MD Whistleblower

I find that the public often exaggerates the benefits of many preventive health measures.   I don’t blame the public for this.   There are several forces conspiring to deceive the average patient into accepting exaggerated claims of various medical tests and strategies.    Of course, the Medical Industrial Complex is a gluttonous beast that must be fed massive quantities of medical testing and treatment if it is to survive. Most of the public thinks that medical interventions, including mammography, lowering cholesterol levels, blood pressure reduction and even colonoscopy are downright lifesaving. Recognize that I am in favor of all of these measures, but that the actual benefit to the individual is much smaller than most folks believe.   In the case of mammography, there is uncertainty as to whether it saves lives at all, a view readers can easily find with a rudimentary internet search.   Mammography experts all agree that any benefit of this screening test to the individu

Readers know how strongly I feel that my profession is suffering from the twin chronic diseases of Overdiagnosis and Overtreatment.  Here's a primer on how physicians make medical recommendations to our patients. Take a look at this grid I prepared, which is worth a full year of medical school.                                     Low Benefit                    High Benefit Low Risk                                                            Medical Sweet Spot!                                  ________________________________________                         High Risk                  DANGER ZONE! When we physicians are contemplating a treatment, or are weighing one treatment against another, we are aiming for the Medical   Sweet Spot highlighted in blue above.   We want low risk and high reward for our patients.    Would we ever consider a treatment within the DANGER ZONE ?   We would if the patient’s medical circumstance were dire and there were n

Our practice will no longer see nursing home patients in our office.  If a nursing home patient is already established with us, then we will see him; but, we have decided not to accept new patients. Of course, we believe that these individuals – like the rest of us – deserve medical care.  This demographic not only deserves care, but has the greatest need for medical services.  Our practice will see every person who wants to see us, including the uninsured.  Why, then, would a welcoming practice like ours close our door to new nursing home patients?  We just couldn’t take it anymore. These patients, who often have serious physical and mental challenges, would typically arrive to our office accompanied by a driver, who naturally has no medical knowledge.  The patient often had no awareness of the reason for the visit.  The ‘medical record’ consisted of a nearly indecipherable list of medications of uncertain accuracy.  Typically, no reason for the visit was documented, or ther

We do most of our colonoscopies in our ambulatory surgery center (ASC), which is attached to our office.  We are proud of the work that we and our staff do every day and are grateful for the outstanding feedback that we consistently receive from our patients.  Some insurance companies will not cover procedures in our ASC so these patients must get ‘scoped’ at the hospital instead.  For many of them, this means required blood tests a few days in advance of the procedure, which we would not have required for an ASC procedure.   On the procedure day, the patient and the driver will enjoy spending hours in the hospital for parking, checking in, interviews with various medical personnel, the procedure and the recovery period.  And, since it is a hospital, delays are inevitable.  Not only does this experience take hours longer than it should, but we are mystified that an insurance company would take on the expense for a hospital test that we could do more efficiently and cheaper in our ASC.

Yesterday, a physician asked my opinion if a patient needed a colonoscopy.  My partner was already on the case and I was covering over the weekend.  The facts suggested that a colonoscopy was warranted.  The patient had a low blood count and had received blood transfusions.  Certainly, a bleeding site in the colon, such as a cancer, might be responsible.  We do colonoscopies to address similar circumstances on a regular basis.  Why did my partner and I demur in this case? We Placed this Sign on the Patient Because to us, our medical judgment trumped the medical facts.  First, the patient was elderly and extremely debilitated.  The challenge of having an individual in her state ingest the necessary laxatives is likely insurmountable.  If any readers have enjoyed the delight of guzzling down a colonoscopy prep, contemplate doing so as an elderly, ailing and bedbound individual. I asked the physician if the patient’s family would consent to surgery if a cancer was found.

I read about artificial intelligence software that can rival high school juniors armed with #2 pencils.  The program attacked SAT math questions and performed at the level of a typical 11 th grader.  The study was too complex for me to grasp. I guess I should ask an 11th grader for assistance.  Artificial intelligence is well beyond conventional computational exercises. It can ‘think’. Man vs Machine Increasingly, we see functions executed by machines that were formerly performed by living breathing human beings.  Examples range from the mundane to the preternatural.  Order food and drink from an iPad.  No server needed. Driverless auto travel.   This may lead to a resurgence in prayer. Pilotless air travel.  Hard times ahead for the Airline Pilots Association.  Making precision tools – from 3D printers. Gourmet meals created with a voice activated command. Theater and film productions starring faux actors created on keyboards. Will artificial intelligence i

Until last week, colon cancer screening for most folks started at age 50.  Why 50?   Why hadn’t the colonoscopy coming of age been set younger to prevent the tragedy of a 45-year-old, or an even younger person, developing colon cancer?   In the past 2 weeks, I had to give a young patient and his wife the sad and serious news that he had colon cancer.  Because of his young age, he never received a screening colon exam, as we routinely do with 50-year-old individuals.  Is it time to make an adjustment? Our colon cancer screening system is not perfect.   It is not designed to prevent every case.   There have been people in their 20’s who have been diagnosed with this disease, and there is simply no way to capture them in the system.   Experts in disease prevention must carefully analyze disease trends and behavior to find the sweet spot of when to begin screening.   And, money is part of this decision.   Let’s face it.   We don’t have unlimited resources to pay for every worthy me

‘I can’t stand the site of blood!’  We’ve all heard that adage.   Blood can provoke emotional reactions from even steely muscle-bound bodybuilders.  We gastroenterologists routinely receive fearful phone calls from patients who have observed even minor rectal bleeding.  Fortunately, in most of these cases, there is a benign explanation for the sanguinary seepage. If blood repels you, then gastroenterology should not be on your short, or even long list of professions under consideration.  We confront blood every day.  Of course, blood is the elixir of life as it courses into every remote recess of our bodies.  But, when blood loses its bearings, takes a wrong turn, and emerges errantly from our gastrointestinal tract, then gastroenterologists - or G-men -are called in.   Indeed, searching out the site of blood leakage in patients is one of our primary diagnostic tasks.  You might say that blood is our ‘bread & butter’. I recently evaluated a patient in my office that confounded

Let me post a question that neither I nor readers can answer. How much of what I do during the course of a day directly benefits patients? Perhaps, I don’t want to really know as I would be dismayed at how much of my effort benefits no one. Ask a nurse who works on a hospital ward, how much of his or her effort is directly applied to patient care.  I would recommend that you have a double dose of antacid in hand – one dose for you and the other for the nurse.  Just today, I was gently reproved by a hospital physician administrator for a lapse in one of my recent progress notes, which I write after seeing every hospital patient I consult on.  Which of the following transgressions do you think I was cited for?  Only one answer is correct. I did not perform an adequate physical examination I failed to address the results of an abnormal CAT scan I neglected to write the time of day along with the date of the note. I did not discuss the case with the patient’s family.

If any reader has heard of C. difficile, affectionately known as C. diff, than I presume you have had closer contact with this germ than you would have liked.  It’s an infection of the colon that can be serious, or even fatal.  There isn’t a hospital in the country that isn’t battling against the infection.   We are not winning the war against this crafty and cunning adversary.  We Need Better Weapons Against C. diff While the infection is not new, the strength and seriousness of current strains of the germ have tilted the odds against doctors and our patients.  The infection usually is a ‘side-effect’ of antibiotic treatment, but it can also be contracted from infected surfaces and people that reside in hospitals and extended care facilities and nursing homes.  For example, nowadays a patient can be admitted to a hospital and pick up the germ from hospital personnel who are contaminated from contact with an actual C. diff patient.  For this reason, C diff patients are k

Knowledge is power.  Increasingly, patients are demanding and receiving access to levers in the medical machine that would have been unthinkable a generation ago.  I have already opined on this blog whether the informed consent process, which I support, can overwhelm ordinary patients and families with conflicting and bewildering options.  Television and the airwaves routinely advertise prescription drugs directly to the public.  Consider the strategy of direct-to-consumer drug marketing when millions of dollars are spent advertising a drug that viewers are not permitted to purchase themselves.  The public can now with a few clicks on a laptop, research individual physicians and hospitals to compare them to competitors.  The ‘Sunshine Act’, an Obamacare feature, publicizes payments to physicians and hospitals by pharmaceutical companies and other manufacturers. "Sunlight is said to be the best disinfectant" Every physician today has the experience of patients comi

Would you have elective surgery in the nearby major teaching institution on July 4 th ? Why not, you wonder? Prowling around the hospital wards every July are the fresh faced interns wearing starched white coats, with stethoscopes draped across their shoulders, with pockets stuffed with reflex hammers, K-Y jelly, and various cheat sheets to rescue ailing patients. These guys know nothing.  How do I know this?  I was one of them.  Luckily, I knew that I was clueless and never pretended that I could treat athlete’s foot or even a splinter. Imagine you are in a hospital bed in early summer complaining of chest discomfort.  Your nurse summons the intern who speeds into your room peppering you with questions.  Before you finish your answer to a question, another question erupts.  This physician is barely out of his shrink wrap and is understandably anxious that he is witnessing an impending cardiac catastrophe.   With his spanking new stethoscope, he establishes that there is a

Some issues do not need to be studied.   For example, would we expect the National Institutes of Health to fund a study to determine if drivers wearing blindfolds have better outcomes?   In the past few weeks, the National Football League (NFL) has conceded that head trauma is linked to chronic traumatic encephalopathy (CTE), a fancy term that means brain damage.  Of course, there have been multiple studies that have examined this question.  And, in a nod to the tobacco companies, the NFL for too long failed to admit what any school child could have deduced.  Smashing your head several hundreds of times against the ground or another helmeted gladiator does not promote good brain health.  Sometimes industries will cite their own ‘studies’ that astonishingly contradict what our intuition and common sense tell us should be true.  Would we accept the results, for example, of a movie industry  ‘study’ that extolled the health benefits of popcorn? Sometimes, in medicine, we need a s

I am known by my patients and friends for my calm, imperturbable manner.  Yes, I am equipped with the full range of human emotions, but few folks have ever seen me raise my voice or demonstrate bulging next veins.  I am not suggesting this is a virtue or a character flaw, but is just the way I am wired. Sure, I get irritated and frustrated with the absurdities of life, as we all do.   For those who cannot relate here, may I suggest calling any airline carrier to discuss changing your ticket reservation.  If that fails,  then have a go at reaching out for tech support when your home internet goes ‘poof’! Last week, I did become irritated when I was notified one evening about a patient’s abnormal blood test result.  I was on-call for our gastroenterology group, so I would be the designated physician to notify with concerning test results.  Why, then, was I miffed? Our community hospital uses a ‘new and improved’ system for notifying physicians after hours of significantly abn

Over the years, I have heard families bemoan that their relative who was just readmitted to the hospital was sent home too early just a few days ago.   Are they right? Was Gramps Kicked Out Too Soon? First, let me say that in some instances they may be correct.  It is certainly possible that the hospital, under increased pressure to kick folks out, may have pulled the discharge trigger too soon.  The hospital is not always right even if their ‘discharge check list’ seemed to be in order.  Of course, patients are not adequately represented by a check list any more than physicians’ quality can be fairly measured in the check off, cook book method that the government and insurance companies are now championing. The hospital discharge check list may indicate that a patient with pneumonia can be safely discharged home as she has no fever or need for supplemental oxygen.  However, this patient may be 89 years old, riddled with arthritis and needs to attend to a spouse sufferin

Most of us are familiar with the concept of medical guidelines.  These are sets of criteria that are supposed to ‘guide’ physicians facing certain medical circumstances. As physicians know, and often lament, guidelines over time morph to become mandates.  Even though by definition, a guideline is voluntary, many hospital oversight committees and insurance companies require physicians who deviate from guidelines to explain their actions. The U.S Preventive Services Task Force guideline states that folks 75 and older should not receive screening colonoscopies.  The  reason is that medical studies have demonstrated that the benefits of colon cancer screening in this age group is not justified by the risk and expense of the effort.  Of course, there is an age when colonoscopy does not make sense, but I’m just not sure what this magic number is. Too Old for a Colonoscopy? Consider these two hypothetical patients. (1)   A 78 year old man in excellent health has never had a scre

We all should know the difference between a slogan and real substance.   One of these has size and shape while the other is just a shadow.   Why then, is the slogan so powerful? A slogan is one of the weapons wielded by the Guardians of Political Correctness.  They will point toward the slogan du jour, and then, with cameras rolling, demand to know if you support it.  Even a moment’s hesitancy will be taken as weakness.   Expect to see your waffling go viral for all to see, edited down and sans context.  Politicians Advised to Avoid Waffles. During a presidential election, this practice is omnipresent.  Mr. Bush, do you support fair trade ? Mrs. Clinton, is your immigration policy to give amnesty to all illegal aliens? Mr. Cruz, do you believe in the rule of law ? These questions cannot be adequately answered with a reflexive yes or no.   The slogans contained within these 'gotcha' questions point to complex and nuanced issues that need layered responses. 

Profiling in this country is highly discouraged and is illegal in many circumstances.  Anti-profilers decry this technique which, they argue, unfairly targets innocent individuals violating their rights.  Our beloved Transportation Security Administration, or TSA, is charged not to use profiling as a screening tool.  Personally, I object to this prohibtion.  While an individual’s rights are important, it must be weighed against the rights of the community.  Our cherished rights to free speech and assembly are not absolute. I have flown on El Al airlines, whose personnel actively profile in an effort to keep its passengers safe.  Anyone who has been a passenger on this airline will likely agree with me that he has never felt safer on an airplane.  I have a right not be blown up, and if profiling further minimizes this risk, then call me a fan. Last year, my mother, who appears as threatening as a school librarian, was patted down twice when she traveled to visit me in Cleveland. 

Practicing physicians like me rely on scientific medical journals to keep us current on medical developments.  We learn about new treatments for old diseases.  New diagnostic tests are presented as alternatives to existing methods.   Established treatments, which are regarded as dogma, may be shown to be less effective or less safe than originally believed. It’s a confusing intellectual morass to sort among complex and conflicting studies some of which reach opposite conclusions in the same medical journal.  What’s a practicing physician to do? While the medical journals that physicians read are fundamental to our education, paradoxically most physicians have only rudimentary training in properly analyzing and assessing these studies.  For example, the quality of medical studies often depends upon statistical analysis, a mathematical field that is foreign to most practicing physicians.   Doctors like me hope that our peer-reviewed journal editors have done their due diligence

I just deposited a check into my bank account by photographing the check with my iPhone and zapping it through cyberspace.  I realize this is a yawn to the under 35 crowd.  Soon, there won’t be any paper checks as the entire transaction will occur electronically.  As a member of the over 35 crowd (plus 20 years), I am wowed by this process.  I remember being astonished when my kids told me how they performed this same process a year ago.   It’s the same amazement I experienced when I first read about a new piece of technology called a ‘fax machine’. "You mean you slide a document into a machine and an exact copy emerges elsewhere?" In my younger days, depositing a check into a bank account meant waiting in line with my bank book in hand waiting for a living, breathing human to count and record my allowance and snow shoveling earnings.   The bank that my kids use today has no physical offices.  It is entirely in the Twilight Zone. Medicine will not be left behind her