MD Whistleblower

Cologuard is a sophisticated stool test that checks for microscopic blood and altered DNA which can signal the presence of colon cancer or precancerous polyps.  Some patients are attracted to this non-invasive option rather than to traditional colonoscopy experience which includes the ever popular cathartic cocktail. This test was approved by the Food and Drug Administration (FDA) in 2014.    The test was initially quite popular as patients and physicians were enthusiastic about this new colon cancer screening option.   Often in medicine, what’s new becomes popular but initial enthusiasm tends to ebb over time.   (With time, the initial safety and efficacy reports for medicines and diagnostic tests may not be sustained.   This is why post-marketing surveillance after initial approval is so critical.) Patients were advised early on, as they are now, that a positive Cologuard test meant that a follow up colonoscopy was mandatory.   Certainly, when I or...

Many patients are aware of Cologuard as a colon cancer prevention option.  The appeal is obvious. One can submit a Cologuard stool test and forego the joys of colonoscopy.  Indeed, what motivates patients to select the easier option is not belief in the product but an opportunity to avoid a much less pleasant alternative.  This is analogous to how many of us vote in elections.  Rather than vote for a candidate we are often voting against another candidate.                                        Did you vote for or against a candidate? Cologuard is much more sophisticated and expensive than the conventional stool testing for occult blood which has been standard fare for decades.   Cologuard will also detect microscopic blood in the stool but will also pick up abnormal DNA which could indicate the presence of a large precancerous polyp or even a cancer.   Hen...

Why do so many unproven recommendations get incorporated into medical dogma?  Put a jacket on so you don’t catch cold! Stress causes stomach ulcers. Caffeine causes _______.   (Fill in the blank since it’s blamed for everything!) Sugar makes kids hyper. Colonic cleansing rids the body of evil toxins. We accept many recommendations as true in the absence of data or in some cases even if data refutes the claim.   Some folks still believe that the measles vaccine causes autism which is been roundly debunked.  And dislodging these myths takes effort and time.   When I was a younger doctor, antibiotics were routinely prescribed for sore throats and presumed bacterial ear infections.. When these patients recovered, the antibiotics were credited with the salutary outcome.   Doctors were simply following the teachings and customs of that era.   Nowadays, physicians approach these patients much more conservatively, but this did take a while. Foll...

The raison d’etre of MDWhistleblower is to give readers a peek ‘behind the medical curtain’.  This post is true to this mission. I offer readers a lesson that I have shared with patients, friends and family over the years.   I suspect that elements of my point have been covered in prior posts.   As I have penned over 800 posts since 2009, I hope readers will forgive me of an example or two of repetition. There is a frequent technique that I’m about to share that misleads patients about the value of various medical tests or treatments.   While these communications to the public are technically true, they are misleading.   Let me explain. If you saw a product or medical test from reputable organizations that promised to cut your risk of a heart attack by 30%, would you be interested?   Odds are that you would be very interested.   Who wouldn’t want their risk of a heart attack to be cut by nearly a third? Medicine is riddled with similar promises...

I am regularly solicited for my opinion on the stool test Cologuard, a colon cancer screening option.  These queries generally come from folks who are angling to avoid the joy of the colonoscopy experience.  It’s hard to fathom why someone would want to avoid the pleasure of a supersized laxative followed by a day of fun on colonoscopy day!  Scientific investigators are working hard on colon cancer screening blood test options, but as I have pointed out , these are not quite ready for prime time. Finding alternatives to screening colonoscopy is a very high priority for the medical profession. There are two driving forces. Colonoscopy, while effective, is a laborious process which is a 2-day experience, requires a driver, frequent time away from work, is expensive and has risk.   If a stool or a blood test could achieve the same level of protection, it would be a game changer. The economic rewards for launching an effective stool or a blood colon cancer screen...

Over the years, I have treated various medical professionals from physicians to nurses to veterinarians to optometrists and to occasional medical residents in training. Are these folks different from other patients?  Are there specific challenges treating folks who have a deep knowledge of the medical profession?   Are their unique risks to be wary of when the patient is a medical professional? First, it’s still a running joke in the profession that if a medical student develops an ordinary symptom, then he worries that he has a horrible disease.  This is because the student’s experience in the hospital and the required reading are predominantly devoted to serious illnesses.  So, if the student develops some constipation, for example, he may fear that he has a bowel blockage, similar to one of his patients on the ward.. More experienced medical professionals may also bring above average anxiety to the office visit.  Physicians, after all, are members of...

Some time ago, a patient arrived to my office prepared to enjoy the joy of colonoscopy.  Many of the patients on my endoscopy schedule are scheduled by other physicians and gastroenterologists.   In other words, I meet many of them for the first time on their special day.   My task is simply to perform the procedure and to then refer them back to their medical professionals.   In general, the system works well as we have many checks to assure that there are no safety barriers to performing the requested procedure in an out-patient setting.   Even when I schedule a procedure on one of my own patients, my patient’s medical record will be reviewed in advance by another medical professional. While the system works well on the safety front, it is less effective on the medical necessity front.   When an endoscopy schedule is open to referring medical professionals, there will be instances when the medical necessity of the procedure is questionable.   T...

Is gluten really Public Enemy #1?   Many seem to regard it as a toxin. .   Restaurants and supermarkets offer a wide variety of gluten-free foods.   Years ago, physicians advised a gluten-free diet only for individuals who had celiac disease (CD), which is an autoimmune disease that largely affects the small intestine.    If a celiac patient wades back into Glutenland, his or her intestine will start an internal uprising.   I care for a few of these folks, but they are but a slim fraction of my patients who are shunning gluten.    Gluten are proteins contained in wheat and other grains.     Many adherents of a gluten-free diet believe that this is a more healthful dietary choice.   For most of them, there is no supportive evidence for this contention.    Why should it matter if an individual chooses to avoid gluten?   After all, there’s no risk here?   In fact, avoiding gluten can lead to vitamin deficiencies...

There are many forces driving utilization in health care.  Patients come to doctors for explanations and relief. They relate symptoms that will likely lead to diagnostic testing.  For example, if you tell your physician that you have a burning sensation when you urinate, it is likely that you will be asked to surrender an aliquot of your urine for analysis.  If you enter your doctor’s office with some difficulty breathing, fever and a cough, I’ll wager that there’s a chest x-ray just around the corner.  These diagnostic tests are appropriate. When does utilization morph into overutilization?   I don’t know where the threshold between them lies.   Moreover, doctors disagree amongst ourselves on what constitutes an unnecessary medical test. Doctors agree that there is too much testing and prescribing going on, but they tend to point their fingers toward their colleagues rather than toward themselves.   Think of politicians here.   It’s common for ...

Over the past several decades, I’ve earned a good portion of my living performing colonoscopies – tens of thousands of them.  And risking a charge of heresy, I’ll say out loud that patients deserve a better colon cancer screening experience.  Progress is just around the corner.  Here’s a list of negative aspects of the colonoscopy experience.  I’ve got some street cred here.  Although I am usually on the operator end of the scope, I’ve also personally experienced the light at the end of the tunnel. Pre-test anxiety over the outcome. Ingesting liquid dynamite – often in the middle of the night -  and praying for a complete cleanse. Time away from work. D-day!  Enjoy IV needle placement, repetitive interviews, posh medical garments and the dignity of a public airing of high-amplitude flatus. The procedure has risks of complications, albeit at a low rate of occurrence. Driver must be present. Post-test anxiety over pending biopsy results. High aggregate...

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....

 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, her...

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...

Over the past several years, there has been an important change in how diverticulitis is treated.  This topic sentence may seem out of place on this blog which is largely a site for commentary.  This is not a site that discusses medical breakthroughs on the treatment of constipation or heartburn.  But diverticulitis does offer a commentary angle, if you will read further. Decades of teaching and dogma have informed the medical profession that diverticulitis is a localized infection of the colon.   Diverticula, or pouches, are weak points in the large bowel.   If a tiny puncture develops at one of these sites, some stool can leak out contaminating the sterile abdominal cavity.   A n infection develops which, of course, needs to be treated with antibiotics. Indeed, for most of my medical career, every case of diverticulitis I encountered was treated with antibiotics.   In most cases, these patients recovered fully.   This observation may be Trut...

My great pal Lewis, with whom I have shared a friendship for over half a century, have much in common professionally.   Is he also a gastroenterologist?    A physician?   A nurse?   Actually, he is a tax attorney.   So, where’s the commonality?   Could it be that my patients and his adversaries both feel that they are being ‘instrumented’?    While I suspect that this may be true, it is a different aspect of our respective professions that binds us. Lewis’s clients and my patients need to grapple with and accept uncertainty.   I find the parallels here to be striking and I’ll do my best to illustrate. Legal Uncertainty The client brings an issue to his attorney seeking a legal remedy or an opinion.    Let us assume a corporation wants to know if a particular expense can be legally considered a tax deduction.   The experienced tax attorney responds, after careful thought and deliberation (yes, the time...

There are two ways to raise the quality level.  The old-fashioned way to work and study and practice and seek assistance and practice again and fail and regroup and ultimately objectively increase performance. Here are a few examples of this technique. A basketball player works with a coach and increases his foul shot success rate by 15%. A new medicine increases the cure rate of a disease by 40%. An engineering team invents a cell phone battery that has 5x the storage of current batteries. There is another way to increase quality ratings that has become quite common.  Lower the standards or game the system.  Here are some examples to illustrate. Lower academic standards in order to increase a high school's can graduation rate. Lower the income threshold of poverty so we can boast that there are fewer impoverished people in our communities. A surgeon's outcome stats rise markedly when he declines to accept very ill patients. So, if you are trying to improv...

In 1990, Desert Storm was initiated by President George H.W. Bush, along with coalition partners to reverse Saddam Hussein’s aggression with respect to Kuwait.   As American and allied forces moved into Iraq, many hawks wanted these forces to advance to Baghdad, and drive out Saddam Hussein.   As we all know, President Bush pulled us out as he did not feel this objective was part of the mission.   He knew when to get out. Now, physicians are not military strategists, but there are parallels between military strategy and patient care, particularly when a patient is hospitalized.   Consider the following schema.   The Conflict:   A patient arrives in the emergency room with a cough and a fever.   The Mission: Disease eradication The Tactics:   Hospitalization Exit Strategy:   Getting the patient out. Physicians, just like the generals in the Situation Room in the White House, need a sound battle plan.   The plan must be...

Doctors make mistakes.  There, I’ve said it.  More than having said it, I wrote it.  This confession has now been memorialized in cyberspace, where no piece of data can ever be truly deleted.  We have all seen how seemingly erased data has been resurrected by forensic experts to the horror and dismay of the eraser wannabees. Doctors work on seriously ill patients.  They do their best to help heal them; or when this is not possible, to comfort them.  Some patients get worse under our care.  Some die.  This sober slice of the human condition impacts deeply on physicians and all health care professionals. I acknowledge that medical errors have worsened patients’ condition or have even contributed or caused their demise, a tragic but unavoidable result of a noble endeavor that is imperfect.  I remind readers that physicians are members of the human species and have all of the flaws and frailties that every other homo sapiens creature pos...

Colonoscopy became ‘breaking news’ about a week ago.  The preeminent medical journal, The New England Journal of Medicine (NEJM) published a randomized trial assessing the effectiveness of screening colonoscopy in reducing the risk of contracting colon cancer and dying from it.  The results were lackluster. While there is accumulated evidence that colonoscopy can reduce colon cancer risk, the bulk of this data has not been the results of randomized controlled trials, the gold standard in medical research.    In the NEJM study, there was a group who was offered a screening colonoscopy and a separate control group who was not. Gastroenterologists, along with the medical community at large, have been preaching the lifesaving benefits of screening colonoscopy for decades.   The simple strategy is to remove ‘pre-cancerous’ polyps that are lurking silently in the colon and to remove them before they have an opportunity to transform into cancer.   What makes c...