MD Whistleblower

Some time ago, a man came to see me requesting a colonoscopy.  His last colon exam was done about 5 years ago.  He is well into his 80’s and has several significant chronic medical conditions.  He wanted reassurance that he did not have colon cancer.  Who wouldn’t want to be reassured of this?  After questioning him closely and reviewing the medical data I advised him that I was not suspicious that he was harboring a colon malignancy.  The patient, however, was not mollified.  As the professional, I advised that in my judgement the risks of the procedure exceeded the potential benefits.  Indeed, this is the risk calculation that physicians utilize daily when advising patients on diagnostic and therapeutic options. While I didn’t categorically refuse to perform the procedure, I was reluctant to proceed.   I asked the patient’s internist, who knew the patient well, to delve into this issue further with him.   As I did not hear back from ...

 A few days before preparing this post, I greeted a patient who was about to undergo her 5 th colonoscopy.  I was the pilot for the 4 prior excursions.   “You should’ve signed up for the rewards program,” I quipped.  “This one would’ve been free!”  Our patients, with rare exceptions, enjoy our light atmosphere seasoned with some humor.  This does not detract from our seriousness of purpose and commitment to their welfare, and they know it.  Our endoscopy team is comprised of outstanding medical professionals. I care for many patients for whom I have performed all of their colonoscopies, which may exceed 10 procedures.   I recently performed an examination on one of my colitis patients who has unique findings which have remained stable for years.   I know his colon as well as I know his face!   Indeed, if I were shown a photo of his colon, I would immediately be able to name the individual.   So, when we gastroenterologists c...

In the medical profession, there is often more than one correct answer.  Present the same case to 10 seasoned medical practitioners and you will likely hear numerous rational plans of action.  This scenario would be bewildering to patients and their families and is one reason that I have warned patients of the hazards of pursuing a second opinion.  Medicine is not mathematics where there is a single correct answer that can be proved. Medicine is not like math. How does a patient reconcile divergent recommendations offered by medical professionals? Should a formal debate competition be held before patients and their families? How does the medical team reconcile our differing views amongst ourselves? Can we expect ordinary patients and their families to decide if surgery, medication or watchful waiting is the best option?  Despite the current culture of patient autonomy, shouldn’t it be the physicians’ task to direct patients toward wha...

Quite regularly, I am asked to comment on the care of folks who are not my patients.  Often, these are friends or their relatives who are suffering gastrointestinal (GI) distress.  “Would you be able to give her a call”?  On other occasions, a member of my own family wants me to connect with someone who has a GI issue. This is tricky terrain and I navigate it very cautiously.   Obviously, I am not the individual’s doctor and would never assume this role.   The individual shares with me only his version of the facts which may not represent the totality of the medical situation. I don’t have the data and have not performed my own examination..   It would be highly irresponsible and unethical for a physician from afar, who has no professional attachment to the individual, to dispense medical advice or to sow doubts about the quality of the medical care rendered.   Indeed, a physician who crosses a line here can cause confusion and doubt which can have d...

 From time to time, I arrange diagnostic testing to ease patients’ minds.  “Could you scope my esophagus?   My boss was just diagnosed with esophageal cancer.”   “I know I’m not due for my colonoscopy for another 2 years.   But I’d like to do it now just to be on the safe side.   My wife is worried.” “No, the abdominal pain hasn’t changed since I had a CAT scan for it months ago, but maybe I should have another scan now just in case something new developed?” When these requests are offered, I do not automatically acquiesce.   I try to understand better the genesis of the anxiety.   Is it rational?   Is it emotional?   Is there a true medical indication to justify a diagnostic test?   I interpret requests for tests as invitations for dialogue.   Very often, the ensuing conversation can settle the issue entirely obviating the patient’s testing request.   These patients don’t really want a test; they want to be reassu...

In the olden days, physicians had the dominant role in the doctor-patient relationship.  During this era of medical paternalism, physicians gave their best medical advice and patients accepted it.  If the gastroenterologist felt that his patient’s gallbladder had to go, for example, then surgery was sure to follow.  Informed consent – as we now understand its meaning – was not fully practiced.  Patients provided consent but were only partially informed. While medical paternalism has largely become extinct, and is inconsistent with today’s societal and medical mores, it was the template for medical practice until only decades ago.   And while we regard the subjugation of patient autonomy to be a fundamental ethical breach, both physicians and patients during that era were perfectly satisfied with the arrangement.   A patient came to the doctor with medical issues.   The doctor -the medical professional - offered advice that the patient accepted. ...

One of the advantages of the computer era is that patients and physicians can communicate via a portal system.  A patient can submit an inquiry which I typically respond to promptly.  It also offers me the opportunity to provide advice or test results to patients.  Moreover, the system documents that the patient has in fact read my message.  Beyond the medical value, it also provides some legal protection if it is later alleged that ‘my doctor never sent me my results’.  I have always endorsed the concept that patients must accept personal responsibility.   Consider this hypothetical example. A patient undergoes a screening colonoscopy and a polyp is removed.   The patient is told to expect a portal message detailing the results in the coming days.   Once the analysis of the polyp has been completed, the doctor sends a message via the portal communicating that the polyp is benign, but is regarded as ‘precancerous'.   The patient is advise...

Gastroenterologists are equipped to assist folks with fecal incontinence (FI) – an awful symptom for reasons that need not be explained.  While many of these individuals experience leakage only occasionally, the fear of an impending episode is ever present.  They leave home wondering if this will be a day when they will experience a lapse in control.  Many remain at home or curtail social activities because of fear and anxiety. So, while the condition is not life threatening, it is an assault on an individual’s quality of life. It’s more common in women and the elderly and is associated with a host of medical conditions.   Fecal incontinence is extremely common in extended care facilities which can result in medical consequences. This post is not to discuss the diagnosis and treatment of this condition.   Indeed, this blog is a medical commentary site, not an ‘ask a doctor’ site. Here’s the point of this post.   More often than not, individuals suff...

With some regularity, patients contact me requesting antibiotics.   Many patients regard this as a casual and routine request, but I don’t.  When I hit the ‘Send’ button authorizing an antibiotic – or any medication refill – I am declaring that I personally agree that the medicine is medically necessary.  In general, I sign off on most routine medication refill requests without issue, unless the patient hasn’t seen me in the past year or so.  I would hesitate to refill if patient communicates that his heartburn is worse and requests that I double the dose of his reflux medicine.  This patient will be asked to see me in the office. There are times that I will prescribe antibiotics without an office visit.   This assumes that there is an existing professional relationship between me and the patient and that the medical facts support sending in a prescription.   There also needs to be a reservoir of trust such that the patient would contact me if h...

How much medical uncertainty can you tolerate?   Most patients have not given much thought to this consequential issue, but it hovers over them in their doctors’ offices.  This is also an issue for medical professionals.  Indeed, how both sides in the doctor-patient relationship navigate through this will be instrumental in choosing the pathway forward. Medicine is not mathematics.  It’s a murky discipline with incomplete data and moving targets.  Many of your symptoms – fatigue, abdominal pain, nausea, weakness, sleep disturbances – often cannot be reliably explained.  How much testing in such cases is reasonable?  I offer no response as this issue needs to be negotiated between the patient and the physician.  Since patients and doctors have different philosophies and experiences, there will be several correct and reasonable responses.  This is why a second opinion may yield different advice but not necessarily better advice. An 8...

Physicians handle thousands of questions annually. We respond to inquiries from patients, their families, insurance companies, nurses, professional colleagues, pharmacies, our staff and even strangers.  This is, of course, a part of our job, and it consumes a substantial amount of our time and energy. Questions come via homing pigeon Questions come via telegraph Was Alexander Graham Bell Calling his Doctor for a Question? And, responding to questions is not as easy as you may think.   Words matter and a clumsy word choice or an omission can wound instead of heal.   Here are some of the challenges we face when a medical inquiry is directed toward us. We may not know the answer. We may misunderstand the question and may misfire with our response. We may have incomplete data and need to calibrate our response accordingly. We may not be aware of the questioner’s true intent and anxiety.  For example, the question may seem innoc...

Ask most of us if we are honest and we will likely respond in the affirmative.   Who among us wants to admit publicly that we are a cheat or a liar? It would be more accurate to describe ourselves as mostly honest, since there are occasions when we do some fact massaging and truth shading.   And, sometimes, applying a little spin may be the better choice. Consider this hypothetical. Your mom has been working all afternoon to prepare meatloaf as a birthday treat for you.   While it appears appetizing with its golden-brown appearance, it is simply not palatable.   Your mom asks you directly how it is.    Choose among the following potential responses. Mom, did you mix in some dog food in by mistake? Hey, are you trying to poison me? I like the ground glass.  It give the meat a great crunch. Mom, this is great!  I hope there will be leftovers for tomorrow, if I can wait that long! 'Mom, the meatloaf was....indescribable!' ...

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 an...

"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....

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 cr...

 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. F...

I have been a conservative medical practitioner since my training days decades ago.  As readers of this blog have read (?endured) repeatedly, I am very hostile to over-diagnosis and overtreatment.  While I don’t have data, my strong sense is that I order fewer scans, offer fewer prescriptions and order fewer lab studies than my peers.  I am not suggesting that my approach is the optimal pathway to medical quality, only that it has always defined my medical comfort zone.  My philosophy can be summarized as less is more . Patients have their own medical philosophies and over time tend to link up with medical professionals who share their approach.  Some patients laud physicians who test them liberally regarding these doctors to be very thorough and conscientious.  “My doctor is so thorough, on my first visit he ordered blood work, a CAT scan and is sending me to 2 specialists!”  Patients who prefer a more measured and conservative approach seek likemi...

For most of my career, I was in a small private practice.  Our staff were like family.  We prided ourselves on providing highly personalized attention to our patients which started at the moment that the patient was greeted by our receptionist.  For a patient to enjoy an optimal medical experience, every member of the team needs to perform at a high level.  The doctor is but one member of a larger team.  Indeed, I have heard personally of patients who have left medical practices who liked the doctors but not the staffs.  Everyone counts. We saw patients who were self-referred or sent to us by referring doctors or by family members.  I have always asked every new patient how they came to see me personally, and I still do.  It is always gratifying when a patient is recommended to us by a medical professional or a family member.   You took care of my grandmother and she raves about you!   This not only feels good to the doctor, but t...

My employer,  a rather large and well known medical behemoth based in Cleveland, recently announced that patients may be charged for medical advice solicited on the patient electronic portal.  This has generated an array of opinions ranging from accusations of corporate greed to defending physicians’ right to be compensated for practicing medicine. Implementing this new program violates the following reality of human nature. Folks will not support losing an established benefit.   Consider how organized labor reacts when management aims to reduce worker benefits.   How would any of us feel if our employer cut back our vacation allowance?     How might homeowners feel if their mortgage interest is no longer tax deductible?   You get my point.   Over the past few decades, I have provided thousands of hours of free medical care on the phone and electronically.   I never felt that I was being ripped off since this was the only system I kne...

I am frequently asked what is the upper age limit for offering screening colonoscopy.   Patients today are often more informed on certain medical issues than their doctors are.   I support their empowerment.   Of course, we physicians, as actual medical professionals, presumably have more credibility in opining on the practice of medicine.   In my own life, I always give great weight to the folks I hire, whether they are tradesmen or professionals.   Why would I not give consideration and deference to one who has years of training and experience?   If I needed an attorney to litigate an issue, would I presume to advise on the optimal trial strategy?   ‘ He who represents himself has a fool for a client.’ Patients can acquire a great deal of medical knowledge, but they are not as easily able to exercise sound medical judgment.   This takes us professionals years to develop.   Consider this weighty maxim:   It takes 10 years to acquire...