MD Whistleblower

 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. ...

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!' ...

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.   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 appe...

When a judge hears a case, neither party is 100% correct.  Each litigant may have a meritorious claim, but one of them will be found to have the better argument. If the dispute could be easily and amicably resolved, or one party was clearly wrong, then the matter would be unlikely to have reached a courtroom.  One litigant may be found to be 'more right' than the other Which litigant's right will prevail? 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. These complex decisions create winners and losers. ...

On the day before writing this, I attended a seminar on medical professionalism.  The room was filled with physicians at all stages of our careers.  I enjoy opportunities to think about aspects of my profession that are beyond the digestive organs that I dally with daily.   At the seminar, a video clip was shown from the 1991 movie The Doctor.  The scene depicted an attending physician berating an intern in the presence of the medical team after he casually referred to the next patient to be seen as being ‘terminal’ without identifying him by name.  If fact, it became clear that the young doctor did not even know the patient’s name.  While the attending physician was correct to recognize that patients are living breathing human beings, not diseases or hospital room numbers, it was a breach of professionalism to humiliate an intern in public. After a few comments were offered by seminar attendees chastising the senior physician’s cruel approach to ...

While I may consider myself to be an ethical practitioner, I am in imperfect member of the genus, Homo, practicing medicine in an imperfect world.  I don’t commit Medicare fraud or lie to my patients.  When I commit an error, I admit it.  I often counsel patients against proceeding with endoscopic studies, because I don’t feel they are medically necessary.  I do my best to keep my patients’ interests as my paramount concern. But the world of medicine doesn’t always have bright lines and borders to keep us confined to an ethical zone.  Physicians and ethicists argue over where to draw these boundaries.  What was regarded to be unethical 10 years ago has become standard medical operating procedure in many instances.  Consider how the field of reproductive medicine has evolved.  The definition of death has been relaxed in order to increase the human organ donor pool. We will surely see human cloning in our lifetime.  Medical ethics is not e...

 I think we’re headed in that direction.  There are various angles and positions to consider.  But, as in so many disputes, it’s not a matter of right and wrong but an issue of which side has the better argument. When a judge rules for one party in a dispute, this does not mean that the other side had no legitimate position.  If means that the judge concluded that an analysis of the facts and the law tilted toward one side. We must acknowledge that an individual has a right not to be forced to accept a vaccine or any medical treatment.   The doctrines of informed consent and patient autonomy are bedrock pillars in American medical care.   If, for example, I recommend a colonoscopy to a patient with symptoms highly suggestive of a serious colon condition, the patient is free to decline my advice.   While I may feel strongly that this decision – referred to as informed refusal – is unwise, no medical practitioner or ethicist would argue that I sho...

It would seem self-evident that an applicant for a job should be scrupulously honest.   First, it is the right thing to do.   Secondly, in our digital era, one’s academic record can be accessed back to kindergarten.   Yet, many applicants will embellish their credentials or claim a skill level that may exceed reality.   Thirty years ago, I was applying for my first job in New Jersey after completing my 2 year gastroenterology (GI) fellowship.   I was not competent to perform ERCP, a complex scope examination that GI practices desperately still want to add to their practices' skill sets.   Yet, I was advised by a practicing GI physician to simply claim that I could do the procedure.   Otherwise, he said, they would simply pass me by.    I queried the practitioner on my proposed course of action after being hired if I were summoned to perform an ERCP.   Decades later, I do not recall his response.    I can imagine what my new e...

We’ve all heard about the blue wall of silence that describes a belief that law enforcement personnel will refrain from reporting misconduct of their colleagues to the proper authorities.  Physicians had similarly been accused of hiding behind a white coat wall of silence , as I have on this blog.   This describes the belief that physicians do not reliably turn in colleagues who are incompetent and impaired.  Personally, I have never knowingly participated in the care of a patient with an impaired colleague.   Competency is a murkier issue and is, of course, variable in the medical profession.  In addition, it’s not easy to define or to measure.  It is this very fact that has made me so hostile to the Pay-for-Performance schemes that claims to be a quality metric, but is truly used as a cost cutting tool. 'I Know Nothing' I am aware of physicians in my community who do not have a strong reputation of medical skill.  Yet, many of t...

Some time ago, I performed a colonoscopy on a patient who was having serious internal bleeding.   He had already received multiple transfusions since he was admitted to the hospital.   After obtaining informed consent for the procedure, I performed the colon exam.    I encountered blood throughout the entire colon, but saw no definite bleeding site, raising the possibility that the source of blood might be higher up than the colon, such as from the stomach.   I had not considered this possibility when I met the patient, but this was now plausible.   Can I proceed with the upper scope test, which the patient did not consent to, while the patient is still sedated from the colon exam? Could the Stomach be the Culprit? Seasoned gastroenterologists can usually predict the site of internal bleeding based on numerous medical facts, but there are times that we are surprised or misled.    Patients don’t always behave according to the textbo...

Many organizations solicit private donations from benefactors and philanthropists.   Is there a stadium in the country that does not bear the name of a prominent donor?   There are also anonymous donors who are not cursed with egos that require their names to be emblazoned in giant font on a building’s façade.   But, most donors want recognition which is often used as an incentive when soliciting the donation. Donors understandably receive perks and privileges that ordinary folks will never be offered.   If you give a ton of money to a theater, you might receive prime season tickets as a gift.   If you make a sizable donation to a symphony orchestra, you may be invited to a private event to meet the conductor and leading musicians.   If you make a robust financial contribution to your city’s art museum, you won’t have to worry about competing for limited tickets to view the visiting Picasso exhibit.   You may very well have your own private tour....

Is there corruption in the medical profession?   Recall Captain Renault’s iconic rejoinder to Rick in Casablanca. “I’m shocked, shocked to find there is gambling going on in here!” In any enterprise with billions of dollars at stake, and when different players have competing interests which may not coincide with the public’s interests, there will be skullduggery.   How do you think our Defense Department and its relationships with vendors would look if we were able to shine a bright light on all its faces?   Do you think it’s possible that a weapons manufacturer might argue, through lobbyists and salesmen, that its weapons are essential to national security and superior to those of a competitor?    How about when a congressman argues for the continued purchase of military equipment manufactured in his district that military experts state is no longer needed?   And, there’s the quintessential and craven corruption of legislators refusing to clos...

  Just because something is legal, doesn’t make it right.  Just because we enjoy a right of free speech, doesn’t mean we should be verbally insulting people. Just because the Food and Drug Administration (FDA) approves a treatment or a test, doesn’t mean we should pursue it. The FDA has given approval to 23andMe, a private company, to provide genetic testing directly to individuals.  The results provide genetic risks of contracting several medical conditions including Parkinson’s disease and Alzheimer’s disease.  No prescription or physician visit is needed.  While 23andMe execs and marketers will undoubtedly claim that their mission is to empower the public, this does not tell the whole story.   Indeed, many patients who undergo the testing will be worse for having done so.   I would never submit to the 23andMe home testing program myself, nor would I counsel my patients to do so.  It seems bizarre that the incredibly c...

Physicians confront alcoholism regularly.    Indeed, nearly every day on my hospital rounds, I treat patients who are suffering the ravages of alcohol abuse.    While these patients may have a genetic predisposition toward alcohol abuse, or faced other personal pressures and demons, ultimately the disease is initiated by a person who made an unfortunate decision.   I do not judge these individuals as their doctor, any more than I do my hepatitis C patients who contracted the virus as a result of intravenous drug use.    But, when are examining the causes of these maladies, personal responsibility and accountability must be considered.   In fact, failure to do so will frustrate our efforts to prevent various injurious addictions.   Physicians and others have heard the vignette when an alcoholic denies his addiction despite that every other person in his life feels otherwise.    “They are all wrong,” he states emphatically. ...

I read yesterday in Cleveland’s main newspaper about the tragic passing of a 14-year-old girl.   She had cancer.    Why would this tragedy have been reported on Page 1?    As sad as a loss of a child is from a medical condition, this is generally not of interest beyond the family, friends and loved one.   This case was different.   The parents refused the chemotherapy that her doctors advised.   They wanted their daughter treated with herbs and feared that standard medication would worsen their daughter’s already precarious condition.    The parents believed that chemotherapy would violate their religious beliefs. The parents sought another medical opinion from Cleveland’s other premier tertiary care center, which affirmed the original medical advice. About 2 weeks ago, the parents received a court order mandating that their daughter receive chemotherapy.   Shortly afterwards, the daughter, who was already on a ventilator,...

People with liver failure and cirrhosis die every year because there are not enough livers available.  Who should receive the treasured life-saving organ?  There is an organ allocation system in place, which has evolved over time, which ranks patients who need liver transplants.  Without such a system, there would be confusion and chaos.  How can we fairly determine who should receive the next available liver?  What criteria should move a candidate toward the head of the line?  Age?  Medical diagnoses? Insurance coverage? Employment status?  Worth to society?  Criminal record? An artist's rendering of the liver from the 19th century. Consider the following 6 hypothetical examples of patients who need a liver transplant to survive.   How would you rank them?  Would those toward the bottom of your list agree with your determination? A 50-yr-old unemployed poet is an alcoholic.  He has been sober for 1 ye...

In our practice we have an open endoscopy system, as do most gastroenterologists. This means that other physicians – or patients themselves – can schedule a procedure with us without seeing us in advance for a consultation.  Of course, we are always pleased to see any of these patients for an office visit in advance, but many patients prefer the convenience of accomplishing the mission in one stop.  This is reasonable for patients who truly need our technical skill more than our medical advice. Our office screens these procedure requests in advance to verify that no office visit is necessary.  While this process works very well, it is not infallible.  There have been times when a patient arrives to our office poised for a colonoscopy with accompanying medical issues more complex than we had expected. No vetting procedure is failsafe.  Have you seen the TSA statistics when they are tested in identifying dangerous items hidden in luggage?  Even though ...

Many of my readers do not know who Barry Goldwater was, let alone of the Goldwater rule established by the American Psychiatric Association in 1973.  The rule advises against psychiatrists commenting on the mental health of public figures they have not examined.   Obviously, a psychiatrist or any physician who has treated a public figure is prohibited to offer any public comment unless he has been authorized by the patient to do so.  On Tuesday, Dr. Ronny Jackson, the president’s personal physician, will discuss the results of the president’s recent medical examination with the press.  The boundaries of what Dr. Jackson can report will have been set in advance by the president.   Senator Barry Goldwater In the past month, the Goldwater Rule has appeared in our newspapers and all over cable news and commentary programs.  Goldwater has probably been a 'trending topic'.  This is in response to suggestions that the president may be m...

We cannot let the anecdote rule over us.   We don’t make sound policy if we are swayed by isolated emotional vignettes.  Of course, a vignette describes a living, breathing human being, but we must consider the greater good, the overall context and the risk of letting our hearts triumph over our heads when making general policy.  Consider these examples. If an expensive drug treatment program keeps 5 addicts clean for 6 months, do we champion this success in asking for funding to be renewed while omitting that 400 enrolled addicts failed? If an experimental medical treatment seems to be effective in one patient with a stubborn disease, should physicians lurch toward it leaving aside standard treatments which have been subjected to Food and Drug Administration approval and years of clinical experience? If a high school student attends an SAT prep course and achieves a near perfect score, do we conclude that every student should enroll in this course...