MD Whistleblower

Each work day, I enter the chamber of horrors also known as the electronic medical record (EMR).  I’ve endured several versions of this torture over the years, monstrosities that were designed more to appeal to the needs of billers and coders than physicians. Make sense? I will admit that my current EMR, called Epic, is more physician-friendly than prior competitors, but it remains a formidable adversary.  And it’s not a fair fight.  You might be a great chess player, but odds are that you will not vanquish a computer adversary armed with artificial intelligence. I have a competitive advantage over many other physician contestants in the battle of Man vs Machine.   I can type well and can do so while maintaining eye contact with the patient.   You must think I am a magician or a savant.   While this may be true, the birth of my advanced digital skills started decades ago.   (As an aside, digital competence is essential for gastroenterologists.) During college, I worked as a secretary

‘Twas the night before Christmas And all through the night, Biden's pet puppies Were ready to bite!   The Dems will run Biden GOP will have Trump While most of the nation Want both of them dumped!   Biden's their man. The race is but done, Yet most of his party Don’t want him to run. Biden is fit! His mind is so keen, Part of his charm? His gaffe-making machine!     Trump is in charge. His nomination can’t fail. But will he be running From a federal jail?     The country’s divided Will this be our fate? Who needs peace and love When we’re nourished by hate?   McCarthy was in. McCarthy was out. Santos was in. Now Santos is out!   With a few civil trials, And 91 counts Trump's polling goes up And his legal bills mount.   The best news for Trump That fits well with his style Was the political gift Of criminal trials!   GOP in the House In search of a speaker, Thumbs down on Jim Jordan

A fundamental skill that physicians rely on is calculating risk/benefit analyses when we advise patients.  My use of the word ‘calculating’ is a misnomer as there is no reliable scientific method to quantify risk and benefit.  Indeed, different physicians might ‘calculate’ such an analysis differently.  Similarly, different patients in the same medical circumstances might gauge the potential medical benefit differently.  This is not hard science.  Some folks might feel that a 5% risk of a major complication is acceptable, while others would balk at this statistic.   And on the benefit side, is it worth taking a medication that has some risk with the hope that it might shave 1 day off of a 7 day illness?   Despite that risk/benefit analyses are not easily quantified, physicians and patients must enter into a dialogue on this issue when a treatment or a test is being proposed.   The participants have to do their best to tease through the issues. If a 25-year-old athlete develops ac

Several times each month patients solicit my view on probiotics.   The tens of billions of dollars spent annually by Americans on these agents provides us with overwhelming evidence of an economic truth – marketing works.   Conversely, the evidence that probiotics actually deliver on their health claims ranges between thin and absent.   Why, then, are they so popular? While modern medicine has delivered much for the public, there are so many mysterious and chronic afflictions that remain out of reach.   Patients and physicians struggle over addressing bowel disorders, chronic arthritis, depression, fatigue, memory lapses, allergies, autoimmune diseases, skin rashes, sleep disorders, obesity and many other stubborn conditions.    When conventional medicine fails to deliver, many other treatments of questionable quality emerge.   This is undeniable.   Claiming benefit, however,  should not be sufficient.   Any new treatment should be subjected to the same rigorous vetting process that

Many professions can be easily identified by their uniforms or state of dress. Consider how easy it is for us to identify a policeman, a judge, a baseball player, a housekeeper, a chef, or a soldier.  There must be a reason why so many professions require a uniform.  Presumably, it is to create team spirit among colleagues and to communicate a message to the clientele.  It certainly doesn’t enhance professional performance.  For instance, do we think if a judge ditches the robe and is wearing jeans and a T-shirt, that he or she cannot issue sage rulings?  If members of a baseball team showed up dressed in comfortable street clothes, would they commit more errors or achieve fewer hits?  The medical profession for most of its existence has had its own uniform.   Male doctors donned a shirt and tie and all doctors wore the iconic white coat.   The stated reason was that this created an aura of professionalism that inspired confidence in patients and their families.   Indeed, even today

 I feel it is more challenging than ever to carve away the chaos and destruction so that we can focus on what we should be thankful for.   Yes, there is beauty in the world which we must seek out and cherish.   Yes, there is kindness and generosity in our midst which we must champion and promulgate. Yes, there is dialogue and open mindedness which we must resurrect and cultivate. Skimming national and international current events on any day reinforces the reality that the space to find gratitude is smaller that it used to be.  But it is there. Never doubt that a small group of thoughtful and committed citizens can change the world;  indeed it's the only thing that ever has.    Margaret Mead On this recent Thanksgiving, I hope that all of you had blessings to celebrate.  Perhaps the task will be easier for all of us next year.

"Doctor, do you think I have cancer?" In a prior post, I did my best to point out that handling questions from patients and their families in a skillful manner requires a measured and cautious approach.   Paradoxically, physicians have not received much training, if any, in this aspect of doctoring, which physicians engage in dozens of times each day. In the unlikely event that you have not yet perused the prior post, here’s the link , which will serve as a brief prep course for this current posting. All of us hope and pray for a salubrious life.   Sickness scares us.   We fear any worsening of our illnesses, future mental decline, loss of physical function or any unforeseen change in our medical fortunes.   The fear of cancer hovers over all of us.    And, understandably, patients want to be reassured that their symptoms are benign and transient.   There is another genre of questions that are directed at physicians that requires a deft response.    Below, I will list s

One pleasure that engage in regularly is taking time to simply think and to collect my thoughts. I don’t have a dedicated time for this pursuit; I can seize the moment at any time.   Often, I am on a walk or maybe simply driving somewhere.   I use these times to rove through recent happenings in my life and in the lives of those I care about.   Or, I might reflect – some might say ruminate – over a news item or opinion piece that I have read.   There is no agenda.   My mind simply roams and wanders stopping periodically at various unplanned destinations.   Think of this experience as akin to entering a large bookstore (younger readers may need to google here) without a specific title in mind.   You simply start ambling through the aisles sampling various books until you find one or two that meet your fancy.   The journey, as I see it, is a central part of the adventure.   Contrast this with purchasing a specific book on Amazon.   I’ve purchased books both ways, but one of these opt

We all recall President Reagan’s adage, trust but verify , with regard to the then Soviet Union.  President Reagan’s choice of words indicated that trust could not be assumed.  I challenge this notion as I feel that to trust another person, an organization or even a country that trust must be assumed to exist.  That’s what trust means.  Conversely, if one has to verify its presence, then true trust is clearly not there.  If a spouse, for example, hires a private investigator to prove that his or her partner is behaving honorably, is trust present? I think that overall the public trusts their doctors, although they are wary about the medical profession writ large.   The public may view their physicians in the same way that it views politicians – they see systemic dysfunction and self-interest in both professions but folks give higher integrity marks to their personal doctor or representative.   Often, patients who I know have confidence in me voice criticisms over various frustrating

Trust is the central element in our national motto.  Do you recall this 4-word phrase?  If you need a reminder of this iconic verbiage, just grab a coin or some paper money and you’ll find it there.  Perhaps, you can’t recall the motto.  Since we don’t study our money when making a transaction, our trustful motto may remain buried in the background – invisible while in plain sight.  I’ll bet that some curious readers are scanning a dollar bill right now!    As our trustful motto seems out of view, so has trust across society become much less visible.  When we do stumble across it, it can feel as if we have struck gold.  Years ago, for example, I wrote a post about a proprietor who showed me such a high level of trust that I memorialized the incident in this blog and will never forget the vignette.  The trust vacuum seems most evident in our political space.  The citizenry does not trust elective officials, particularly those of the opposing political party.  This phenomenon has sp

Since I started practicing medicine a few decades ago, I have been recertified every 2 years for Advanced Cardiac Life Support (ACLS).   Readers might not perceive any newsworthiness regarding this issue.  After all, I am a doctor and I should know how to respond to unexpected medical emergencies.  Except I have barely a clue. Yes, I pass the exam every other year.   The truth is that I do so because all of the institutions that I have worked for require this certification.   There must be a group of bureaucrats sequestered somewhere who decided that physicians should be ACLS certified, at least doctors like me.   But, as is so often true in life, mission creep sweeps in participants who should have been excluded in the effort.   The only moments that ACLS has my attention are those 2 hours every other year when I recertify. In between these episodes, I don’t read about it, dream about it and certainly never do it. Advanced life support is not simply a certification status – it’s

 I will share with readers a recent occurrence between me and another doctor that was both rare and refreshing.  I was serving as the gastrointestinal consultant on one of the doctor’s patients.  I performed a scope examination of the stomach and obtained some routine biopsy specimens.  The pathology results were abnormal, but benign.  No urgent action was needed, but a full airing of the significance of the results would require a conversation between me and the patient in an office visit.  I notified the patient that there was no medical threat at all and we would unpack it all during his next visit. The referring physician wondered about this delay, which perhaps is a different style from other gastroenterologists (GI’s) who he works with.   (My guess is that other GI’s may opt to handle the issue with the patient on the phone or via the portal. I think, however, that there’s too much complexity to fully address this issue in this manner.) So, here’s what the referring doctor did.

Here is a reality of human behavior.  Folks behave differently when they know they are being watched.  Consider two examples that we have all seen.  We are sitting in the driver’s seat of our parked car.  The driver in the adjacent car sees us and then opens his door with particular care so as to avoid dinging us. We wonder what his car door action might have been had our own car been empty.  Similarly, in most business scenarios, I suspect that the staff perform at a higher level when the boss is around. This phenomenon is referred to as the Hawthorne Effect, whose name derives from some industrial research done in the Hawthorne suburb of Chicago nearly a century ago. Do you behave the same way when someone's watching? And yes, this truth exists also in the medical profession. Consider the following proposed studies and if the results might be distorted by the Hawthorne Effect. The Chairman of the Department of Surgery announces an initiative to improve patient satisfactio

 Now that I am employed by a colossal medical center whose reach extends internationally, many patients land on my schedule seeking a 2 nd , 3 rd or even a 4 th opinion on recalcitrant and unexplained digestive issues. Many of these patients travel from neighboring states coming with the hope that yet another gastroenterologist will crack the code of their illness.  Obviously, any patient who seeks another medical opinion is already dissatisfied, hence the reason for seeking additional advice..  Here is a sampling of some reasons why patients solicit or are sent for new medical opinions. Persistent symptoms Search for an explanatory diagnosis for unexplained symptoms. Quality check to verify that the original doctor’s advice is correct. Encouragement of family or close friends to seek another opinion. Dissatisfaction with the doctor’s bedside manner. Friction with the office staff or the billing personnel. Office schedule of original doctor is booked out for months. Fear that a ser

One of the conundrums in medical practice is to determine if a medication is causing a side effect.  Sometimes, this issue is very straightforward.  A new medicine is prescribed.  Three days later, the patient develops a new symptom of constipation.  The medicine is stopped and the bowel pattern normalizes.  Most of us would agree that the evidence that the medicine was responsible for the bowel change is beyond a reasonable doubt. The above is a textbook example of a side effect, but alas, patients often have not read the textbook.   Consider a patient having diarrhea from colitis.   The gastroenterologist prescribes an appropriate medication.   Two weeks later, the patient contacts the doctor to report that his diarrhea has worsened.   Although diarrhea is among the long list of potential side effects of the medicine, might the increased diarrhea simply be from his underlying colitis? It's 'alimentary', my dear Watson! I have seen many examples of patients who come to

I have penned a few posts recently illustrating the difficulties in measuring medical quality.  Indeed there's a category on this blog entitled, Medical Quality, ready for your perusal. How do we measure something that is very difficult to measure?   Why is a painting hanging in a museum considered to be a masterpiece while others – which appear quite similar to most of us – are relegated to a much lower status?    And art experts may not agree on these designations! I have already performed approaching 50,000 colonoscopies in my career, and my colonoscopy counter notches more of these each week.   This is my gift to humanity.   Quite often, I am stopped in a store or on the street by a grateful recipient of one of my probing endeavors.   Clearly, patients regard the event as a bonding experience. Found this in a garage sale.  Worth anything? But how do they or anyone know if I am any good?   How do you assess the quality of a proceduralist? It sounds easy enough, except that

I have written how challenging it is for ordinary folks, let alone medical professionals, to assess the quality and competence of physicians. There are no easily measurable and reliable parameters.  Industries have emerged that specialize in assessing the competencies of practitioners and organizations in fields beyond medicine.  It is typical for those who are targeted for assessment to howl in protest claiming that the testing methods are irreparably flawed and should be abandoned.  Sometimes, these folks have a point. But other times, they are simply trying to avoid accountability. And just because an evaluation process hasn’t been perfected, doesn’t mean it offers no value.  For example, teachers have recoiled against using student test scores as an element in assessing their pedagogical skills.  I think that both the teachers and the testers have legitimate arguments. Professionals and tradesmen and their leadership advocates will reject processes that will disparage their members