patients more.  Make sense?  If so, please leave a comment so you can explain it to me. 

And, permit me to offer an example when the absurd transforms into the insane.  If a polyp is found on a screening colonoscopy, then the procedure will be changed from a screening to a diagnostic colonoscopy automatically!  So, such a patient who believed that his screening procedure will be fully covered, may have a $urpri$e awaiting him.  The federal government's position that even if a polyp is a discovered, this should not impact patients financially, although not all insurance carriers are on board with this.

Before you have your colonoscopy, it is important to contact your insurance company about your benefits so that you understand the coverage prior to undergoing the procedure.  Ask if your financial obligation changes if a polyp is removed or any biopsies are taken.   I always advise that you write down the name of the insurance company representative and make some notes of the conversation just in case. 

On occasion, patients will contact us after the fact and ask us to change our code from diagnostic to screening, for reasons that readers will now understand.   While we may sympathize with their plight, we are not in the business of altering medical records or otherwise gaming the system. Such behavior would risk a whistleblower turning me in.   

Sunday, June 19, 2022

Practicing Medicine in the Gray Zone

Many issues have clear and obvious solutions.  Consider some illustrative examples.  If a light bulb has burned out, then most of us would agree that popping in a new bulb should be the enlightened response.  If a flower bed is dry, then we reach for a hose.  If our car’s fuel gauge is nearing empty…   I think you get the point here.

Here's a slightly more complex scenario.  Let’s say that your car has a rattle.  The mechanic may not know the cause or the solution, at least initially, but we can all agree that there is a specific malfunction that can be remediated with a targeted intervention.  As with the dead light bulb example above, there is a specific, reparable defect present. 

Unlike in the automotive world, other disciplines operate with a loose, flexible and proprietary framework.  Consider the financial industry.  One need only read a newspaper’s business section for a week to appreciate the divergence of opinions on financial and investment matters.  Experts cannot agree on the diagnoses or the treatments of sundry economic ailments.  Over the past year or so, for instance, we have seen widely differing explanations of rising inflation and how to combat it.  Of course, political considerations regrettably affect people’s views here, so we may not know what they are really thinking.

If you solicit investment advice from 10 financial experts on where to place funds, you would likely receive a smorgasbord of advice.  Individual stocks?  An annuity?  A managed mutual fund?  Real estate? Tax free municipal bonds?  Or maybe keep as cash for now?   You would be offered an array of financial products with each firm arguing that it would best meet your portfolio’s objectives, after considering market trends, your risk tolerance, age and other factors.   And here’s the confounding part; there is no single correct answer here as there is with a rattle in your car.  Some or even all of the investment firms may be ‘right’.


Everything is not black or white. 


This is the same murky terrain that medical professionals occupy.  Patients’ symptoms are very different from an engine squeak that will disappear after oil is squirted in the right spot.  Consider routine medical symptoms including fatigue, depression, ‘brain fog’, stomach aches, headaches, sleep disturbances, dizziness, nausea or joint pains.  Skilled medical practitioners may disagree on the cause of these stubborn complaints and the preferred path forward.  And similar to the investment industry, various differing medical approaches may be ‘correct’, which can be a vexing reality for patients and their families who have a false sense that there should be a single correct medical response.  Patients who have consulted various physicians for fatigue can corroborate that they have received divergent and conflicting advice.  

If you see 10 gastroenterologists like me with stomach pain, should you expect an unanimous response?  (Hint: answer ‘no’ here.)

When you enter a gray world, don’t expect a black and white solution. 

 

Sunday, June 12, 2022

Is My Stomach Pain in my Head?

Stomach Pain and Mind-Body Relationship

This is a delicate issue and must be approached by medical professionals with care.  Of course, it is an established fact that psychic distress can be responsible for physical ailments.  Did you ever get a headache after having an argument?  Were you one of those students who experienced diarrhea before final exams?

This past week, I saw 3 new patients in my practice with abdominal distress all of whom volunteered that they felt that emotional stress and anxiety were the culprit, or at least a major contributor to their gastro issues.  Obviously, when the patient has this level of insight and expresses it to the physician, it paves the way for a fruitful conversation.

But, this is not always the case.

When I see new patients with long histories of unexplained abdominal complaints, I do not initially raise the possibility of a psychic connection.  I think this is arrogant and has the potential to communicate the wrong message to the patient, even if stress-induced gastro distress is ultimately diagnosed.  My obligation as a gastroenterologist is to consider medical explanations of patients’ symptoms.  Patients with bipolar disease, anxiety and PTSD can develop ulcers, Crohn’s disease, cancer and appendicitis, etc.,  just like everyone else.  I do my best to keep my mind open so as not to miss a lurking medical condition.

And if a doctor raises the ‘mind-body connection’ too soon, it risks rupturing the doctor-patient relationship.  Once this relationship is better established, then deeper conversations become possible.

Is my headache real or just in my head?

Is my headache real or just in my head?

Consider a patient who comes to see me for the first time with a history of anxiety and abdominal pain.  She has seen a digestive specialist who has been unable to explain her distress.  Should I suggest that her anxiety may be responsible and direct her toward treating this disorder?  Here are some of the pitfalls of that approach. 

  • She may have a medical diagnosis that was missed by the prior specialist.
  • Suggesting that anxiety is the cause, if done at the wrong time and in the wrong manner, risks communicating to the patient that the ‘pain is in her head’.  This forfeits any opportunity to help this individual.
  • Anxiety may be a contributor, but there may be other contributing medical conditions such as irritable bowel syndrome or constipation, which can be successfully addressed.
  • Invoking anxiety in a general way may miss an important path forward.  For instance, the patient may have a fear of  a specific illness, beyond general anxiety.  Discovering this takes physician effort.  Knowing, for example, that a patient is scared that she may have an esophageal tumor is extremely useful to the doctor, who can address this directly.  A simple question of, ‘are you scared that you might have something serious’, can expose a healing opportunity.

And while physicians need to tread this terrain carefully, patients have a responsibility here also.  Both sides need to be open to all reasonable diagnostic possibilities as they contemplate the complex tangled web of the mind-body relationship. 

 

Sunday, June 5, 2022

Medical Ethics -vs- Medical Behavior

When a judge hears a case, neither party is 100% correct.  Each litigant may have a meritorious claim, but one of them will be found to have the better argument. If the dispute could be easily and amicably resolved, or one party was clearly wrong, then the matter would be unlikely to have reached a courtroom.  One litigant may be found to be 'more right' than the other


Which litigant's right will prevail?

Medical ethics has a similar construct.  Rarely, is an issue clearly and easily decided.  For example, with limited financial resources, tough decisions must be made on how to ethically allocate these funds.  Those who will not receive any funds may still have an ethical right to receive them, yet other groups may have a stronger right.  If our society decides that it will not pay for dialysis in moribund individuals, it does not mean that these individuals have no right to this treatment.

These complex decisions create winners and losers.  Those who are ruled against are likely to view the process as unfair.  Conversely, those whose wishes are granted will gush about the reasonable and just decision that served their interests.  Such is life.   In these matters, we need an advisory process with many voices to assure that medical ethical recommendations are made fairly and equitably, recognizing that these imperfect human beings are operating in a world where unfairness lurks.  Medical ethicists and their colleagues struggle to do right when every choice seems wrong.

Sometimes, the ethical issue is agonizing and painful.  Should a child with an aggressive cancer be approved by the insurance company for a promising, yet experimental treatment?  Do we feel differently if the patient is our kid? On other occasions, the ethical path is clear.  Should a physician write a prescription under the spouse’s name who has met her deductible to save the patient money? 

What is your judgment on the following hypothetical ethical scenarios?
  • A family demands and receives intensive care treatment for an ailing loved one.  The medical care team has advised hospice.  Leaving aside the futility aspect of the case, the insurance company is spending thousands of dollars each day.  Is this ethical?  Should the family be told that if this care is continued, that they will be financially responsible?
  • A physician routinely gives out drug samples to his patients.  These are left in the office by pharmaceutical representatives who want their products within easy reach of physicians.  Many patients who receive these free samples have drug coverage, but receive the samples anyway. Obviously, pharmaceutical companies must raise their drug prices in order to pay for these office giveaways.  Is this fair to the rest of us?
  • A nurse on an evening shift at the hospital is told that he will be responsible for 2 additional patients since they are understaffed.  The nurse feels that this workload is excessive, but has little recourse but to submit to the request.  No additional compensation will be provided.  Is this ethical to the nurse or to his patients?  
We often know what the right choice is, and yet we often choose differently.  Why do we stray when we know what is right?

Sunday, May 29, 2022

Memorial Day 2022 - Honoring the Fallen

 After the Civil War, which had more casualties than in any other American conflict, Decoration Day was established to honor the war dead.  Over time, this sacred commemoration transitioned to Memorial Day, which became a federal holiday in 1971.  This day honors all who have fallen in the service of the nation’s armed forces. 

Although our debt to them can never be satisfied, we can at least pause and reflect on the inestimable sacrifice that they and their families have offered this nation.  We salute you all.


Gettysburg National Cemetery on the 50th Anniversary of the Battle.


As we all see at this very moment in eastern Europe, freedom is never guaranteed.  It must be protected and defended from those who fear it and aim to destroy it.  Threats may emerge both from without and within.  

It’s easy and understandable that we take our freedoms for granted – the freedom to criticize the government, the right to equal justice under law, the right to peaceably protest, the right to worship without interference and the right to author a blog without fear of arrest or censorship.

On Memorial Day tomorrow, let’s honor the memories of those who died so that we can live in freedom.

Sunday, May 22, 2022

Justifying Unnecessary Medical Tests

Would a doctor ever order a diagnostic test that was not medically necessary?  I’ll give you a hint to this ‘yes or no’ question; the answer has 3 letters.

Of course, in a perfect medical world, every medication would perform flawlessly with no adverse reactions.  All medical tests would be justifiable and painless.  Physicians’ diagnoses would always be accurate.  Drugs would be affordable.  All patients would recover from whatever ails them. And doctors would never be late for their appointments!

Sound like the medical world you know?  I doubt it.  The medical universe that I inhabit is riddled with flaws and imperfections.  It is, after all, a human endeavor which guarantees variable outcomes. Sometimes, the patient just doesn’t get better.

So why would doctors like me at times order medical tests that are not necessary?  Wouldn't this violate my professional oath and code of conduct?

Years ago, when the plaintiff’s bar was on fire suing doctors, many physicians ordered questionably necessary tests thinking that this might protect them from a successful malpractice claim.  Thankfully, the volume of med mal litigation has diminished and so has the defensive medicine response.  This is a welcome development for doctors and their patients.

Trapped in a medical maze

Sometimes, patients feel trapped and need to be set free.


But often it is the patients themselves who drive the pursuit of unnecessary diagnostic testing.  Even when the doctor tries hard to reassure the patient that the test result will be normal, the patient is often not persuaded.  Nearly always the patients steadfastness originates from anxiety – the fear that a serious disease is lurking.  On a regular basis, for example, a patient will see me a year or two before his colonoscopy is due asking for the procedure because a neighbor was diagnosed with colon cancer. Or a patient may insist on a CAT scan of the abdomen, even though one done months ago was normal, worrying that something was missed.  Many times I have performed a scope examination of the esophagus to calm a patient who truly doesn’t need the test medically, but is worried because his grandfather’s esophageal cancer was found too late.

When doctors order such tests, is this fair to insurance companies who are paying for the studies?

Is this fair to society to be consuming finite medical resources?

Is it even fair to patients to expose them to the risks of medical testing?

I have come to think that a strict medical justification for a test is not the only criterion that merits consideration.  If a patient has a level of anxiety that is diminishing his quality of life, and a medical test can assuage it, then I think a case can be made to proceed.  I can’t define the precise anxiety level that needs to be present in a particular patient in order to proceed.  This judgment needs to be made by individual physicians and their patients.

And finally, even though the doctor may balk at the test, sometimes the patient ends up being right. Doctors, after all, are members of the human species with all of the flaws and frailties that define everyone.

 

 

Sunday, May 15, 2022

What To Do While Waiting for the Doctor

The day before writing this, I had two unusual experiences in the office.  I am not referring to the patient whom I had not seen in years who gifted me yesterday with a full size New York style cheesecake.  I now must decide how I will apportion those 15,000 calories.  Perhaps, if I have 1 teaspoonful a day for a year that my BMI won’t be unduly affected. 

The newsworthy events had nothing do with my medical skills.  I did not nail down a rare diagnosis or provide a cure that evaded other practitioners.  In fact, the events that I will highlight below occurred prior to my entering the exam room.

When I enter an exam room to greet patients, they are generally engaged in the same activity – they are on their phones.  They are watching videos or playing games.  They are checking their e-mails.  They are pecking at the keyboard as they are issuing forth text messages of monumental importance. 

Where did this come from?  How did we find ourselves in a world where no spare moment can be wasted?  Why do we feel the need to be ever occupied?

Two individuals yesterday who didn’t get the tech memo were clear anachronisms.  One was reading an actual book, not a kindle or an electronic reader but an actual book, complete with printed pages and a book cover.  At first, I thought this may be a mirage as I haven’t seen such a tableau in some time.  Or, was I dreaming?  But I soon realized that the scene was real.  The second person was a family member who was immersed in a newspaper – not Apple news or beeping notifications bleating from a phone. I mean actual ink on newsprint. 


Two Relics from Days of Yore


To those who know of my own zealous devotion to the printed page, these two singular events impressed me deeply.  These were two people, three including me, who were not yet willing to brandish the white flag.

Some months ago, I greeted a patient who was transfixed on his phone when I entered the exam room.  I offered unsolicited non-medical advice.  I laid out a challenge for him.  The next time he is waiting for a doctor, I urged him to just sit quietly and leave his mind open. Yes, this was a bold and risky experiment.   He might be surprised and refreshed, I suggested, at what thoughts and ideas cross his mind.

Sunday, May 8, 2022

What Makes A Good Doctor? The Answer Might Surprise You.

Many physicians understandably pride themselves on special skills or knowledge that they have acquired.  This is true of so many professions.  A lawyer is admired for her skill in the trial arena.  A musician is lionized for his virtuosic technique.  An athlete inspires his peers and the rest of us with his record-breaking accomplishments.

We have all heard of physicians who are renown for particular talents.  

You need an operation on the pancreas?  Here’s the guy you should see. 

Your Crohn’s disease is not responding? You should see my specialist who saved me from surgery!

Your fibromyalgia is on fire?  Have you heard of this new doctor in town who runs a fibromyalgia clinic? 

Obviously, a physician’s skill set is a critical asset in the practice of medicine.  Indeed, when a patient sees me, he comes with the belief that I have the training and experience to address his concerns. Usually I do, but not always.  It is very important for physicians to know which patients should be referred elsewhere. The best physicians restrict their portfolio to what they do well.  

As obvious as this is for doctors and other occupations, it can be challenging for many of us to recognize when we should divest ourselves from tasks that we routinely performed for years.  Some of us may not wish to admit – or might not even be aware - that we don’t have the same surgical skill and stamina that we had previously.  Or, we are prescribing the same treatments that were state-of-the-art years ago, but the field has since moved on.  If a doctor gives up performing a medical procedure, this may directly affect his income and marketability. 

Excellence means that we are excellent at everything we do.  This means that we either have to set aside tasks that we do not execute at a high level or raise the quality of our performance.  If 4 athletes are on a relay race team, and one of the runners is slow, the team will lose regardless if the other 3 runners race like cheetahs. 


To win the relay race, all runners must perform well.

Years ago, I decided to give up performing a complex gastrointestinal procedure for good.  This scope procedure investigated issues involving the liver and the pancreas and was technically demanding.  While I felt that I was competent, the field continued to advance and I felt that I just couldn’t keep up.  It can be very difficult for doctors to learn new and evolving technical skills when we are in practice as opposed to during our training years.  Had I continued on with this fancy scope test, my procedural competence would have surely eroded to a mediocre level.  So, I gave it up and never looked back.  From that point onward, I referred patients who needed this procedure to colleagues who were experts.  Everybody wins.

There are other examples of aspects of gastroenterology that I no longer practice.  It’s not important that I do everything. But I want everything that I do to be done well.

So, you may seek out a doctor for what he can do.  But an important aspect of being a good physician is also what he doesn’t do. 

 

 

Sunday, May 1, 2022

How Do Patients Choose Doctors?

My last blog post contrasted the experience of being an employed physician with being a private practice doctor. I expressed that at this stage of my career that I much preferred being employed to running a medical practice. (This means that I can now spend all of my time just being a doctor!) But there are desirable features of private practice medicine that simply do not exist in the medical megalopolis where I now work. Not surprisingly, the vibe is different in a gargantuan organization that employs tens of thousands of caregivers, staff and support personnel who serve millions of patients domestically and overseas. 

It is simply not possible to recreate the intimacy that I enjoyed in my prior small practice with my patients and my own staff.  Here’s an example that will illustrate my point effectively.


Telephone Directory

Here's how I found my doctor!

For as long as I’ve been practicing medicine, I’ve queried every new patient who came to see on how they ended up with me.  Yes, there were a handful who found me in the phone book (readers under the age of 40 are encouraged to google this item) and some who simply wandered into the office with digestive issues.  But most of them had a more personal reason that led them to my office.  I would routinely hear remarks from patients similar to these:

My dad loved how you fixed up his stomach for him and told me to come here.

I got your name from my neighbor who raved about you when she was in the hospital.

I looked up your reviews and wanted to see you.

I am not citing the above examples in a boastful or self-promotional manner.  Indeed, nearly every doctor has similar vignettes and examples of patient loyalty.  When a patient has made a conscious and deliberate decision to see a particular doctor, this automatically advances the doctor-patient relationship. Every restaurant or tradesmen or consultant or retailer appreciates a word of mouth referral.

In my current job, I do see some patients who were referred to me by other patients, but this is much less common.  Typically, patients or their primary care professionals call a centralized scheduler who scans the sea of gastroenterologists and plugs the patient into an available appointment slot.   Of course, there is no difference in the quality of my work, but the vibe is not the same.  When I ask these patients how exactly they came to see me, often they reply ‘I don’t know.’

Remember (or imagine) going to the local hardware store in search of a particular tool?  You would be greeted by a friendly associate or maybe even the owner to assist you.  He might even know you by name.  While one could purchase the same item in a big box store, the experience is not the same.

When an organization is dealing with zillions of patients, guess who prevails in the Intimacy vs Efficiency contest?

 

 

Sunday, April 24, 2022

Employed versus Independent Physicians - Which is Better?

In my illustrious (or at least long) career, I have had 3 jobs.  After I finished all of my training, I was an employed physician for nearly 10 years.  Afterwards, I joined a small private practice group where I remained for 20 years.  Over time, as partners in the practice left or retired, I became the practice’s president by default.  I don’t really have an authority persona, which my staff was well aware and hopefully appreciated.  In nearly all cases when a decision could either favor the interests of our employees or the practice, I favored our staff. This earned a huge measure of staff loyalty, but no achievement award from the Chamber of Commerce. I am more than content to be regarded as a caring boss than a shrewd businessman.  Three years ago, I joined a rather large Cleveland medical enterprise where I now serve as a physician employee.


Employed versus Independent Physicians

Employment                         Independent


I know the advantages and drawbacks intimately of both models – employment vs business owner.  Indeed, an entire blog could be devoted to comparing and contrasting the two models.  It’s a complex issue.  It is self-evident that each option has its own advantages.  But the analysis likely changes depending upon the phase of the physician’s career.  For example, now in the autumn of my career, do you think I miss worrying over making payroll, erosion of patient referrals to the practice, declining reimbursement, grinding paperwork fighting insurance company denials, rising overhead expenses, compliance with state and government agencies, endoscope repair and replacement and physician recruitment?  Sound like fun?  Not at this stage of my career.  Presently, all of the above cited tasks are now in my employer’s in box – not mine.  I am now fully and enthusiastically devoted solely to the practice of medicine, which has been a joy.

But at earlier phases of a physician’s career, he or she may willingly take on the burdens of managing a private business in return for the autonomy and independence that this model affords.  Indeed, that was me for 20 years.  But no longer.

Of course, I miss the freedom that I enjoyed when I was the decision maker.  It is no longer effortless for me to take days off.  I do not hire my own staff.  No one, save the patients, asks my advice on anything.  But I am using a different set of weights and measures now.  And for me at this stage of my professional life, my scale tilts markedly in the employed direction.