Sunday, June 26, 2022
The Difference Between a Screening and Diagnostic Colonoscopy.
Sunday, June 19, 2022
Practicing Medicine in the Gray Zone
Here's a slightly more complex scenario. Let’s say that your car has a
rattle. The mechanic may not know the cause or the solution,
at least initially, but we can all agree that there is a specific malfunction
that can be remediated with a targeted intervention. As with the dead light bulb example above, there is a specific, reparable defect present.
Unlike in the automotive world, other disciplines operate with a loose,
flexible and proprietary framework. Consider
the financial industry. One need only
read a newspaper’s business section for a week to appreciate the
divergence of opinions on financial and investment matters. Experts cannot agree on the diagnoses or the treatments of sundry economic ailments. Over
the past year or so, for instance, we have seen widely differing explanations
of rising inflation and how to combat it.
Of course, political considerations regrettably affect people’s views
here, so we may not know what they are really thinking.
If you solicit investment advice from 10 financial experts on where
to place funds, you would likely receive a smorgasbord of advice. Individual stocks? An annuity?
A managed mutual fund? Real estate? Tax free
municipal bonds? Or maybe keep as cash
for now? You would be offered
an array of financial products with each firm arguing that it would best meet
your portfolio’s objectives, after considering market trends, your risk
tolerance, age and other factors. And here’s the confounding part; there is no single correct answer here as there is with a rattle in your car. Some or even all of the investment firms may
be ‘right’.
Everything is not black or white.
This is the same murky terrain that medical professionals
occupy. Patients’ symptoms are very
different from an engine squeak that will disappear after oil is squirted in the right spot.
Consider routine medical symptoms including fatigue, depression, ‘brain fog’,
stomach aches, headaches, sleep disturbances, dizziness, nausea or joint
pains. Skilled medical practitioners may
disagree on the cause of these stubborn complaints and the preferred path forward. And similar to the investment industry, various differing medical approaches may be ‘correct’, which can be a vexing reality for patients and
their families who have a false sense that there should be a single correct
medical response. Patients who have consulted various physicians for fatigue can corroborate that they have received divergent and conflicting advice.
If you see 10 gastroenterologists like me with stomach pain,
should you expect an unanimous response? (Hint:
answer ‘no’ here.)
When you enter a gray world, don’t expect a black and white
solution.
Sunday, June 12, 2022
Is My Stomach Pain in my Head?
Stomach Pain and Mind-Body Relationship
This is a delicate issue and must be approached by medical professionals with care. Of course, it is an established fact that psychic distress can be responsible for physical ailments. Did you ever get a headache after having an argument? Were you one of those students who experienced diarrhea before final exams?
This past week, I saw 3 new patients in my practice with
abdominal distress all of whom volunteered that they felt that emotional stress
and anxiety were the culprit, or at least a major contributor to their gastro
issues. Obviously, when the patient has
this level of insight and expresses it to the physician, it paves the way for a
fruitful conversation.
But, this is not always the case.
When I see new patients with long histories of unexplained
abdominal complaints, I do not initially raise the possibility of a psychic
connection. I think this is arrogant and has the
potential to communicate the wrong message to the patient, even if stress-induced
gastro distress is ultimately diagnosed.
My obligation as a gastroenterologist is to consider medical
explanations of patients’ symptoms.
Patients with bipolar disease, anxiety and PTSD can develop ulcers,
Crohn’s disease, cancer and appendicitis, etc., just like everyone else. I do my best to keep my mind open so as not
to miss a lurking medical condition.
And if a doctor raises the ‘mind-body connection’ too soon,
it risks rupturing the doctor-patient relationship. Once this relationship is better established,
then deeper conversations become possible.
Consider a patient who comes to see me for the first time with
a history of anxiety and abdominal pain.
She has seen a digestive specialist who has been unable to explain her
distress. Should I suggest that her
anxiety may be responsible and direct her toward treating this disorder? Here are some of the pitfalls of that
approach.
- She may have a medical diagnosis that was missed by the prior specialist.
- Suggesting that anxiety is the cause, if done at the wrong time and in the wrong manner, risks communicating to the patient that the ‘pain is in her head’. This forfeits any opportunity to help this individual.
- Anxiety may be a contributor, but there may be other contributing medical conditions such as irritable bowel syndrome or constipation, which can be successfully addressed.
- Invoking anxiety in a general way may miss an important path forward. For instance, the patient may have a fear of a specific illness, beyond general anxiety. Discovering this takes physician effort. Knowing, for example, that a patient is scared that she may have an esophageal tumor is extremely useful to the doctor, who can address this directly. A simple question of, ‘are you scared that you might have something serious’, can expose a healing opportunity.
And while physicians need to tread this terrain carefully, patients
have a responsibility here also. Both
sides need to be open to all reasonable diagnostic possibilities as they
contemplate the complex tangled web of the mind-body relationship.
Sunday, June 5, 2022
Medical Ethics -vs- Medical Behavior
Medical ethics has a similar construct. Rarely, is an issue clearly and easily decided. For example, with limited financial resources, tough decisions must be made on how to ethically allocate these funds. Those who will not receive any funds may still have an ethical right to receive them, yet other groups may have a stronger right. If our society decides that it will not pay for dialysis in moribund individuals, it does not mean that these individuals have no right to this treatment.
- A family demands and receives intensive care treatment for an ailing loved one. The medical care team has advised hospice. Leaving aside the futility aspect of the case, the insurance company is spending thousands of dollars each day. Is this ethical? Should the family be told that if this care is continued, that they will be financially responsible?
- A physician routinely gives out drug samples to his patients. These are left in the office by pharmaceutical representatives who want their products within easy reach of physicians. Many patients who receive these free samples have drug coverage, but receive the samples anyway. Obviously, pharmaceutical companies must raise their drug prices in order to pay for these office giveaways. Is this fair to the rest of us?
- A nurse on an evening shift at the hospital is told that he will be responsible for 2 additional patients since they are understaffed. The nurse feels that this workload is excessive, but has little recourse but to submit to the request. No additional compensation will be provided. Is this ethical to the nurse or to his patients?