MD Whistleblower

Patients understandably focus on who will be managing the scope during their procedure.  They expect that the proceduralist – a physician, at least so far – is a highly skilled practitioner.  They want accuracy and safety.  Indeed, from time to time, after I have reviewed the risks of colonoscopy, a patient will query me directly on my complication rate, particularly with regard to the dreaded event of a bowel puncture.  They are hoping to hear, of course, that I have never had a procedural misadventure, but I point out that the only gastroenterologists who haven’t been involved in a complication are new specialists who are just starting out.  This is a mathematical issue.  If the perforation rate is 1/2500 cases, and the GI physician has performed 20,000 procedures, then there will have been some adverse events. As an aside,  the term complication does not imply culpability.  They are blameless events that occur at low frequency despite the med...

After a few decades of medical practice, I am increasingly humbled by how much I do not know.  In some ways, I felt more confident just after completing my training in internal medicine and gastroenterology (GI) than I do now.  While some aspects of the profession have remained unchanged, such as the value of taking an accurate medical history from patients, other aspects of medicine have morphed into a more expansive and complex landscape.  Compared to yesteryear, the array of diagnostic tests and medications has truly exploded.  It has been a great challenge to remain current in my own specialty of GI, particularly since I am a GI generalist who has seen a very broad range of digestive conditions.   Nowadays, there are more and more drugs to become familiar with and more complex disease monitoring and treatment strategies to know.   It is incumbent on those who advocate a new treatment to demonstrate that actual human patients will benefit.   While...

Some time ago, a patient was sent to me for a scope test.  This is hardly a newsworthy event since I do thousands of scope exams every year.  This patient had a known, benign narrowing at the lower portion of the esophagus, which is called a ring.  Years ago, another gastroenterologist stretched the ring which had been catching food on the way down.  My assigned task was to examine the ring and determine if a stretching was necessary.   This introduction of this case is the set up for the point I wish to make.   Too often, medical decisions are based on objective data without sufficient consideration of the patient.   Consider a few hypothetical examples. An MRI of the back shows disc protrusions in the lumbar spine.   A surgeon reviews the study with the patient and explains the rationale for surgery.   However, a detailed review of the patient’s symptoms suggests that the back pain may not be caused by disc protrusion at all.   I...

Gallbladder removal, known as cholecystectomy, is one of the most common surgical procedures performed.  Over a million Americans will give up their gallbladders this year.  The most common gallbladder symptom is abdominal pain which is usually caused by gallstones.  There are other reasons that gallbladders are removed which I will leave aside in this post. It’s very gratifying for physicians when a patient enjoys a pain free life after gallbladder removal.  However, every gastroenterologist and general surgeon has seen patients whose abdominal pain lives on after cholecystectomy.  This is a frustrating scenario primarily for patients but also for the medical professionals.  Some of these disappointed patients had consulted with numerous physicians for advice on their abdominal pain.  Did all of these physicians mess up?  How could this happen? Of course, physician error can never be excluded since we doctors, like everyone, are flawed member...

Five years ago, I left hospital wards and emergency rooms behind and entered a new & improved medical practice model, at least for me.  Since then, I only see patients for office consultations and procedures.  Office medicine is a very different trade than hospital practice each having very distinct skill sets.  If I were to return to the hospital now to see patients, it would be uncomfortable for me (and them) having not used these skills for years.  Similarly, hospital-based doctors might find transitioning to an office practice to be clumsy and uncomfortable. While it might seem that a gastroenterologist or any medical specialist should be able to see patients in any location, this is not the case for most of us.   Hospital medical issues are quite different from office medical complaints.   Physicians, as in so many other occupations, need repetition in order to maintain high competency levels.   There’s a reason, for example, that airline pi...

As readers know, the unifying theme of this blog is medical quality.  Indeed, the role of a whistleblower should be to raise the performance level of a profession or organization.  One need only scan this blog's category list for evidence of the blog's purpose.  Feel free to sample a post or two. The medical procedure that is fundamental to the practice of gastroenterology is colonoscopy.  I have performed north of 50,000 of these procedures on some very lucky inhabitants of northeast Ohio.  This will be my professional legacy, not quite a true gift to humanity such as music, art or literature.  I’ve been in practice long enough that there are patients whom I’ve performed more than 10 colonoscopies on.  Patients prefer to remain with a doctor whom they are comfortable with.  Long term relationships with patients is one of the joys of medicine. I also routinely perform colonoscopies on patients whom I have not met previously.  They are ref...

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 occasional instances when 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 ...

 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 clinicia...

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...

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 as well as 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 r...

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 th...

Since I started practicing medicine a few decades ago, I have been recertified every 2 years for Advanced Cardiac Life Support (ACLS).   Readers might expect that all medical professional receive this training so that they are locked and loaded if an emergency arises.  Let me share a little secret with you.  If a situation develops that requires a true ACLS response, then I'm not your guy.  I barely have 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 like me should be ACLS certified.   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...

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 procedura...

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 re...

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 pat...

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 ...

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 ...

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 n...

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 ...