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Showing posts with the label Physician Quality

Do I Have a Rare Disease?

 There’s an adage known to every medical student, intern, resident, and practicing physician. When you hear hoofbeats behind you, don't expect to see a zebra. This quote has been paraphrased into several iterations, but the quote is credited to Dr. Thomas Woodward in 1940.   Dr. Woodward, a wise medical professor and Nobel Prize nominee, offered his advice to medical interns.   The aphorism has timeless value. The point is for physicians to exhaust common explanations when confronting medical clues before broadening the exercise to contemplate rare potential diagnoses.    It is more likely that hoofbeats are made by a common horse than a more exotic hoofed beast.   Get it? Let me offer a brilliant quote.   Common things occur commonly.   If a patient sees his physician to evaluate a fever, it’s unlikely that the doctor will entertain malaria as a diagnostic consideration, even though fever is a hallmark of malaria.   Seasoned clinicians will widen their diagnostic view when

How to Choose the Right Surgeon

Let me test my readers to gauge how skillful you have become in choosing wisely in the Byzantine medical universe.  You develop abdominal pain and, although you are not a trained medical professional, you fear that you have appendicitis.  There are two surgeons available and you want to engage in due diligence to ascertain which physician should be granted access to your abdomen.   A quick internet search uncovers the following data. Surgeon A:  Twenty patients had proven appendicitis.  This surgeon operated on all of the patients.  No case of appendicitis was missed.  Surgeon B: Twenty patients had proven appendicitis.  This surgeon chose to operate on 18 patients.  Two cases of appendicitis were missed.   Before reading on, think to yourself which surgeon would you choose? While this is not a trick question, I wonder how many readers were entrapped to select Surgeon A.  Who wouldn’t choose a surgeon with a 100% track record?  I wouldn’t.  I’d place my belly under the

When Should Your Doctor Refer for a Second Opinion?

As a gastroenterologist (GI), I am regarded by primary care physicians and other medical professional as having special expertise in digestive diseases.  Indeed, I have highly specialized training in digestive maladies and function.  I regard myself as a GI generalist, that is a practitioner who treats the full array of digestive conditions.  Over the past decades, I have treated patients with diseases of the small and large bowel, stomach, and esophagus issues and pancreatic liver and gallbladder disorders.  And I have had a full endoscopy practice – the tools of the GI trade.  One of the appeals of being a GI Gen is that I see a wide and diverse span of medical conditions.  In a single week, I may address heartburn and ulcers. Crohn’s disease, hepatitis, bowel changes, internal bleeding, nausea and vomiting, abdominal pain, and hemorrhoids.  I enjoy the variety.   GI Generalists Cover a Lot of Ground! During most of my career, I seldom referred patients to other gastroenterologists

What do Medical Consultants Do?

I am a gastroenterologist.  Like most medical specialists, most of the patients I see are referred to me by other medical professionals.  In this role, I am serving as a consultant.  Similarly, when a specialist is asked to see a hospitalized patient by the attending physician, the requested doctor will be serving in a consultant role. Consultants are recruited when the medical team or an individual practitioner feels that additional knowledge and experience is necessary.   Consider three hypothetical scenarios. A patient has not responded to a standard course of antibiotics.   The attending physician asks an infectious disease physician to make recommendations. A primary care physician is uncertain if the abnormal chest x-ray is heart failure or pneumonia.   The doctor calls in a cardiologist to assist. A patient with colitis comes to an emergency room with worsening diarrhea after starting a new medicine.   The ER physician is uncertain if the patient’s diarrhea is a side-eff

Should Doctors be ACLS Certified?

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

Measuring Colonoscopy Quality: Who Should Do My Procedure?

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

How to Read a Chest X-ray

To succeed is to struggle.  Indeed, up to now, an accomplishment was the result of sweat, study, setbacks, discipline, collaboration and hopefully triumph.   Of course, the latter result is never guaranteed which makes this outcome so much more satisfying.  This process of struggling for success is well known to athletes, musicians, scientists, students, writers, chefs, farmers and many others.  All of us go through the same process in more mundane pursuits such as doing a crossword puzzle, learning a new language, testing out a new recipe or reaching a new goal in our exercise routine. I recall a very small personal struggle I engaged with during my internship and residency days decades ago.   Every patient that physicians-in-training cared for had x-ray studies done.   Checking the results was one of the myriad tasks that fell to interns and medical residents.   Not only was this important medical data, but we wanted to be prepared with the result just in case any of our superiors

Is Anesthesia for Colonoscopy Safe?

Sometimes, we read about a study result that is widely publicized, yet we are reluctant to accept its absurd conclusions.   I’m sure there are studies buried somewhere that conclude that seat belts and bicycle helmets are dangerous and that cigarettes prolong life.   If such studies do exist, they would face mountains of contrary scientific evidence.  In other examples, a medical study’s conclusions may be false or misleading because the data are improperly or inadequately interpreted.   Consider this hypothetical study.  One hundred patients with rheumatoid arthritis (RA) patients and 100 control patients are questioned about their exercise habits.  Ten percent of RA patients exercise regularly in comparison to 40% of the control group.   The authors than conclude that exercise might protect against the development of RA.  There are many scientific reasons why this conclusion is erroneous including the probability that RA patients don’t exercise as much because they have arthritis. 

Is My Doctor Too Old?

I am regularly asked by patients and others at what age should colonoscopies end.  Some patients inquire hoping that they are one year beyond the limit! Other physicians face similar inquiries with regard to Pap smears, mammograms and other routine preventive tests.   Turning the tables, I have even read opinion pieces asking if there should be a retirement age for physicians.   Commercial pilots have an upper age limit of age 65.   Should an octogenarian surgeon be allowed to operate on patients?   Federal judges have lifetime appointments.   Is the public well served by this?    There are at least two sides to this lifetime appointment policy. Some argue for aging out folks in order to rejuvenate the ranks.   This makes sense.   Others argue that any individual who is competent should be permitted to continue working regardless of age.   Why should we jettison folks with decades of valuable experience just because a certain age has been reached?   The issue becomes sticky whe

What Makes A Good Doctor? The Answer Might Surprise You.

Many physicians understandably pride themselves on special skills or knowledge that they have acquired.  This is true of so many professions.  A lawyer is admired for her skill in the trial arena.  A musician is lionized for his virtuosic technique.  An athlete inspires his peers and the rest of us with his record-breaking accomplishments. We have all heard of physicians who are renown for particular talents.    You need an operation on the pancreas?   Here’s the guy you should see.   Your Crohn’s disease is not responding? You should see my specialist who saved me from surgery! Your fibromyalgia is on fire?   Have you heard of this new doctor in town who runs a fibromyalgia clinic?   Obviously, a physician’s skill set is a critical asset in the practice of medicine.   Indeed, when a patient sees me, he comes with the belief that I have the training and experience to address his concerns. Usually I do, but not always.   It is very important for physicians to know which patients sho

Reforming Medical Education

Medical school, residency and specialty fellowship cannot prepare physicians for every eventuality.   Many important skills must be acquired on the job.   And, of course, physicians need to remain current with respect to cognitive and procedural advancements.   Here are just few critical subjects that I was not prepared for when I entered the healing profession. What happened to my phone medicine lectures? Phone medicine.   Treating a patient with abdominal pain at night on the phone requires different skills than when the patient is in my exam room. And, te phone call may be the first time I have ever spoken to this patient. Breaking bad news to patients and their families.  Wouldn’t you think that we would have received training for such a critical skill? Nutrition.  Patients are understandably amazed at my paucity of nutritional knowledge.  I suspect that most gastroenterologists can make the same claim.  Wouldn't you think that nutrition science would be part of a

Is the Physical Examination Still Useful?

Medical students, please read no further. I am going to challenge one of the bedrock beliefs in medical training – the value of the physical examination.   Indeed, I was taught of the primacy of the physical exam as a young pup during my 4 years of medical education in New York City.   I believed it and did my best to acquire these skills from master diagnosticians.   Indeed, this was one of the thrills of being a medical student – learning what those clicks and clacks meant when we listened to hearts with our stethoscopes, seeing changes of diabetes and other diseases when we peered into your eyes with an ophthalmoscope or palpating a pulsating aneurysm that was lurking in your abdomen. An Ophthalmoscope and Otoscope The Eyes and Ears of Medicine I was in awe of these seasoned physicians who could make a diagnosis just by watching a patient walk across the room. While I still think the physical examination is useful, I have found over the years that it is less valuab

Changing Physician Behavior - A Difficult Challenge

How many actions do we take in our lives simply because this is how we and others have always done them?    In these instances, shouldn’t we at least pose the question if there might be a superior alternative?    I admire innovators who view the world through a prism that aims to shake up and disrupt the status quo.   You know who I mean; the folks who hear the music in between the notes.   Medicine is riddled with practices that have remained in place for decades and are, therefore, hard to change.   Acute appendicitis is treated with surgery.   Why aren’t antibiotics an option here as they are for other similar infections in the large intestine? Diverticulitis has been treated for decades with antibiotics?   Only recently, have experts wondered if this treatment should be reexamined. For a generation, children with red eardrums received antibiotics presuming that this was a bacterial infection.    Ultimately, a skeptic started asking questions, and most of these kids are no

Is My New Doctor Qualified?

When one applies for a job or a position, it is expected that the interviewer will assess if the applicant has the necessary skill set and experience. Doesn’t this make sense?  Consider these examples. A clarinetist applies for a position in a symphony orchestra.   While many criteria will be assessed, he will surely need to audition to demonstrate his musicianship.   Would he ever be hired without playing a note? A college student wants to join the swim team.   The applicant can expect to show off her speed and technique as she cuts across the pool.   Would any coach accept a new swim team member without watching her swim? A journalist for a town paper applies for a job at a large metropolitan newspaper.   The interviewing editor will surely review the applicant’s prior work product to gauge his competence and suitability for the new position.   Would an editor bring on a new reporter without ever reviewing his writings? A college graduates applies to the State Department as a

Can Sherlock Holmes Teach Today's Doctors?

To Sherlock Holmes, she is always the woman.    Thus begins Conan Doyle’s, A Scandal in Bohemia published in 1891.   In this gripping tale, Holmes is bested by a woman who proves to be the detective’s equal in intelligence and deception.   For reasons I cannot explain, I restrict my exposure to Holmes and Dr. Watson to podcast listening when I am airborne.  Years ago, I did love watching the classic movies starring Basil Rathbone and Nigel Bruce who defined the roles for me.  Conan Doyle, a physician, was a superb story teller, who wove his tales with texture, plot and humanity.  I think he wields words with surgical precision.   I admire his skill. I wonder to what extent Conan Doyle’s medical training influenced his writing?  Certainly, the stories often discuss arcane medical conditions that provide the detective with important clues.  In The Adventure of the Blanched Soldier, Holmes suspects that the protagonist is suffering from leprosy, a diagnosis that is revised af

Can Doctors Help You Lose Weight?

As a gastroenterologist -a trained specialist in digestive issues - I should have expertise in obesity, nutrition and weight loss strategies.  I really don’t.  While I have knowledge on these issues that likely exceeds that of most of my patients, I received inadequate formal training on these subjects during my gastroenterology training.   It is inarguable that digestive doctors – and indeed all physicians – should bring a high level of expertise on these medical issues into their exam rooms.  The impact of obesity reaches nearly every medical specialty.   Obesity is linked to heart disease, stroke, cancer, arthritis, diabetes, sleep apnea, high blood pressure and many other illnesses.  Most of my overweight patients tend to remain so.  Many of them are simply resigned to a shape and size that they feel they cannot alter.   Some are not motivated to engage in the hard work and long journey that can lead to a leaner dimension.  Some do not recognize that successful weight loss req

Can Doctors Still Examine Patients?

Does your doctor really know how to use a stethoscope or palpate your abdomen? Today’s physicians do not have the physical exam skills that our predecessors did.   We can argue if this truth has diminished medical quality – I’m not sure that it has.   But it has completely changed how medicine today is practiced.   The reason for declining physician exam skills is that technology has largely supplanted physicians’ hands, eyes and ears.   In the olden days, the stethoscope was the diagnostic tool for examining hearts.   I spent a month as a medical student with a legendary cardiologist who could make all kinds of cardiac diagnoses right at the bedside using 2 advanced medical instruments known as ears.   Surgeons and gastroenterologists in years past had to make   diagnoses of acute appendicitis and other abdominal emergencies based on feel and their ‘gut’.   Neurologists made accurate diagnoses of stroke just using their clinical skills. An Advanced Medical Instrument

What Makes a Good Doctor. You Be The Judge

I’ve delved into the issue of medical judgment more than once on this blog.  I have argued that sound judgment is more important than medical knowledge.  If one has a knowledge deficit, assuming he is aware of this, it is easily remedied.  A judgment deficiency, per contra, is more difficult to fix.  Who doesn’t think he has good judgment? For example, if a physician cannot recall if generalized itchiness can be a sign of serious liver disease, he can look this up.  If, however, a doctor is deciding if surgery for a patient is necessary, and when the operation should occur, this is not as easily determined.  Medical judgment is a murky issue and often creates controversies in patient care.  Competent physicians who are presented with the same set of medical facts may offer divergent recommendations because they judge the situation differently.  Each of their recommendations may be rationale and defensible, which can be bewildering for patients and their families.  This is one of t

Do You Really Need Plastic Surgery?

We live in an era where plastic surgery is routine.   Indeed, in many parts of the country, plastic surgery is an expected rite of passage.   Years ago, face lifts and ‘tummy tucks’ were done on those in middle age who were trying to experience a surgical time machine.  Now, folks in their 20’s are having all kinds of work done, not to recreate a prior image, but to create a new one. The traditional scalpel in only one of many tools used to perform body design work.  There is a smorgasbord of injectable fillers that plastic surgeons, dermatologists and other physicians provide to a public who is zealously combating every wrinkle.  Once a person is of the mindset that the only good wrinkle is a dead wrinkle, he will commit himself to a lifelong odyssey of cosmetic work.  These folks are generally never fully satisfied with how they look.  They are always finding imperfections that they target for correction. I enthusiastically recommend readers to read Nathaniel Hawthorne’s short

Physicians and the Art and Power of Observation - Has This Bird Flown?

Medicine is for the birds, or it should be.  Hear me out. A day before I wrote this, I was on the trail in northwest Ohio, binoculars in hand, trying to tell one warbler from another.  This was the final weekend of The Biggest Week of birding in Magee Marsh on the shore of Lake Erie.  Birders converged here from neighboring states and even from foreign countries to participate in this ornithological adventure.  My companion and I were new to the game.  Indeed, my birdwatching prowess had consisted of being able to successfully identify a blue jay at the feeder on our deck.  I had now entered a different universe. There were serious birders afoot equipped with photographic and telegraphic equipment that looked like stuff that James Bond might have used.  Birds flitted about that heretofore would have generated no interest on my part.  When a rare warbler was spotted, the excitement raced through the birders like a brushfire, causing a crowd to gather to view the feathered pheno