Sunday, December 25, 2022

Whistleblower Holiday Cheer 2022!

 


The Dems were all nervous

Back in October.

The Red Wave was coming!

Would their blue reign be over?


The tables had turned,

After November,

This midterm result

Will be long remembered.

 

Deniers fell short,

One by one,

And the public ensured

That democracy won.

 

With the House barely red,

And the Senate still blue,

Might we move beyond

‘I win so you lose’?

 

The last 2 guys standing

Were Raphael and Herschel.

We were finally spared

Their endless commercials.

 

On his own time,

Trump did announce,

While a new special counsel

Is ready to pounce.

 

Lurking in waiting,

A stealth praying mantis,

Eyeing his prey

Is Ron DeSantis.

 

Biden is 80

Is he the Dem’s best shot?

If he steps aside,

Who else have they got?

 

Wishing you all,

Good health and good cheer,

And prayers to enjoy,

A much better year.

 

 

 

 

 

 

Sunday, December 18, 2022

Am I Spreading Covid-19 Misinformation?

I presume that most of us are hostile to hate speech, misinformation and disinformation.  Politicians and others want social media to be scrubbed of all nefarious postings.  Twitter is most recently in the crosshairs on this issue after Elon Musk assumed ownership of the company.  They still haven’t settled on a moderation policy.  Social media and other information sources have been accused of radicalizing Americans, fostering hate, undermining our elections, providing a forum for bullies and predators, promoting division and coarsening our national discourse. 

One man’s cleansing of disinformation is another man’s censorship.

There is some speech that all reasonable people would agree should be banned, such as incitement to violence or prurient matter that children can access. 

I challenge those who advocate against publishing hate speech, misinformation or disinformation to offer precise definitions of these categories.  Trust me, this is no easy endeavor.   And if you are able to construct definitions, can you assure that they will be applied consistently all across the public square?

We can’t even agree on what constitutes a fact!  What is the definition of a lie?   Is there any politician who has been honest with every utterance and action?   If a political leader governs or legislates differently than he or she campaigned, is this a lie?   If the White House issues a statement praising improved economic metrics while ignoring persistent inflation, is this dishonest disinformation?  There is a huge spectrum spanning from pure mendacity to absolute truth.  There could never be consensus on where to draw the truth line. 

The Covid-19 pandemic has been fertile ground for legitimate and groundless allegations of misinformation and disinformation.  Remember hydroxychloroquine?   It is also true that many public health policies were imposed without rigorous scientific evidence.   Remember the prolonged and inconsistently applied lock downs?   Was closing down our schools for a year truly best practice?


Covid - A Divider, not a Uniter


I received the two-shot Moderna series as soon as I was eligible.  Sometime afterwards, I received the 3rd booster shot as advised by health authorities.  However, I declined to take the 4th booster.  Although the government was advocating this shot, I wasn’t convinced from my reading that there was adequate evidence of efficacy.  Many experts were divided on this very issue.  It seemed that the government’s position was that they believed it was effective and hoped that accumulating data over time would confirm this.  In my world, proof of efficacy precedes approval.

When I shared misgivings of this booster with friends, was I spreading Covid-19 misinformation or was I simply telling the truth?  If I posted my opinion on social media, should it have been taken down?

 

 

 

 

Sunday, December 11, 2022

Telemedicine is Here to Stay! The Demise of the Doctor Visit?

In a prior post as a teaser, I promised to prove that the medical profession agreed with me that the physical examination is not a critical component of patient care.  In my medical training days, such a remark would have been considered heresy and the sinner would have found himself in a stockade in the public square.  

Proof that the physical examination in many cases is superfluous is the explosion of telemedicine.  The volume of these virtual office visits is rising by the month.  If the physical examination was so critical and indispensable, then telemedicine could not operate successfully.  But it is and it threatens to make traditional doctors' offices like mine quaint, if not obsolete.  

I anticipate that in the next 10 to 15 years that most patients will be seeing physicians or other medical professionals in digital arenas, not face to face in traditional offices.  By then, I may have gracefully exited the profession, but I will be an avid spectator.  The centuries old paradigm of how medical care is delivered is undergoing a metamorphosis that will transform the profession into a new entity, just as a butterfly emerging from a cocoon as a distinct creature.   Physicians will be interacting with a patient or groups of patients via some digital interface.  Physicians will no longer be hamstrung by the balkanization of medical record systems that cannot communicate with each other.  Every individual’s entire library of medical data will be accessible.  (Isn't this what electronic medical records were supposed to deliver to us?)



A Medical Metamorphosis is in Progress


Digital access should also permit quality health care to reach vulnerable populations and others who do not have reliable access to the health care that all of us deserve.

If you accept my premise that the physical examination is often unhelpful, then it stands to reason that a video chat with a patient, with access to laboratory and other medical data, would be sufficient.  And, if a physician on a virtual visit felt that a patient's circumstance necessitated a hands on approach, then the patient would be so advised. 

While it may be hard to fathom, perhaps technology will allow the performance of a thorough physical examination remotely.  Virtual visit advocates maintain today that many elements of the physical exam can already be performed.  Patients, after all, can take their own vital signs, palpate their own abdomens or feel for leg swelling.  Physicians can observe the breathing pattern, visualize a rash and assess the mental status. While these are of value, it does not seem equivalent to me to a hands on experience.  

I am not suggesting that the physical examination is not a valuable tool.  We all know that it can be a case cracker and a game changer.  My point is that in many cases, the physician does not need this tool to render sound medical advice.

I've largely abandoned virtual visits in my practice.  My patients and I have largely agreed that they don't feel the same.  The vibe is transactional, efficient and mechanical.  For us, there's wasn't much fun in it.

And if you're nostalgic for a stethoscope, a tongue depressor or the reflex hammers that used to tap on your knees, they'll all be waiting for you - i a medical history museum.  

Sunday, December 4, 2022

Deaths From Medical Errors: Hell or Hype?

Doctors make mistakes.  There, I’ve said it.  More than having said it, I wrote it.  This confession has now been memorialized in cyberspace, where no piece of data can ever be truly deleted.  We have all seen how seemingly erased data has been resurrected by forensic experts to the horror and dismay of the eraser wannabees.

Doctors work on seriously ill patients.  They do their best to help heal them; or when this is not possible, to comfort them.  Some patients get worse under our care.  Some die.  This sober slice of the human condition impacts deeply on physicians and all health care professionals.

I acknowledge that medical errors have worsened patients’ condition or have even contributed or caused their demise, a tragic but unavoidable result of a noble endeavor that is imperfect.  I remind readers that physicians are members of the human species and have all of the flaws and frailties that every other homo sapiens creature possesses.   Every aspect of the profession is imperfect – physicians, nurses, medical devices, drugs, surgical equipment, hospital sanitation and the various processes and procedures involving scheduling, administering of drugs and blood products and labeling of specimen jars.  Indeed, no profession can boast 100% performance, although admittedly the stakes are higher in the medical arena than in many others.

Air Travel is not 100% Safe

Nearly 20 years ago, a report appeared in the Journal of the American Medical Association that stated that nearly 100,000 patients died as a consequence of medical mistakes.  Last year, the British Medical Journal raises this number to 250,000.  Many have challenged the accuracy of both of these reports, claiming that the quality of the studies’ interpretations is suspect.  While I have no opinion here on this challenge, I do offer two observations, neither of which is scientific.
  • In my quarter century of medical practice, I have not witnessed a medical act or omission that clearly caused a patient’s death.   Of course, I have seen, and surely committed, plenty of mistakes and flawed judgments, but I cannot recall any medical act or decision that was the proximate cause of a patient’s death.
  • It’s not a simple task to determine if a medical error was either responsible or a major contributor to a patient’s death.  For example, consider an elderly patient with history of a stroke and heart disease who is in an intensive care unit for pneumonia who is on a ventilator. A doctor mistakenly prescribes an excess of intravenous fluids and the patient develops congestive heart failure (CHF).  The CHF is treated but the patient’s condition deteriorates over the next 3 days leading to his death.  It’s not easy to accurately ascertain in this hypothetical example to what extent the doctor’s error contributed to the outcome of this seriously ill and elderly individual.   
I’m not carrying water for my profession.  Rather than fight over how many deaths doctors are responsible for, let’s work together on our shared mission to make our health care as safe as we can.  

Sunday, November 27, 2022

A Day of Thanksgiving 2022

It can be a struggle in a turbulent and violent world to find space to give thanks, but we must try.

I hope that we can commit ourselves to making the world better one day at a time accumulating a series of small acts of kindness.  While each individual action may seem insignificant, if enough of us step up, then the world can change.  A rainbow is the effect of millions of drops of water.

Perhaps, next year there will be more to be thankful for.

Wishing blessings to all.







Sunday, November 20, 2022

Is Medical Marijuana Safe and Effective? We Still Don't Know.

I’ve never subscribed to the caveat to scrub politics and religion from my discourse.  Indeed, you will find these two subjects riddled throughout this blog.  I think we need more dialogue, not less.  I do agree, however, that dialoguing is a skill.  But it’s not brain surgery.  Any of us can become adept practitioners of this seemingly lost art, if we so desire.  It requires listening with an open mind.  It implies that your view on an issue might be modified in the face of a persuasive argument.  And your responses should respond to what has just been said to you indicating that the other side has been heard.

So, now let’s talk some politics.  First, assess your political acumen by answering the following quiz question.

Which of the following issues should not be handled by elected officials?

(a) Tax policy

(b) Zoning ordinances

(c) Which chemotherapy regimen should be permitted for breast cancer patients

(d) Parks and Recreation issues

I realize that this is an extremely difficult question and many readers are probably struggling over it.  Perhaps, you might confer you with your own city council representative for some assistance. 

Well, here in Ohio and elsewhere, elected legislatures are issuing medical directives, as crazy as this sounds.  Would it make sense for elected officials to offer a bill on how best to treat diabetes, heart disease or depression?  (Hint:  No it wouldn’t). 

Politicians are not medical professionals and are wholly unqualified to offer medical advice.

Their ‘medical’ opinions would surely be tainted by political considerations.  If a pharmaceutical company, for example, was in a politician’s district, might this shape the politician’s bill?  (Hint:  It would.)

We already have a group of folks who are trained to render medical advice. Have you heard of the medical profession?

In Ohio, medical marijuana has been legal these past few years.  The state legislature – not doctors or the Food and Drug Administration (FDA) – have decided which medical illnesses are marijuana eligible. Periodically, the list of illnesses lengthens.   I hope that my points earlier in this post have convinced you of the insanity of this absurd process.  Not surprisingly, the quality of medical evidence supporting marijuana’s efficacy for nearly all of the illnesses on the list is very low.  Trust me, if the FDA’s standards of safety and efficacy were applied, the list might be reduced to zero items. (FDA assessment can’t happen now as marijuana is a Schedule 1 controlled drug and is an illegal substance.)

Medical cannabis is not a new remedy.  Medicine bottle from 1937. 

Here's the latest ‘medical news’ from our Ohio politicians.  A bill has passed the Ohio Senate that would permit marijuana use to any individual who can “reasonably be expected to benefit” from its use.  Can we agree that this designation is rather broad and could be applied to any and all medical conditions on the planet?  Let’s see if the Ohio House goes along with this scam.

I'm not against medical marijuana.  But I do think it should be vetted in the same way that all other drugs are.

Remind me, is it still illegal to practice medicine without a license?

 


Sunday, November 13, 2022

A High Reward Investment with No Risk!

ROI (return on investment) is an investment principle.  If we contemplate an investment – whether money, time or training – we often speculate on what return on our investment we can expect.   What is the ideal ROI?  There is none.  One’s view of a financial ROI depends on the investor’s goals, risk tolerance, financial portfolio and stage of life.   For example, two experienced financial experts might completely disagree on the worth of a particular investment.

What if I offered you an investment that costs nearly nothing but promised a huge yield?  Interested?  Am I sounding like a 2 a.m. telemarketer promising to make you rich on some 'no money down' scheme?

If you follow my advice, you may surely become enriched, but don’t expect that you would enjoy any financial enhancement.  You can decide if it would be worthwhile to include these ‘investments’ in your life’s portfolio. 

Here are some life investments that I think might make our lives better.   I’m certainly not preaching.  I need these in my 'portfolio' as much as anyone.    


Hey buddy, this one's on me!

When you are in line for coffee, buy a cup for the person behind you.  You will be amazed at the payoff.  Both of your days will be better.  Perhaps, this will be the first link in a long chain.

If a driver changes lanes and slides in front of you, even if you feel the driver came across too soon, do not regard him as a traitor to the nation. There is no need to accelerate until you nearly collide with his car while you hurl verbal epithets or gesticulate wildly.  Does the world really need more rage?  Have you ever committed the same offense?  How about a small measure of forbearance?

As you are boarding a plane, help someone to lift his suitcase into the overhead compartment. 

The next time you are poised to raise your voice, consider if the situation truly warrants this.  My guess is that it doesn't.

Tell one of your subordinates at work what he is doing right.

Send a handwritten note to someone you care about.  No reason needed.

Try using this phrase.  "Wow, I've never thought of it that way."

Be gracious and understanding about someone’s error.

Try striking up a real conversation with someone beyond idle small talk. 

Say ‘thank you’ and mean it. 

I would be grateful for any additions to this list.  I thank you for this and trust me, I really mean it.



Sunday, November 6, 2022

Do I Need a New Doctor?

I am a parsimonious practitioner.  While I can’t cite statistics, I strongly suspect that I order fewer laboratory studies, prescribe fewer drugs and order fewer diagnostic tests than do my peers.  Medical minimalism has always been my medical world view.  This can feel a bit lonely at times in a profession that is rife with over-diagnosis and over-treatment.  I am not suggesting that my approach is the only reasonable medical approach, only that it’s the style that I’m most comfortable with. 

All of us should consider the philosophy of the professionals we engage.  And the professionals need to gauge the goals and risk tolerance of those they serve.  These relationships may need to enter into negotiations from time to time in order to agree on which pathway to pursue.

Physicians, judges, law enforcement professionals, teachers and others are not homogenous philosophically.  While folks may (hopefully) agree on the facts, the interpretations may differ.

Consider two different financial planners.  One advocates for a more aggressive portfolio arguing that this has the promise of a greater financial return.  This approach might allow the client to retire earlier or to retire with greater security.  A different advisor has a different approach, perhaps because he sees the world differently or has been molded by certain experiences.  He counsels for a more conservative approach arguing that earning less over time is worth the added security that the investment will remain secure.

Who has the better argument here?  Folks will disagree here and their response will depend upon their own philosophies.  For example, a very cautious investor will likely be partial to the second advisor I cited above.



Balancing One Philosophy Against Another

It’s the same with medical care.  Physicians over time tend to retain patients who share their doctors’ philosophy.  Let's face it, there are many patients who are not satisfied unless the office visit ends with a prescription or a test.  This action validates their reason for the office visit. They likely regard no action as medically inadequate.  Such a patient may not find my restrained medical approach to be compatible with their needs and likely will find doctors who are more comfortable using the medical gas pedal than the brake.  Some of us feel that less is more while others feel that more is more.

Of course, doctors and others need to be somewhat flexible in order to meet the needs of those we serve. And we are.  But being flexible doesn’t mean abandoning one's core principles.  There are limits to how far any of us can or should bend.  If, for example, you are a reluctant investor who is worried about the health and safety of your retirement money, and your advisor wants you to invest it all in cryptocurrency, then perhaps, you need a different advisor.  Similarly, the same principle may apply to your doctor. 

 

Sunday, October 30, 2022

Should the FDA Approve More Drugs?

Life can be vexing.   Life is not a math problem that has one indisputable correct answer.   We are constantly weighing options as we make decisions.  How much risk would we tolerate in order to hope to capture a reward?  Does an NBA star go for the three pointer or drive to the rim?  Does a defense attorney put his client on the stand or leave him mute hoping that the prosecution hasn’t met the required burden of proof?   Does a surgeon recommend an operation today or should the patient wait another 24 hours to see if his condition improves without surgery?

All of us struggle where to draw the line.   Look at the ongoing debates in the public square regarding national security.   While some government officials deny this, most of us acknowledge that there is a tension between guarding our civil liberties and protecting our security.  Civil libertarians claim that we can do both, but I believe that trimming civil liberties would provide our intelligence community with more tools to protect us.  I am not advocating this, but simply acknowledging what I believe to be a truth.  There will never be consensus on where to establish this boundary. 

Weighing the Options

The Food and Drug Administration (FDA) also struggles with an analogous issue.  They must balance the public’s need for new medicines while protecting us from unsafe medicines.   How much testing should a pharmaceutical company have to pursue to satisfy the FDA of the drug’s safety and efficacy?  This query is not easily answered.  More testing would likely enhance the safety of drugs that the FDA approves for our use, but would result in fewer medicines becoming available to us.  Would the public want medicines released sooner that show real promise for conditions such as Alzheimer’s disease, cancer, depression and autism?  Would the public tolerate greater risk of unknown side effects of drugs that are released on an expedited track?  What would these companies’ legal exposure be here?  Conversely, should the FDA’s pathway toward drug approval be lengthened in order to increase the margin of safety?

Desperate patients and their families may demand drugs that have minimal safety and efficacy data.  We all understand this.  But short circuiting the process means that there won't be high quality clinical trials, often with a placebo arm, to vet the drugs properly.  This does not serve the public at large as well as ill patients who deserve effective and safe drugs.

These are tough calls to make.  When the FDA deviates from established protocols, the results can be disastrous,  as occurred with their botched accelerated approval of Aduhelm in 2021 for Alzheimer's disease.  

So, do you want more drugs or more safety?  

Sunday, October 23, 2022

Can Pepto Bismol Relieve Indigestion and Upset Stomach?

Pepto Bismol remains one of the most popular over-the-counter medicines that my patients swallow.

They take it for all kinds of digestive distress.  Does it work?  Hard to say.  The elixir does have anti-bacterial and anti-diarrheal properties, but I suspect that there is a potent placebo effect at play also.  I personally think that these sales are largely the result of decades of brilliant marketing by the company.  We can all remember their television commercials in the days of yore when we would watch the pink liquid oozing down the esophagus and then gently coating the stomach creating a blanket of healing and protection.  What a graphic!  Many patients have internalized this marketing believing that this medicine is the fire extinguisher that can quiet their internal flames.  



Right out of the doctor's 'black bag'.

Patients are generally unaware of two important properties of this product. First, Pepto Bismol can turn the stool black.  Three or four times a year I receive frantic calls from patients with black stools who are scared that they are experiencing internal bleeding.  At times, a medical colleague refers such a patient to me wondering if a bleeding ulcer might be present, when the culprit is actually the pink drink. 

Secondly, Pepto Bismol is actually an aspirin product, which is not a medicine that most gastroenterologists recommend for stomach distress.  I have not yet met a single Pepto Bismol consumer who was aware of the medicine’s aspirin component.  Following this same therapeutic strategy, many of my patients drink apple cider vinegar – an acid – to combat heartburn which is caused by acid.  And many of them swear it delivers relief!

Healing is complex and extends beyond the boundaries of science.  We have all experienced this phenomenon and have witnessed it in others.  We simply cannot understand every pathway that leads to relief.  Those of us who are in the healing business need a daily tincture of open-mindedness and humility if we are to heal others.  This shouldn’t be too much for doctors to swallow.

Sunday, October 16, 2022

New Study Questions Screening Colonoscopy - Doctors Push Back

Colonoscopy became ‘breaking news’ about a week ago.  The preeminent medical journal, The New England Journal of Medicine (NEJM) published a randomized trial assessing the effectiveness of screening colonoscopy in reducing the risk of contracting colon cancer and dying from it.  The results were lackluster.

While there is accumulated evidence that colonoscopy can reduce colon cancer risk, the bulk of this data has not been the results of randomized controlled trials, the gold standard in medical research.  In the NEJM study, there was a group who was offered a screening colonoscopy and a separate control group who was not.

Gastroenterologists, along with the medical community at large, have been preaching the lifesaving benefits of screening colonoscopy for decades.  The simple strategy is to remove ‘pre-cancerous’ polyps that are lurking silently in the colon and to remove them before they have an opportunity to transform into cancer.  What makes colonoscopy such an attractive screening tool is that is can destroy a precursor to colon cancer – a benign polyp – which can remain dormant for years.  Other cancers, such as lung and pancreatic cancers, do not have ‘pre-cancerous’ lesions like colon polyps that can be easily screened for and removed.  This is one reason why these cancers often announce themselves after they have already spread. 

In the NEJM study, the group who was offered screening colonoscopy had an 18% reduction in developing colon cancer, a statistic much lower than prevailing opinion. Let me illustrate how modest an 18% reduction truly is. If your lifetime risk of developing colon cancer is 4%, then an 18% reduction lowers your risk to 3.28%.  In other words, you won’t enjoy much benefit with this risk reduction even though an 18% decrease may sound substantial.  In the NEJM study, it was calculated that for every 455 patients invited into the colonoscopy arm of the trial, 1 case of colon cancer would be prevented.  I’ll let readers decide if this statistic represents a game changer. 



Colon cancer under the microscope.
Is colonoscopy the weapon we thought it was?

As expected, professional gastroenterology societies argued that the study was flawed for several reasons and argued that screening colonoscopy does protect patients from colon cancer.  I felt that their criticisms of the study were legitimate.  However, I wondered if they would have voiced these same concerns if the study concluded that colonoscopy was highly effective.  

As one who has read many of these studies over the years, I don’t think we truly know to what extent colonoscopy reduces risk and mortality.  Shouldn’t we know this when designing colon cancer prevention strategies for the public?  Colon cancer screening is difficult to study as it may take a decade or longer to demonstrate a benefit when the rate of colon cancer development is very low and the disease is relatively uncommon.  It’s much easier for investigators to show that an intervention is effective when a disease is more common.

I have done more than 50,000 colonoscopies thus far in my career.  Have I saved lives?  I certainly hope so, but perhaps less so than I had thought.  The vast majority of my colonoscopies have been normal or have discovered small polyps, which I removed.   Gastroenterologists have no method to determine which polyp may be at risk of malignant transformation.  That is why scour the colon and remove any and all polyps encountered.  But, most of them will remain benign and innocent.  We are using a wide net.

How much risk reduction would justify screening every adult starting at age 45, which is the new recommended age to begin screening.?  I doubt 18% would be the holy grail.  Even doubling this to 36% risk reduction seems modest to me.  I’ll bet if you asked most doctors, including gastroenterologists, how effective colonoscopy is, you would likely hear much more optimistic responses than is justified by existing data, including this latest study.  Same issue with mammography.  The actual benefit that women enjoy from this test is much less than most of them, and perhaps their doctors, believe.

I still recommend screening colonoscopies to my patients, but we will have to see how all of this shakes out.  And the issue will be moot as new technologies such as stool or blood testing will soon render the colonoscope obsolete. 

Sunday, October 9, 2022

Why Do I Have Abdominal Pain?

I am a gastroenterologist who has been practicing for decades.  One would think that with my diagnostic cunning and length of service that I would be able to identify the cause of your stomach distress from across the room.  Alas, abdominal distress is often more cunning than the medical sleuths who aim to unmask its identity.  A reality of gastroenterology is that abdominal pain – an issue I confront every day  – is often unexplained and unexplainable, a frustrating reality for patients.

Here’s another frustrating aspect of the experience that patients must often deal with.

A patient with months or years of abdominal distress is seen in an emergency room.  In some instances, there have been more than one ER visit for the same issue.  Despite repeated laboratory data, a CAT scan or two, other imaging studies of the abdomen, a thorough review of the patient’s history and physical examinations which may be repeated over the course of hours in an ER, no diagnosis is made.   The patient is advised by the ER doc to consult with a gastroenterologist for an office consultation to unravel the conundrum.

The patient then sees a specialist like myself – the ‘expert’- with the expectation that I will untie the Gordian knot and bring clarity to chaos with a wave of my hand.  Indeed, it’s very natural for a patient to feel that seeing the digestive specialist will be the key to unlocking the mystery of his abdominal distress.  And there are many times when I see patients referred to me from area emergency rooms that I sense a new diagnostic angle to pursue or recommend medication modifications. But not always.



Is the Human Brain a Diagnostic Tool?

Even though I have special training and experience in digestive ailments, I face some handicaps that don’t exist in the ER.  I'll explain.  Which scenario would seem more likely to explain a patient’s abdominal pain?  An ER visit with state-of-the-art technology with a team of medical professionals who can assess a patient over several hours or a half hour visit with a gastroenterologist who is equipped with knowledge and experience?   In other words, if an ER or two can’t figure it out, then we gastro specialists might be mystified also.

When I explain all of this to the patients I see sent from ER’s, it makes perfect sense to them.  I still try to do my best for them.  And, I may have an advantage over the ER.  Since I have no available technology in my office to distract me, I have time to really think over the case.  There is only the patient and me sitting in a quiet room as I meditate on the case.  Imagine that, a physician’s brain being a diagnostic tool!

 

 

 

Sunday, October 2, 2022

Why Isn't My Drug Covered by my Insurance Company?

Over recent weeks, several times I have prescribed medications for patient that they could not afford.

Insurance plans do not cover every benefit.  With respect to drug coverage, each insurance plans has a formulary - a listing of drugs that are covered.    As patients have learned well, covered medicines are categorized into different tiers, which determines to what extent the medication will be covered  The lower the tier number, the more money that the patient will have to surrender.  Some drugs are simply not on the formulary and can have eye-popping costs which might approach a patient’s monthly mortgage payment.


Distraught woman hoping for a win so she can afford her colitis medicine.


The two medicines that I had prescribed which were then stiff-armed for coverage were for colitis.  I had the patients research the costs and they and I were shocked by their findings.  At first, I thought they may have misplaced the decimal point, but the more expensive of the two was priced at $2,000 for a prescription.

Sparing my readers the medical details, both of these medicines are considered mainstream colitis medicines.  They have been approved for this use by the Food and Drug Administration (FDA) years ago.  And importantly, neither has an equivalent alternative.  For example, if I prescribe a heartburn medicine and discover it is ‘off formulary’, there will (hopefully) be equivalent alternatives available for the patient.  Not so with my recent colitis patients.

How would it feel to be sick, have medical insurance and not be able to afford the medicine that would make you well?

For luckier colitis patients whose medical plans cover these drugs, the costs are extremely low.  What this means to me is that the system is unfair and broken.

Leaving aside contracts and formularies and the overall labyrinthine insurance companies, shouldn’t a patient who has insurance and who’s played by all the rules be covered for an FDA approved medicine that his doctor recommends? 

Sunday, September 25, 2022

Should I Fire My Doctor?

A day prior to this writing, a man well into his eighth decade came to see me for the first time.  He wanted advice from a gastroenterologist.  So far, this quotidian event is hardly newsworthy.   I asked him, as I ask every patient, if he had ever consulted with a gastroenterologist (GI) previously.  For me, this is a critical inquiry as it often opens a pathway to a reservoir of information.  For instance, if the patient responds that he saw a GI specialist 3 months ago for the same symptoms, but no cause was determined even after extensive testing, then I know that obtaining these records will be critical.

Or, if a patient tells me that he loved his prior GI specialist, but he has to see me because his insurance has changed, then I know that I have be particularly mindful to establish good rapport.
Sometimes, patients change physicians or specialists because they are dissatisfied.  Patients uncommonly volunteer the reason, but I ask them directly why they have sought to make a change.  This is not simply to satisfy my curiosity; it can yield very useful information.   Read through the following sample explanations of why patients have left their gastroenterologists.  I think it will be readily apparent why this information would be very useful to the new physician
  • I need a new GI.  My former gastro doc wouldn’t give me any more pain medicine.
  • All he did was do one test after another.  I think he was in it for the money.
  • She thought the pain was in my head and I know I’m not crazy.
  • He was more interested in the computer than he was in me.
  • He just didn't seem to care about me.
  • She messed up and totally missed my appendicitis!

For my new patient, it was a matter or time.

I am not suggesting, and readers should not infer, that the above reasons are all factually correct.  They are perceptions and it is likely that the prior gastroenterologists would offer different narratives.   My task is not to establish the truth.  The patients stated reasons for abandoning a prior physician help me to understand them better and adjust my approach. 

The septuagenarian who was now before me left his GI physician whom he had been seeing for nearly 30 years. This physician was always running behind and the patient routinely waited an hour for  his appointment.  This increasingly irritated him and persisted even after he voiced his annoyance to the doctor.  I can’t explain why he waited decades to act, but everyone has a breaking point.  So, now he’s mine.  And, you can bet I’ll do my best to see him on time.  


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?