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Showing posts from 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.            

Was 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

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 ce

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

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.

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 a

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 ce

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

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

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

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

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 pat

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 pric

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 m

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. 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 deducti

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

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

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

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 surprisin

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

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

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