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?  

Sunday, July 24, 2022

Why This Doctor Gave Up Telemedicine

During the pandemic, I engaged in telemedicine with my patients out of necessity.  This platform was already destined to become part of the medical landscape even prior to the pandemic.  COVID-19 accelerated the process.  The appeal is obvious.  Patients can have medical visits from their own homes without driving to the office, parking, checking in, finding their way to the office, biding time in the waiting room and then driving out afterwards.  And patients could consult physicians from far distances, even across state lines.  Most of the time invested in traditional office visits occurs before and after the actual visits.  So much time wasted! Indeed, telemedicine has answered the prayers of time management enthusiasts.

At first, I was also intoxicated treating patients via cyberspace, or telemedically, if I may invent a term.  I could comfortably sink into my own couch in sweatpants as I guided patients through the heartbreak of hemorrhoids and the distress of diarrhea.  Clearly, there was not much of a physical exam that could be performed virtually, but as I have opined elsewhere on this blog, in most cases the physical exam is not essential.  I felt that the quality of my virtual care approached the level that I performed in my traditional office visits.  There were instances, however, when a virtual visit was inappropriate and I advised a face-to-face meeting with me.

But the novelty of the experience wore off after a few months.  Many of my patients are chronologically advanced but technically limited.  A recurrent frustration for many participants was when they couldn’t connect to the platform or activate the audio.  Those lucky enough to have a 12-year-old grandchild nearby could be easily rescued.  For the rest, my staff would be calling the patients to try to guide them toward cyber success, an exercise that burned up staff time and burned out my patients.  This demographic rapidly became disenchanted with this experience. And so did I.

Remember this?

From my standpoint, telemedicine was simply less fun.  I realize that the work of doctoring is serious business, but the personal rapport and interactions I have with patients contributes greatly to the reward of what I do.  I found that this could not be replicated with two of us staring into our computer screens.  Virtual visits are transactional experiences.  Similarly, much of America soon tired of zoom meetings recognizing that efficiency has costs.  Ever heard of the term ‘zoom fatigue’?

But telemedicine won’t be deterred as the forces favoring it are overpowering.

Wonder what the patient experience will be when conventional medical care is replaced by artificial intelligence?  How important will the human physician be then?

There is already too much technology separating patients from medical professionals.  How much time do patients watch us pecking on our keyboards during their visits?  Do you think that telemedicine and the next technological frontiers will bring patients and physicians closer together?  As technology advances, our health may be much better and we will reminisce about doctors of yore as we do today about typewriters, pay phones and the Kodak Instamatic camera.

Sunday, July 17, 2022

The Overuse of Heartburn Drugs

Stomach acid must be Public Enemy #1 for gastroenterologists and primary care physicians.  Why else would more than 10 million Americans swallow proton pump inhibitor (PPI) medicines each day? These medicines are potent stomach acid blockers.  Common examples of these medicines include Prilosec (omeprazole), Nexium (esomeprazole) and Protonix (pantoprazole).  PPI medicines have generated tens of billions of dollars for pharmaceutical companies.  And several of these medicines are available over-the-counter (OTC), which permits the public to self-prescribe for a variety of ailments.

Are ordinary folks selecting these medicines appropriately when they purchase OTC?  I have my doubts particularly since medical professionals often prescribe these agents very liberally going beyond the boundaries of medical evidence.  I have also been culpable of the transgression of PPI mission creep.  Indeed, studies have shown that physicians prescribe these acid blockers for the wrong reason and also maintain patients on them for too long, which may be indefinitely.  I have taken on new patients, for example who have been on these medicines for so long that they cannot even recall their purpose or their efficacy.  Often, these medicines are started during a hospitalization and are continued after discharge and then may be granted eternal life.

These drugs are life-changing for patients with frequent heartburn and gastroesophageal reflux disease, known as GERD.  They are also extremely effective in treating peptic ulcers.  And they are an important component of treating or even preventing acute internal bleeding in hospitalized patients.  But PPI use, or overuse, has reached far beyond these drugs’ established indications.

Stomach Ulcers Heal with PPI Treatment

Stomach Ulcers Heal with PPI Treatment

Why has this happened?  The phenomena of drug overuse is much less common in hypertension or diabetes, for example.  Here’s the difference.  Abdominal pain, indigestion, upset stomach, abdominal cramps, nausea, and bloating are among the most common symptoms that patients suffer from.  The reality is that at a huge percentage of these individuals will not be found to a have a specific diagnostic explanation, such as an ulcer or gallstones or appendicitis.  Many will be told that their symptoms are ‘functional’ or the effects of irritable bowel syndrome, a stubborn syndrome associated with a variety of chronic intestinal distress.  And modern medicine doesn’t have very effective drugs for these conditions.  Medical professionals, therefore, often prescribe PPIs in these instances hoping to bring patients a measure of relief. 

But is this practice good medicine?  Should well meaning medical professionals like me prescribe drugs outside of the drugs' reach because there are no effective drugs available? What would the medical profession look like if all medicines were prescribed this loosely?




Sunday, July 10, 2022

Treating the Medically Uninsured

Imagine that you are a physician and the patient sitting before you has no medical insurance. This means, of course, that this individual will have to pay personally for the costs of blood tests, radiology studies, consults with medical specialists, prescriptions, diagnostic tests and even surgeries.  What do you think it might cost your patient if he is suffering from issues such as chest pain, weight loss, abdominal pain or dizziness?  Standard evaluations for these medical symptoms can cost many thousands of dollars. 

Treating the medically uninsured

Medical Care Ain't Cheap

So, assuming you are the doctor, how would you modify your advice to be sensitive to your patient’s sober financial realities? 

Which of the following modifications would you support for a patient who has no insurance?
  • Instead of ordering a stress test for chest pain, prescribe heart medicine to see if this resolves the issue.
  • Instead of sending the patient to the Emergency Room for a question of appendicitis, prescribe an antibiotic and have the patient see you in the office in 24-48 hours to reassess him.
  • Instead of referring the patient for a colonoscopy to evaluate rectal bleeding, prescribe medicine for hemorrhoids to see if this controls the bleeding.
I recognize that compassionate folks – Whistleblower readers – would be tempted to bend their medical advice to spare a patient from financial hardship.  However, if any reader believes that any of the above 3 hypothetical actions are acceptable, then permit me to respectfully point you in a different direction. All 3 responses are entirely unacceptable and unethical.  Here’s why.

A patient’s financial status should have no bearing on the medical advice.  Indeed, to modify it would be a breach of medical ethics and professionalism.   Every patient is entitled to the physician’s best medical advice, regardless of cost or ability to pay.  Sympathy for a patient’s personal circumstances, while understandable, must not taint the medical advice.

The patient, however, may opt to decline the doctor’s recommendation for cost reasons.  This is perfectly acceptable and understandable.

So, if a millionaire or an uninsured person comes to me for advice, I can’t guarantee that my recommendation will be perfect, but I assure you that the advice for each would be the same.

Sunday, July 3, 2022

Independence Day 2022

We are not, thank the Almighty, engaged in a civil war.  But it does seem that we are waging a war on civility.  Rage, anger, violence, division, hate and fear have crept into every corner.  Politics is increasingly regarded as a zero sum game.  Compromise and accommodation are considered by many to be signs of weakness.  If I can't get everything I want, then you will get nothing.  Should this be our modus operandi?

And the country is in pain.  We are still suffering from the aftershocks of a horrendous pandemic.  Our kids lost a year of education.  Inflation is roaring ahead with no clear end in sight.  A recession with rising unemployment may be just around the corner.  Folks are scared.   A war in Europe reminds us that democracy is at risk. Political campaigns have taken on a coarse vulgarity that mirrors the erosion of etiquette and decorum at large.  The January 6th hearings, while necessary, are only further dividing a fractured nation.  And as all of this was boiling over, the Roe decision was handed down by the Supreme Court.

Tomorrow is Independence Day.  Can we pause for a few hours and collectively reflect on the birth of this nation and what it has meant to us and the world?   There were spirited disagreements among the colonies who had competing priorities and interests.  They knew that the greater good was worth the compromises that would be necessary to achieve it.  How would we fare if we faced such a challenge today?

Independence Day

”I am apt to believe that it will be celebrated, by succeeding Generations, as the great anniversary Festival. It ought to be commemorated, as the Day of Deliverance by solemn Acts of Devotion to God Almighty. It ought to be solemnized with Pomp and Parade, with Shews, Games, Sports, Guns, Bells, Bonfires and Illuminations from one End of this Continent to the other from this Time forward forever more.”

John Adams