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.

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.

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.



Sunday, April 17, 2022

What is Causing My Stomach Pain?

One of the most vexing issues for patients and their doctors is dealing with unexplained abdominal pain.  Indeed, over the course of my career, I have treated thousands of these patients.  Every day, one or two of them are on my office schedule.

Many of them have had abdominal distress for decades.  Many have had several visits to emergency rooms and have seen multiple gastroenterologists and other doctors over the years.  Diagnostic tests are done and often repeated in the ongoing quest to find an explanation.  When I review a patient’s entire medical record, I am often astonished to learn how many CAT scans have been repeated to evaluate the same pain.

These patients understandably are operating under the notion that the medical profession should be able to explain the cause of their pain. This is the primary reason that these individuals seek care.  This is, after all, the job of a doctor.  In addition, they also want decent pain control so that they can live a more normal life.

Sometimes, it's best to choose another route.

If a patient has chronic and unexplained pain, there are two possibilities.  The first is that the physicians and medical professionals who have evaluated the patient over months and years have missed a lurking diagnosis.  Perhaps, no one considered a rare illness. Or a common condition was the culprit but was behaving in an uncommon manner making it difficult to recognize.  No physician can ever be 100% certain that every conceivable diagnosis had been excluded.  Here are samples of patient inquiries that I am unable to categorically reject.  “Could this be a parasite?”  “Are you sure this couldn’t be cancer?” “My aunt had the same symptoms and it took years until they knew it was her gallbladder.”  While these possibilities may be unlikely, I can never absolutely dismiss them

The second possibility is that the unexplained pain is also unexplainable.  Readers may be surprised to learn that this group of patients is the largest category in our abdominal pain patients.  Most of the abdominal pain we see won’t light up on an imaging study or a lab test.  Many of these patients may be assigned a diagnosis of irritable bowel syndrome, which may include an array of digestive symptoms which are difficult to explain even though a ‘diagnosis’ has been made.

Can folks with unexplainable abdominal pain be helped?  Absolutely.  But for many of them, gastroenterologists may not be the most skilled specialists for these cases, even though we are ‘stomach doctors’.  For example, if a patient sees me for a 3rd or 4th gastro opinion, it is likely that the patient is not on a healing pathway.  If the same approach in medicine, or in life, is failing, then it’s time to change direction.  And this is often the advice I offer these patients.  I tell them that I do not know which particular path they should pursue, but they need to make a left or a right turn rather than continue along on the same road.  They should be open to alternative approaches including functional medicine, integrative medicine, acupuncture, naturopathy, meditation and even hypnotism, among others.  This is not time for physician arrogance.  Many times, I have looked these patients in the eye and pointed out that since the prior strategy has brought no relief that a new approach must be considered.  In nearly every case they immediately get it since it just makes sense.  For many of them, it’s a why didn’t I think of that’ moment. 

When physicians’ and patients’ minds are open, there is much greater chance to find healing and relief. 


Sunday, April 10, 2022

Fake News - Why are We So Gullible?

It’s certain that you have heard the phrase ‘Fake News’ bandied about these past few years.  It seems there is no consensus defining this term.  Here are a few differing interpretations.
  • Inaccurate reporting where minor, immaterial errors appear, but the essence of the story remains true.  For example, if an article wrongly names a restaurant where a meeting is held, the article should not crumble.
  • Deliberately slanted reporting to serve a political agenda.  I do believe that this happens daily.  Reporters and editors are charged to compartmentalize their own views, similar to judges, but they are human like the rest of us.  The next time you open a newspaper, read the headlines carefully and you will find examples of wording that is less than fair and balanced
  • News reports that are completely on the level, but are attacked by those whom are threatened by the reporting.  I don’t feel that I need to give examples here.
Fake or On the Level?

A close cousin of Fake News is gullibility.  Folks today tend to believe what they read and hear, even if the position is untested or even disproven.  Remember how many diehards maintain that certain vaccines caused autism even though this linkage was thoroughly and repeated debunked by the scientific community?

Several times each week I have to reassure my heartburn patients that their medicines will not corrode their bones or lead them to kidney dialysis.  A screaming headline, Nexium Linked to Hip Fractures, may gain clicks, but it is misleading and not based on scientific facts. 

Our gullibility is exploited when malicious foreigners and those among us load Facebook and other social media sites with false and provocative information to divide and confuse us.   And, it works.   We are all too ready to accept as fact what is truly fake news hiding under camouflage.  

I am not excusing the purveyors of Fake News or those who falsely assign this label to truthful reporting.  But, don’t we – the consumers of news – have an obligation to perform some measure of due diligence?

Sunday, April 3, 2022

Will Smith Gets Slap Happy at the Oscars!

In my own life, I do my best to use one set of weights and measures.  By that I mean applying the same standard always when judging individuals, businesses, politicians and even nations.  There is not a day that passes that we do not see exasperating evidence of double and triple standards being applied.  We saw Republican senators recently excoriating a nominee under consideration for Associate Justice of the Supreme Court by senators who previously voted to confirm her!  No gloating here, Democrats.  Your treatment of Justice Brett Kavanaugh during his Senate Judiciary hearings was not your finest hour either. 

The Cleveland Browns recently acquired a superb quarterback, Deshawn Watson whose 5 year contract will provide him with a miserly $230,000,000. Presumably, after taxes, he should still have enough to live comfortably.  As everyone in Cleveland who is breathing knows, Watson is facing 22 civil lawsuits accusing the athlete of sexual abuse.  In fairness, two grand juries declined to indict him for a criminal offense and Watson has of yet not been convicted of anything. He denies the allegations.  However, the NFL was sufficiently persuaded of his misconduct that it is expected that he will be sanctioned by them.  I’ll ask readers to consider how their employers or prospective employers might react if they faced nearly 2 dozen civil lawsuits for sexual abuse.  Let me be the first to respond.  In my case, I would expect that my employer would arrange for a pair of security guards to escort me to my car.

A week before this posting, during the (yawn) Academy Awards ceremony, actor Will Smith charged the stage and slapped comedian Chris Rock hard across the face.  This wasn’t merely a demonstration of unrestrained rage and horrible judgement.  It was a crime witnessed by millions of people.  Smith returned to his seat and avoided any consequence either from Academy security personnel or law enforcement.  Later on in the ceremony, Smith received his Oscar award and was seen celebrating later that night.  Of course, the Academy promises a ‘full investigation’, but I think we all know where that will land.  A day after he committed assault and battery, Smith issued a lawyerly apology that was obviously crafted by others. 

What would have happened if an ordinary person in the Oscar audience -or anywhere else- stood up and approached another person and slapped him silly without warning?  (Here’s a hint.  If you’re thinking ejection from the auditorium followed by arrest, then you’re on the right track here.)  Suppose one of my patients arrived 20 minutes late and I seethe over this disrespect and opt to let my hands do the talking.  Do you think that I would be permitted, if not encouraged, to continue seeing patients later that day or ever?  More accurately, that would be the day that my retirement would begin.

Using one set of weights and measures would restore so much faith in the system and in each other,  Many folk prefer to have multiple sets at their disposal.  I guess this depends if your mission is fairness or to win.    


Sunday, March 27, 2022

EMR - Promises Made, Promises Broken

 Over the past 15 years or so, I have endured several electronic medical record (EMR) systems. Indeed, there is an entire category, EMR Quality, on this blog where I share with readers the good, the bad and the ugly in the EMR space.  If you are suffering from insomnia, I invite you to review these posts nightly.

When EMR was creeping onto the medical landscape, physician grunts like me were salivating over the prospect that one of our thorniest and frustrating challenges was about to be solved.  EMR promised that all of our patients’ records could be accessed with a couple of keystrokes in our own offices.  This made sense as we all knew that the digital world could create linkages that would permit access to all of a patient’s medical experiences.  Regrettably, this promise that was made to medical professionals and the public remains unfulfilled.

Here’s why physicians were so ripe for the EMR seduction.  Consider this typical scenario in the pre-EMR era.

A patient comes to my office with stomach pain.  She was seen for this complaint at 2 local emergency rooms (ER) which fully evaluated the patient with laboratory studies, CAT scans, an EKG and history and physical examinations  (It is likely that the 2nd emergency room repeated everything that was done in the 1st emergency room as they might not have known of the initial ER visit or they had difficulty obtaining the records, especially if the 2nd visit occurred at night.)  The patient then followed up with her primary care physician (PCP) who repeated labs that he told her were abnormal in the emergency room.

Seeing patients without records was like wearing a blindfold.

When I see such a patient today, I may have none of the above records when the patient is before me.  Do readers think that these records might be helpful  to properly advise the patient?   If the patient tells me that the CAT scan results were normal, do I rely upon this without viewing the actual reports?  When she tells me that the first ER physician sent her home with some kind of antibiotic, which the 2nd ER physician told her wasn’t necessary, might I need to know more about this?  

Every physician over a certain age can recall thousands of similar scenarios.  In my hypothetical vignette above, in the olden days we would send both ER’s and the PCP signed authorizations to forward the medical records to my office.  It might take weeks to hear back.  Or we might not hear back at all.  Or we might get only a portion of the requested records.  Or, we might get records we didn’t request at all.  There were instances, for example, when I requested a CAT scan report and a mammogram result arrived weeks later.  

Can you imagine how difficult it is to treat the patient above who had ongoing abdominal pain without the prior records?

Can you imagine how often patients have unnecessary medical testing that had already been done elsewhere but this was not known to the ordering physician?

Can you imagine why medical professionals believed the seduction that EMR was the holy grail for accessing patients’ medical data from near and far?




Sunday, March 20, 2022

Is the West Doing Enough for Ukraine?

 The world is watching as a maniacal dictator methodically levels a country, displaces millions of citizens and attacks civilian infrastructure and lives.  The Ukrainian response has been unexpected, effective and downright inspiring.  To paraphrase JFK’s iconic remark in a 1963 speech in West Berlin, ich bin ein Berliner, we are all Ukrainians today.

By all accounts, the Russian military assault or war or invasion has stalled.  Their current ‘military’ strategy now appears to be that if you can’t occupy a Ukrainian city, then destroy it.  The ghastly footage is reminiscent of newsreel footage from London in 1941, when the city was bombed for months by another maniacal dictator.  The entire world, except one country, is aware of the deliberate targeting of maternity wards, schools, residential neighborhoods and civilians.  Of course, the Russians deny all of this and maintain that they are liberating Ukraine from genocide and other crimes.

The West, under the guidance of the American administration, has responded superbly, certainly beyond expectations.  Americans are united over this issue more than any other issue in recent times.  While there are additional actions contemplated to support Ukraine and to isolate Russia, we have generally hit all of the right notes, short of entering the conflict directly.  There are debates over sending aircraft into Ukraine or cutting off the purchase of all Russian energy. 

Many counsel restraint so as not to escalate the situation and risk a Russian response.  But who is the aggressor and the escalator here?  Who should be dictating the terms?

Should we hold back on certain actions because we fear the unlawful and immoral aggressor might act out? 

What will be the cost to free peoples if Ukraine is lost or dismembered?

Does anyone maintain that if Ukraine is Russified, that Putin’s appetite for expansion will have been satisfied?

Isn’t it easier and preferred to crush a bully sooner than later?  Had we responded differently in 2014 when Russia seized the Crimea, would we be in the current situation now?  I doubt it.

Of course, I don’t know the right answers here.  I trust that seasoned professionals in a broad coalition of nations are carefully weighing the risks and benefits of a variety of actions.  But as a general principle, I don’t support allowing a murderous aggressor to be limiting and confining our actions to save millions of people who only seek to be free and to be left alone.  We should be restraining his actions.

Many years after the Rwandan genocide, President Bill Clinton expressed regret for failing to respond.  Years from now, will the world be issuing a similar statement?

Sunday, March 13, 2022

A Plea for Medical Education Reform

On the day before writing this, I attended a seminar on medical professionalism.  The room was filled with physicians at all stages of our careers.  I enjoy opportunities to think about aspects of my profession that are beyond the digestive organs that I dally with daily.   At the seminar, a video clip was shown from the 1991 movie The Doctor.  The scene depicted an attending physician berating an intern in the presence of the medical team after he casually referred to the next patient to be seen as being ‘terminal’ without identifying him by name.  If fact, it became clear that the young doctor did not even know the patient’s name.  While the attending physician was correct to recognize that patients are living breathing human beings, not diseases or hospital room numbers, it was a breach of professionalism to humiliate an intern in public.

After a few comments were offered by seminar attendees chastising the senior physician’s cruel approach to an intern, I raised my hand.  I shared that his behavior was very typical of my medical school experience in NYC decades ago.  On a regular basis, I and other students were humiliated.  It seemed that abusive behavior and publicly exposing the ignorance of team members who are lower on the medical hierarchy was an actual pedagogic technique.  I asked at the seminar  if others in the room had  similar experiences and nearly every hand was raised. Indeed, very recently I spoke with a 3rd year medical student who is attending a different medical school in NYC, and the vignettes she shared were very reminiscent of my student days.

Here’s a typical medical hierarchy schema:

Attending Physician
Chief Resident
3rd Year Resident
2nd Year Resident
Medical Student
Medical Student’s Pets
Pet's Chew Toys

To paraphrase a common aphorism, the excrement flows downhill.

The hapless intern gets blamed for everything and is eligible for direct criticism from any of the layers above..   If the intern is up all night and performs a hundred tasks admirably, but has not yet had time to check on a lab result, guess what feedback he or she is likely to hear when the team assembles in the morning?   To those who are outside of the medical profession, imagine that you are an intern.  You are given tremendous responsibility, often without adequate supervision, with a very limited medical knowledge base while suffering from chronic sleep deprivation.   I’ll let readers ponder if adding public humiliation to the intern’s job description is likely to enhance job performance and professionalism.   (I’ll give you a hint.  It doesn’t.)  It is more likely to create jaded interns who will later assume an abusive posture as they ascend the medical hierarchy. 

A somnambulating intern cares for complex patients.

The intern has but one avenue of relief.  While he or she is low on the ladder, luckily the medical students hang on the lowest rung below.   So, if the intern feels a need to unload, guess who the target will be?

Of course, there were and are physician role models very different from those I have described above.  But, the darker culture I have presented still exists.   If you were designing a medical training system to cultivate and model humanity, empathy and compassion, would it resemble the one I described? 

Sunday, March 6, 2022

Reforming Medical Education

Medical school, residency and specialty fellowship cannot prepare physicians for every eventuality.  Many important skills must be acquired on the job.  And, of course, physicians need to remain current with respect to cognitive and procedural advancements.  Here are just few critical subjects that I was not prepared for when I entered the healing profession.

What happened to my phone medicine lectures?

  • Phone medicine.  Treating a patient with abdominal pain at night on the phone requires different skills than when the patient is in my exam room. And, te phone call may be the first time I have ever spoken to this patient.
  • Breaking bad news to patients and their families.  Wouldn’t you think that we would have received training for such a critical skill?
  • Nutrition.  Patients are understandably amazed at my paucity of nutritional knowledge.  I suspect that most gastroenterologists can make the same claim.  Wouldn't you think that nutrition science would be part of a gastroenterologist's skill set?
  • Leadership skills   I have done my best in 30 years to treat my staff well, earn their loyalty, reward their performance and to set an example.  I hope I have done well in this regard, but I have had no formal instruction in this discipline.
  • Attracting patient referrals from potential referring physicians.   Might this important to a medical practice?
  • Caring for difficult and demanding patients.  It’s easy to treat cooperative and appreciative patients.   But, caring for patients who are angry or entitled requires special skills.  Shouldn’t these be taught?
And, we never received any training in the business aspects of the profession.  I was in private practice for 20 years, although I am currently a happily employed physician.  As a private business owner,  I had to grapple with overhead, payroll, medical coverage and retirement benefits for my staff, landlord issues, tax and accounting issues, scope purchases and repair, physician referral patterns to the practice,  cash flow, our competition and office personnel issues..   How much training in these skills do you readers think I have had?  Let me enlighten you. Zero!   I was smart enough, however, to know how ill equipped I was so we hired real professionals to make it all work smoothly.

Perhaps, medical educators should have a word with us grunts in the field to find out what was omitted in our training.  

Sunday, February 27, 2022

American Anger and Rage - A New Epidemic

 A doctor arrives just a few minutes late to his office and is warned by his staff that the patient slammed the exam room door and starting swearing.   A passenger on an airplane erupts in anger and has to be physically restrained.  Parents at school board meetings are foaming at the mouth objecting to revisions in the curriculum.  An angry mob storms the seat of our democracy attacking law enforcement professionals, an event that is later referred to as ‘legitimate political discourse’.

So much anger.

Where did all of this rage come from?  Is there a pathway back to civility?

Anger today is more prevalent and intense than I have ever seen in my lifetime.  Moreover, it has spread over the landscape like hot flowing lava reaching regions that were heretofore anger-free zones.  Violence on an airplane?  Really?  In years past, there was a time and a place for anger.  Here are a few examples when anger was understandable.

A coworker who is related to the boss gets the promotion that you deserved.

You are a rabid football fan.  Your team loses a Super Bowl opportunity because the referee makes a terrible call.

You discover that your business partner has been quietly but steadily stealing from you.

Your neighbor argues that your political views are neanderthal.

These examples make sense to us.  We can likely relate to them personally.  But now, no corner of society is spared from anger.  Indeed, it’s a national epidemic and there is no vaccine on the horizon.  (I’ve heard a rumor that ivermectin may soothe the savage beast but this has not been substantiated.)

Children Learn the Art of Finger-pointing at a Young Age

I suspect that there’s a psychological benefit that many angry people enjoy.  It is a method to avoid personal responsibility by claiming that others are responsible for some misfortune.  It is so much easier to cast blame elsewhere than to do the hard work of building and healing and self-improvement. 

It’s the politicians’ fault!

These immigrants are ruining the country!

It’s Fauci’s fault!

It’s the radical woke left’s fault!

It’s the radical right’s fault!

And, as we have all seen, it’s easy for politicians and others to exploit and validate this anger for political advancement.  Some might suggest that anger and grievance can even propel a candidate elected to the American presidency, although this notion seems too incredible to even contemplate.

Of course, sometimes anger is the appropriate emotion.  We have all been angry.  But just as often, angrily blaming others is really just a deflection of responsibility, even though it might feel good at the time.  At the very least, it’s an abdication of civility.

One process that anger reliably sabotages is dialogue.

How often have you heard a triad of remarks like these?  

It was my fault. 

I screwed up.  

I’ll try to be better next time.




Sunday, February 20, 2022

Russian Skater Doping Scandal Stains Olympics

I have been much less enthralled this year in the Beijing 2022 Winter Olympic Games.  And I’m not alone.  There are many reasons for this global Olympic ennui.  International publicity on China’s horrendous human rights record resulted in several nations, including ours, issuing diplomatic boycotts.  The Peng Shuai affair was also a turn off when this Chinese tennis athlete made an accusation of sexual harassment against a Chinese government official.  Then, she disappeared and issued a statement denying her allegation.  Sounds like she was being squeezed in a Chinese Olympic vice.  The shameless spinelessness of the International Olympic Committee is itself a reason to boycott watching the games.  And Americans and folks abroad have been absorbed with the ongoing pandemic and worsening economic realities.  Many are preoccupied with inflation or rising crime or an imminent war in Europe.  For them, watching the Olympics isn’t even on the list.

And to those who have tuned in, they have been treated to the Kamila Valieva affair, a debacle that will be remembered for decades.  She is a 15-year-old Russian virtuoso skater.  She failed a drug test.  And yet she was permitted to continue competing deferring the investigation and ultimate judgement until months or years after the games conclude.  

5 Rings Representing


The correct decision, of course, would have been to suspend her from the games.  Such a decision would have spared the bulk of the following consequences that predictably occurred.

The integrity of the Olympic Games has been further tarnished.

It disrespects all of the clean athletes who have complied with the rules.

Those who earned medals in events along with Valieva had no medal ceremony, the dream of every Olympic athlete.  If Valieva is ultimately disqualified, will the remaining winners receive their medals in an Amazon delivery dropped at their front doors?

It communicates to all of us that integrity in our lives is an elastic concept. 

Valieva completely dominated all of the attention of the Olympics instead of the competitions and the athletes.  What a shame for everyone involved.  How might families and supporters of Olympic athletes feel about this?

It was another example of Russia receiving an undeserved free pass.  Remember Sochi 2014?  Is changing the name of their team to the Russia Olympic Committee an adequate consequence for years of state sponsored doping?

And, it was unfair to Valieva who will now be stigmatized forever.  And who can predict the personal health consequences that she may suffer in the future over this horrendous affair.  For coming attractions, after her final skate when she fell repeatedly, her coach at the sidelines glared at her and harshly said, “Why did you let it go?  Why did you stop fighting?  Explain”. 

It’s not relevant if Valieva was unaware that she had ingested a banned substance.  By the rules, she was ineligible regardless of how the drug found its way into her body.

In an analogous situation, the Australians deported Novak Djokovic who did not comply with the nation’s COVID-19 protocols.  Afterwards, the Australian Open proceeded without incident.  I give the Aussies a Gold Medal for this. 




Sunday, February 13, 2022

Canadian Truckers Protest for Freedom! No End in Sight

During the pandemic, which has not yet ended, we’ve all heard lots of chatter about freedom.  Folks are figuratively burning their masks as a statement of their personal freedom.  We have seen patrons packed into bars and other venues, against the advice of medical professionals, claiming they have the freedom to congregate.  Political leaders in some states have banned mask mandates in schools arguing that parents have the freedom to make their own decisions regarding their kids. And the fundamental reason given by so many anti-vaxers and government skeptics is that they have the freedom to accept or reject any medical intervention. 

These arguments are framed as pro-freedom positions in an effort to make it difficult for opponents to challenge them.  Who wants to be seen protesting against freedom? 

Not surprisingly, and as I have posted previously on this blog, these issues are more complex.  Freedom is not absolute.  That’s why we have laws, regulations and societal mores to encourage and restrict certain actions and behaviors.  You might believe that you have a right to withhold a measles vaccine from your kid.  But, this collides against the rights of the rest of us to avoid this highly contagious infection.  You may believe in your constitutional right to assemble, but this right does not permit you to do so on private property.  You get the idea.

Look what’s happening in our neighbor to the north.  Truckers in Canada are clogging up bridges and roads over the past few weeks all in defense of freedom!  As an aside, this behavior seems so incongruent with our impression of docile and polite Canadians. Wonder who might have influenced them to take to the streets?  They call their movement Freedom Convoy 2022. 

Should We Loan This Flag to Canada?

I guess the truckers and their supporters who are against the lockdown mentality give themselves a pass after they have locked down hundreds of their trucks throughout the country at the expense of everyone. 

A day before writing this, a Canadian judge ordered trucks in the Ambassador Bridge region to disperse or face consequences.  So far, the trucks are still in neutral.

What about the rights of thousands of businesses on both sides of the border to earn a living? What about the rights of tens of thousands of customers on both sides of the border to be able to purchase products?  What about the rights of all of us to avoid further inflation as a result of supply line disruptions?  What about the rights of ordinary folks to be able to use their own roads and bridges?

And they are defying a court order?  I thought that these fans of freedom were strong defenders of the rule of law.

Freedom is a balance between one man’s rights against another.  If freedoms become absolute, then we will have absolute chaos.  




Sunday, February 6, 2022

My Right to Refuse a COVID-19 Vaccine

I’m long on the record that we need to recalibrate the balance between individual freedom and society’s rights.  Personal freedom is often at the direct expense of society’s rights and expectations.  For example, an individual may argue that he has a right to air travel without having to proffer a government authorized ID or to submit to a search of his luggage. On this example, I think most of us would argue that society’s rights would prevail.

And there needs to be personal responsibility and accountability when one exercises particular personal freedoms.  If you want to ride a motorcycle, for example, then your insurance risks should be priced accordingly.  And if you don’t want to wear a helmet while riding, then you and other helmetless riders need to share in this risk so the rest of us don’t have to pay when an unwelcome event occurs on your ride. 

As in everything else in life, this terrain can become murky.  If a patient declines surgery that her medical team unanimously recommends, and as a result a long and expensive hospital stay ensues, would we hold her to be financially responsible?  No, we would not, but it does pose ethical questions.

Choosing Death Over a Vaccine!

Recently, an individual on kidney dialysis was deemed to be ineligible for transplant after refusing a COVID-19 vaccine.  Another patient was denied a heart transplant for the same reason.

Of course, these patients have the right to refuse the vaccine and any medical intervention.  I suspect that most of us in their circumstances would have decided the matter differently. The cardiac patient will likely die and the renal patient will face a shorter lifetime suffering under dialysis. And because of these 2 patient’s decisions, the rest of us must pick up the lifelong costs of dialysis, hospitalizations, etc.  Of course, society will absorb all of these avoidable costs which does bring up an issue of fairness.

Transplant physicians are empowered to establish medical criteria that must be abided by transplant candidates.  They have a responsibility to maximize the probability that the transplanted organs will successfully endure. 

In the current political climate, I’m surprised that no politician has railed from a podium demanding a law that would prohibit medical professionals from requiring a COVID-19 vaccine.

What would we think of another country, whose policies we would ordinarily decry, who mandated 100% vaccinations and have very low rates of illness, death, hospitalizations and economic disruption?  I’m not advocating for authoritarianism, but personal freedom can exact steep costs on society.  Are you ready for a conversation to consider a recalibration of our rights?

Sunday, January 30, 2022

Is Medical Marijuana Safe and Effective?

I am on the record in opposition of Ohio’s system for authorizing the use of medical marijuana.  While I am not an expert on the issue, my reading over several years has informed me that persuasive medical evidence of safety and efficacy – the legal and regulatory standard used for prescription drug approval -  is lacking for nearly all ‘approved’ uses of this drug.  And while it is true that there is some evidence that marijuana offers benefit in a very narrow range of medical conditions, the broad claim of efficacy for a panoply of illnesses is unfounded scientifically.  Champions of medical marijuana use should want, if not demand, that the drug is vetted and tested under the auspices of the Food and Drug Administration.  Wouldn’t you want to be assured of any drug’s safety and efficacy?  Should anecdotes of benefit or beliefs of benefit be sufficient to release a medication for general use?  Is this the standard that we use to approve drugs used to treat hypertension and cancer?

Beyond the lack of rigorous medical evidence, I strenuously object to legislatures commandeering the medial marijuana approval process.  The notion of politicians granting medical approval of a drug for an ever-enlarging list of ailments is preposterous.  Of course, such a process should be wholly under the control and authority of medical professionals and appropriate governmental agencies.  Not only are lawmakers unqualified for this task, but the political process is contaminated with conflicts of interests, business concerns, lobbying influences and upcoming elections.  For example, if a medical marijuana company wants to build a large dispensary in a certain district, might this make the legislator representing that district likely to vote in support of any medical marijuana measure?  

Marijuana - Panacea or Faith Healing?

Look how ridiculous the situation has become here in Ohio.  This past December the Ohio Senate passed a bill that aims to legalize medical marijuana for a patient whose condition may reasonably be expected to be relieved by the drug.  Think of that absurd language!   Doesn't this seem just a mite too broad?  Who defines what constitutes reasonable?  What if a patient or even a doctor reasonably expects that medical marijuana will be effective against acne or arthritis or asthma or hair loss?  Remember, even now there are folks who believe that ivermectin is effective against COVID-19.

This horse has left the barn and there is no turning back. How did we let this happen?  The political and economic forces who favor (read: stand to benefit from) expanded medical marijuana use outmaneuvered medical professionals and enjoyed strong public support from ordinary people who truly believe in the product’s promise of healing.  But belief in benefit should not be the standard used to determine safety and efficacy of medical drugs and devices.  Politicians should rank dead last or lower on the list of folks who should be in charge of drug approval.  




Sunday, January 23, 2022

Vaccination is Tyranny!

Thus far, to the best of my knowledge, I have dodged infection with the coronavirus.  I am up-to-date on the recommended vaccinations and have comported myself with caution.  However, I am not in a state of personal lockdown and I still enter area retail establishments to make personal purchases, although I am always masked.  Currently, I am sipping a sugar-free peppermint mocha in a very sparsely populated coffee shop.  I accept that public health experts might challenge my definition of cautious.  Indeed, I’m sure many of them wouldn’t step foot, let alone a toe, into a supermarket these days.

But the risks of catching the corona on my personal forays in the community pale next to the risks I face each week at work when I am in direct contact with several dozens of patients and staff.  The omicron variant spiked into the stratosphere here in Northeast Ohio, but thankfully it appears to be in a steady descent now. It does not seem that the vaccines and boosters protect us against omicron infections as much as they do against serious illnesses.

The percentage of Americans who have been vaccinated has plateaued.  Clearly, those who have not yet been vaccinated have no intention to do so.  Perhaps, some might decide that the vaccine is preferable to job loss. But many will walk away rather than succumb to what they perceive to be an assault on their personal freedom.

There is always a patient or two I see in the office each day who are unvaccinated. Being a seasoned professional, I inquire of them in a measured and neutral manner as to what their concerns are.  'The reasons span a wide spectrum ranging from ‘I don’t believe in it’, ‘they rushed it through’,  I’m already immune' or 'it’s not safe'.

Recently, I heard a more strident exhortation of vaccine antagonism.

‘I won’t let a tyrannical government tell me what to do!’

I reflected on this angry remark afterwards and thought it was possible to connect it back to the January 6th insurrection.  Many of those who stormed the Capitol that day likely felt that they were attacking tyranny in the same way that the colonists rose up against the British a few centuries ago. But, of course, the January 6th insurrectionists can never be fairly analogized with Paul Revere, Benjamin Franklin  or Thomas Paine.  The January 6th rioters were not seeking freedom but tried instead to dismantle our freedom as they joined together on their evil joyride over the cliff.

If only there were a vaccine for every illness.  However, we can see plainly that there are maladies out there that we are not able to prevent or treat.

Sunday, January 16, 2022

Gray Areas in Medical Ethics

While I may consider myself to be an ethical practitioner, I am in imperfect member of the genus, Homo, practicing medicine in an imperfect world.  I don’t commit Medicare fraud or lie to my patients.  When I commit an error, I admit it.  I often counsel patients against proceeding with endoscopic studies, because I don’t feel they are medically necessary.  I do my best to keep my patients’ interests as my paramount concern.

But the world of medicine doesn’t always have bright lines and borders to keep us confined to an ethical zone.  Physicians and ethicists argue over where to draw these boundaries.  What was regarded to be unethical 10 years ago has become standard medical operating procedure in many instances.  Consider how the field of reproductive medicine has evolved.  The definition of death has been relaxed in order to increase the human organ donor pool. We will surely see human cloning in our lifetime.  Medical ethics is not easy to define.

Community physicians like me must tread into the ethical gray area at times.  Do these indiscretions contaminate our personal integrity? 

Could Noah Webster Precisely Define Medical Ethics?

Imagine you are the physician in the following common scenarios. How would you respond? 

A 30-year-old comes to the office with nausea.  He insists that an upper endoscopy be performed so that he can be reassured that no serious issue is present.  I advise that the test result will likely be normal.  I offer a less invasive and safer x-ray examination, but he wants the Cadillac scope exam.  Do you acquiesce and arrange the requested scope test?

A 60-year-old comes to see me because she seeks antibiotics.  She has a cold and antibiotics are not medically indicated.  She rejects my explanation and is unconcerned about the risks of antibiotics.  She points out that her previous doctor, who recently retired, always gave her antibiotics a few times each year for the exact same symptoms, which she believed was responsible for her rapid recoveries.  Do you cave?

You are a gastroenterologist who is asked to place a feeding tube in a failing and demented nursing home patient. The primary physician has already recommended the tube to the family who have been told that we cannot ‘just let her starve’.  The family accepts this physician’s advice.  The gastroenterologist is highly skeptical that the individual will derive any medical benefit or comfort from the procedure, but he has been called in simply for his technical expertise, not to offer an opinion.  Do you keep mum and place the tube as ordered?

While the principles of medical ethics are firm, the landscape can be murky and it can be challenging to find the light among the shadows.  

Sunday, January 9, 2022

Tennis Star Djokovic Held Captive in Australia?

Should the Serbian government send in elite commandos for a stealth rescue?

If you are a political leader or a celebrity, and you’re looking for some media attention, here’s a method that works every time.  Simply flaunt the pesky  rules that the rest of us obey. And then get caught. Remember when Governor Gavin Newsom was photographed dining out at a posh restaurant in violation of the COVID-19 safety protocol that he imposed on Californians?  Such behaviors only reinforce the recognition that many entitled folks believe that rules apply to the hoi polloi, but not to them.

Presently, tennis superstar Novak Djokovic is being detained in Melbourne, Australia after his visa was cancelled upon his arrival. There will be a court hearing tomorrow that will rule if the government can proceed with deportation. Djokovic, whose ranking is number one on the planet, arrived to compete in the Australian Open, one of tennis’s four major tournaments.  Djokovic is keen to compete since a win there would grant him the record of the most wins in singles in major tennis tournaments. 

Djokovic May Soon Be Hoppin' Back to the Airport!

Djokovic, who apparently has not been vaccinated against COVID-19, arrived having received a medical exemption for declining vaccination.  The Australian government has very specific criteria for what constitutes a medical exemption.  While it is true that he was granted an exemption, the waiver was granted by groups who have ties to the tennis tournament.  In other words, the exemption personnel may have had more fidelity to the tournament than they did to adhering to public health rules and restrictions.  Djokovic apparently was granted a medical waiver on the basis of a positive COVID-19 PCR test result last month.  However, the government does not recognize this as an exception and communicated this to the Australian tennis authorities in November 2021.  

Presumably, the Australian federal government has primacy with regard to COVID-19 and border entry policies.

Now, of course, the issue has been internationalized with Djokovic supporters in Serbia and elsewhere claiming he is being held captive.  He is free to leave at any time.

The Australian citizenry is inflamed at the prospect that an elite athlete is angling for special treatment.

Based on my knowledge of the issue, I anticipate that deportation will be deemed  lawful.   Djokovic may expect special treatment, but he deserves the same treatment and outcome that the rest of us would receive.  After all, an athlete of his stature and accomplishment should understand why rules and fairness are so important.

Sunday, January 2, 2022

Looking Back on 2021. Time to Look Ahead.

2022 is here!  2021 has been an annus horribilis for America and the world.   We have simply not been able to vaccinate and boost ourselves free of the suffocating tentacles of an evolving coronavirus. Here in Ohio and elsewhere COVID-19 tests are endangered species.  Folks spend hours trolling around town hoping that a local pharmacy or a public library will receive a supply at the very moment he or she walks in.  My own inquiries have all yielded the same result – no tests available and no idea if and when they may arrive.

Did you watch the ball drop on New Year's Eve?

The pandemic, which in any earlier time in our history would likely have drawn us together, is cleaving the nation.  The day before writing this, I saw 2 patients who had elected to shun the vaccine.  I’ll spare readers their explanations which originated in the huge ‘science-free zone’ that tens of millions of Americans inhabit.  And earlier in the week, a medical professional who had been vaccinated expressed opposition to a vaccine mandate.  Her objection is that the government should not be able to force us to take such an action.  (Keep in mind that this individual and myself and millions of health care professionals are required to accept yearly influenza vaccines, TB testing and to be up to date with various routine vaccinations.)  I understand the personal freedom argument.  And I agree that we must be very cautious about granting the government excessive control over our individual decisions. Clearly, many private businesses and organizations favor a vaccine mandate as is their right. Others are concerned that a mandate would leave them short of workers after a mandate walk out.  I responded to my medical colleague that her argument that a mandate encroaches on her freedom is vulnerable.  I have no objection, I remarked, if she wishes to refuse a mammogram.  Such a decision only affects her health.  But an individual who declines to be vaccinated can affect the health of others.  These folks have rights also.  But I admit that there is nuance and a slippery slope potential here.

And the FDA and the CDC haven’t inspired much confidence with fumbling decisions and mixed messaging.  Who can blame folks for being confused and skeptical?  The CDC’s most recent iteration of quarantine and isolation policies has been roundly criticized - not by anti-vaxxers but by public health experts.  In fairness, the CDC's new and improved version is an acknowledgement that the prior policy of prioritizing public health over the economy and education was misguided and needed to be recalibrated. 

This past year has also laid bare our politics at its worst.  Comity and collaboration are out and hatred and revenge are in.  The mantra for many of our leaders and their constituents seems to be, I win if you lose, not an uplifting strategy.  And, a year ago the nation was treated to an actual insurrection!

Beyond the pandemic, inflation is surging, our southern border is in chaos and lawlessness and violence abound.  We are all horrified at the smash and grab episodes that are captured on video.

And internationally, our relations with China, Russia, Iran are all going swimmingly. 

Here’s to 2022!  Hoping and praying for a new mantra.  How ‘bout, If we both win, we all win?

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