Sunday, May 29, 2022

Memorial Day 2022 - Honoring the Fallen

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

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

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

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

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

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

Sunday, May 22, 2022

Justifying Unnecessary Medical Tests

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

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

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

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

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

Trapped in a medical maze

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

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

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

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

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

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

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



Sunday, May 15, 2022

What To Do While Waiting for the Doctor

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

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

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

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

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

Two Relics from Days of Yore

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

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

Sunday, May 8, 2022

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

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

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

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

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

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

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

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

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

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

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

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

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



Sunday, May 1, 2022

How Do Patients Choose Doctors?

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

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

Telephone Directory

Here's how I found my doctor!

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

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

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

I looked up your reviews and wanted to see you.

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

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

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

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