MD Whistleblower

In the medical world, when a physician, a scientist, a hospital, a drug company or a panel of experts issues a report, the games begin.  If one agrees with the statement or benefits from it, then the report is heralded as breakthrough brilliance.  If, however, the report suggests a new medical pathway that diminishes your relevance or reimbursement, then the report and its authors are regarded as misguided.  Yes, I am generalizing somewhat here, but you get the point. As readers of this blog know, I am a conservative medical practitioner.  I do not mean conservative as in supporting the NRA, prayer in public schools, self-deportation of illegal aliens (or should I say ‘undocumented residents?), ‘clean coal’ and lower taxes for millionaires and billionaires.  Conservative physicians describe those who are extremely judicious with regard to medical treatment and diagnostic testing.  We don’t lurch to treat or test unless a high threshold of necessity and effectiveness is crossed. 

                                                                                       Obamacare has promised to provide all of us with quality medical care that is affordable and accessible.  The very name of the law is the Affordable Care Act, which I have maintained will be short on both affordability and quality care.  Most of the country agrees with me.  The postponement for a year of the  corporate mandate to provide insurance in businesses with at least 50 full time employees was a great relief to these businesses and to Democrats across the country who were shivering from fear that voters would hold them accountable in 2014 when the country witnessed the debacle.  Was this solely a policy decision independent of politics?  I won’t insult readers’ intelligence by weighing in here. Mandate Postponed from Electoral Anxiety? How will the Obama and insurance company vanguards of bureaucrats ensure quality?  They will measure of bunch of silly stuff that is easy to m

I’ve never logged onto Angie’s List, but I might be on it.  Physicians are now routinely rated on various internet sites that the public can view before making appointments, or just as a parlor game.  You can look up doctors just as you would check ratings on toaster ovens, snow blowers, cars and restaurants. Are these sites truly useful? Can a grading site inform the public about a physician’s medical quality? Can a visitor to the site be confident that the view expressed is true and objective? I’m skeptical. Easier to rate a fridge than a doc I’ve thought deeply on the issue of medical quality since I was a medical intern in 1985.  Indeed, it was my preoccupation with this subject that led to the birth of this blog years ago.  Review the blog’s categories at the right of your screen and note how many labels include the term ‘quality’.   A recurrent theme here is how difficult it is to measure medical quality, even for medical insiders who know the blood and

Saint George slaying the dragon. Bernat Mortorell, 15th century I’m sending a patient downtown to see a pancreatic expert.   He’s a young man who didn’t fully appreciate the health risks of a former alcohol addiction.  He’s been sober for well over a year, but alcohol toxicity can be unforgiving and permanent.   We don’t fully understand why some alcoholics develop cirrhosis and other complications while others seem to skate by without a scratch.  While I want folks who have the strength to conquer addictions to regain lost health and opportunities, many life choices lead to irreversible consequences.   Life is often an unfair mystery.  We witness this in medicine often.  Some smokers live well into their 80s, while others become tethered to oxygen tanks or contract cancer.   Trim athletes who eat seaweed salads seasoned with probiotics keel over while obese Whopper-swallowers wallow their way into old age.  My guy has chronic pancreatitis, a known consequence of alcohol ab

Before Michael Jackson, most folks didn’t know what propofol was.  Now, patients are asking me for it by name.  It’s an awesome drug.  It provides a beautiful sedation, is extremely safe and rapidly clears after the procedure.  Under its effects, colonoscopy has become a sublime experience.  We administer it in a different manner than Conrad Murray did.  For those who may have just awakened from a 5 year coma, Conrad Murray was Michael Jackson’s personal physician who administered propofol to Jackson in his home to promote sleep.  Murray succeeded and received the modest salary of $150,000 per month for his medical services. Sleep Aid? Administering propofol in a patient’s home without necessary monitoring and training is an egregious breach of standard medical practice.  Those of us who use the drug properly were shocked to learn of this doctor’s reckless and indefensible care.   Here are a few hypothetical examples of similarly negligent care. A surgeon removing yo

We gastroenterologists are regularly summoned to bring light into dark places.   We are the enlightened ones who illuminate anatomical shadows.   Sure, we have ‘tunnel vision’, but we like to believe that we can think broadly and creatively as well.  We are the scope doctors. Am I Just a Tool? We are commonly consulted by primary care physicians and hospitalists to perform colonoscopies, upper endoscopies (EGDs) of the esophagus and stomach and other gastrointestinal delights.  We deliver a probing element to patient care.  We are called to serve as technicians – plumbers, if you will - although we actually have cognitive knowledge of our specialty.  Yes, we can think.  Often, we have tension over what we are asked to do and what we think we should do. Do I think that every procedure I am asked to do is medically necessary.  Of course, not.  Before you target me for investigation and professional censure, realize that every physician in America and beyond would

Folks must think than all doctors know all things medical.  I know this is true by the questions that I have been asked over the years.  While my expertise spans hemorrhoids to heartburn, I am routinely queried on medical issues well beyond the specialty of gastroenterology.  When I can’t answer questions about a new medicine for hypertension or if an MRI of the shoulder makes sense, folks look at me quizzically as if I must not be a real doctor. Today, more than ever, physicians are highly specialized with a very narrow medical niche.  There are ophthalmologists, for example, who only treat retinal disease.   Perhaps, there are even retinal specialists for the left eye only.   It wouldn’t surprise me.  My partners and I perform routine gastroenterology procedures in an ambulatory surgery center.   Patient safety is our priority and our staff and us are dedicated to this mission.  All of us are required to be certified in Advanced Cardiac Life Support in the unlikely event th

One of the points I offer in this blog and elsewhere is to be skeptical to assume that something is true because we think it should be. We’ve been brainwashed to believe that obesity is a killer, despite research performed this year concluding that a little more weight may add years to your life.  Many argue that an assault weapons ban will save lives despite the absence of social science research that supports this.  Fewer guns should save lives, right? When skeptics like me point to Chicago which boasts extremely strict gun control legislation while being a murder theme park, we are given excuses to reject the data that contradicts gun control dogma.  Isn’t the term assault weapon itself unfairly charged and loaded?  I have supported medical education reform advocating that medical residents and interns should not be worked to exhaustion and yet be expected to administer high quality and compassionate care to ill patients.  I had believed that somnambulating medical interns wer

One of the gripes that patients have about the medical profession is that we physicians don’t communicate sufficiently about our patients. In my view, this criticism is spot on. Patients we see in the office often have several physicians participating in their care. The level of communication among us is variable. While electronic medical records (EMR) has the potential to facilitate communication between physicians’ offices and hospitals, the promise has not yet been realized. The physicians in our community, for example, all have different EMR systems which simply can’t talk to each other. We can access hospital data banks from our office, but this is cumbersome and burns up time. Ideally, there should be a universal system, an Esperanto approach where all of us utilize the same EMR language. On the day I wrote this post, I participated in a direct conversation with the treating physician at the hospital bedside which vexed me. This scenario would seem to be ideal from the patien

History matters. I didn’t realize this as a kid, but I sure do now. I endured 2 years of U.S. history in high school, as New Jersey state law required. Can you say, soporific? Only years later, as an adult, did I realize that history is a potent intoxicant that lured me into a deep addiction. Along with my Dad and brother, we sojourned many times across the country to many of our nation’s historical treasures. Most of these were civil war sites, which we properly regarded as hallowed ground. Through happenstance nearly 2 decades ago, I learned of an aging physician in Saginaw, Michigan, Dr. Richard Mudd. I read that he had spent nearly his entire life trying to clear the name of his grandfather, Dr. Samuel Mudd, who was convicted as a participant in the conspiracy to assassinate Abraham Lincoln. My Dad and I drove up to Dr. Mudd’s home and listened to him tell his stories in in his parlor. The memory of this wonderful afternoon is vivid and indelible. This man, just 2 generations r

As of this writing, 5 air traffic controllers have been found asleep at the switch. By the time this piece is posted, several others may have joined the slumber party. Keep in mind, there’s a lot more snoozing in the towers than we’re aware of. We don’t know the denominator here. Our wise reactive government has recently issued orders that airport control towers must not be manned by only one individual. Somehow, prior to NappingGate, our bloated and inefficient government that is riddled with redundancy thought that one sole guy watching the radar at night was sufficient. There are some jobs where nodding off poses no risk. Let me test my readers’ acumen on this issue. Which of the following professions would not be at risk if an unscheduled siesta occurred? A race car driver A congressman A circus clown (not to be confused with above listing) A lawyer (not to be confused with the above listing) A school bus driver Let’s face it. Some folks on the job simply can’t safely snore

At this writing, I am in Atlanta visiting our daughter at Emory University. This may be the only college campus in the nation where you can’t buy Pepsi. Coke is King here. If you don’t know this, do some due diligence before you or someone you love interviews here. I remember a few decades interviewing at the medical school here. There are only 2 medical school interviews that I recall after all these years. At N.Y.U. School of Medicine, the canny interviewer asked me what the death rate of Americans is. I correctly responded, “100%”. I suppose that untangling enigmatic questions was an N.Y.U. admission requirement, since they did accept me, and I did attend. The other medical school interview I still recall was at Emory, although it’s not the questions I remember. Their unique interview format made the experience memorable. Three medical school applicants were interviewed simultaneously as we faced a bank of questioners. This was reminiscent of the ancient and popular TV show, The D

Last summer, at the Cleveland Film Festival, I saw a movie called The Lottery, which is still swirling in my head. It is a documentary about the enormous obstacles that true education reformers confront when they try to help our kids learn. The film was raw and powerful and made me angry. It led to many family discussions about the state of education in America and a search for a way forward. The film is certainly not a balanced view on this issue, and teachers’ union supporters who view it will need to have industrial strength antacids available. I found The Lottery to be more powerful than the more popular movie Waiting for Superman, which addresses the same theme. Assuming the facts are as presented, viewers are shocked to learn how long and how expensive it is to remove an incompetent teacher. The New York Times reported that governors across the country are seizing on the public mood and are working to dismantle the teacher tenure system, where jobs are protected regardless o

Photo Credit More and more, I read about physicians who are ready to give it up. I hear similar views in the physicians lounge and in hospital hallways. These conversations are a modern phenomenon; they did not occur when I entered the profession 20 years ago. They have germinated as a result of rising forces that have demoralized many practitioners. Some of them include: • Loss of autonomy • Loss of income • Loss of stature and prestige • Required ‘Quality’ initiatives • Health care ‘reform’ • Infighting within the medical profession • EMR • Medical liability system • Insurance company hurdles to get paid • General gerbil wheel existance Luckily for me, I am still happy on the job. Of course, I am not immune to the above realities, and would readily accept a vaccine to protect against them, if one existed. I try to focus on the core purpose of being a physician, and work to sequester the noise and static, at least while a patient is seated before me. Since I am a memb

Professional sports has never been a dominant personal interest, although I admit that I become more engaged if my town’s teams reach the post season. Here in Cleveland, folks assign a priority level to sports that is just a notch below breathing. I do make it a point to know enough of what is happening within the various stadiums and arenas so that I am not ostracized or placed in a stockade in the public square to serve as a deterrent. If the Cleveland Cavaliers do not emerge as national champions this year, then northeast Ohio will sink into the Sea of Melancholy There is an aspect of professional sports that I greatly admire. This transcends the athleticism and skill of the athletes, the work ethic, coaching expertise, teamwork and the thrill of the game. This is one of the only institutions that is a pure meritocracy. The philosophy is simple and not blurred by arguments for diversity or massaging the qualifications for admission to serve another agenda. Coaches, managers and ow

The concept of medical excess is very difficult for ordinary patients to grasp. The medical community has worked hard for decades teaching them that more medicine meant better medical care. The public has learned these lessons well. Physicians who sent their patients for various diagnostic tests or specialty consultations were regarded as conscientious and thorough. Patients approved of doctors who prescribed antibiotics regularly for colds and other viruses believing that something beneficial was being done for them. We can’t expect a patient to know if a CAT scan a physician orders is medically necessary. From a patient’s perspective, a test is medically necessary if the doctor orders it. However, physicians, with professional training and experience, know whether medical testing is urgent or optional. Isn’t that our jobs? Of course, the practice of medicine often resides in the murky gray area where there is no single correct answer. In these instances, there can be several rational

Here are some pointers in how to choose a good physician. Remember, while these tips offer guidance, there is no guaranteed method to rely upon. Ask friends and coworkers who their doctors are and why they like them. Keep in mind that they may like their doctors for the wrong reasons. If a neighbor recommends his doctor, because “he prescribes antibiotics over the phone whenever I want them”, then you may have learned something important – choose another physician. Conversely, a person may be dissatisfied with a doctor who truly performed well. For example, a patient may complain because his doctor wouldn’t give him a refill on addictive sleeping pills. While I encourage canvassing opinions about local physicians, use these recommendations cautiously. Ask hospital nurses for their advice. They see physicians working when doctors don’t know they’re being watched. They are an unrivaled source for obtaining a candid review of medical professionals. They know who is caring and co

If it were easy to know how to choose a good physician, then everyone would have one. As discussed in prior postings, it’s tough just to define a good doctor, let alone find one. There is no surefire way to select a high quality physician. Methods and advice that sound like a winning strategy, just don’t reliably deliver. For example, you are ecstatic to have an appointment with a renowned doctor at a prestigious medical center, but his fame might be from rat research, not from patient care. You feel privileged to consult with a medical school’s chief of surgery, but it may be residents and other training physicians who are actually doing your operation. You feel fortunate to have an appointment for your asthmatic son with a specialist who lectures widely on lung diseases and has authored several textbooks. However, he might be a much more skilled writer and public speaker than he is a treating physician. You are reassured that your cardiologist is a wizard at placing stents in clogged

Here’s a list of attributes that define high quality physicians. This is not a controversial posting. After each entry, you will be nodding in agreement that it is an essential element of a high quality physician’s skill set. Here’s the unsolvable challenge. After reading each listing, decide how you could accurately rate a physician on the specific item and compare him to colleagues. I’ve been a physician for 20 years, and I have no idea how to do this. Perhaps, smarter folks can figure this out, since this is where true medical quality can be found, not in mindless, meaningless and downright dumb data and statistics. Great physicians have many of the following skills and qualities. They are skilled at palpating abdomens and hearing subtle cardiac and pulmonary abnormalities with a stethoscope. They know when not to prescribe an antibiotic. They know when a symptom can be safely observed and not investigated immediately. They know whether a CAT scan finding should be ignored or pursue

Over the years I have had countless conversations on how to select a competent physician. Advice on this issue is easy to find, but the desired result is more difficult to achieve. In the last posting, I listed many of the recommendations of ‘experts’ and indicated the pitfalls of their advice. The New York Times recently published a column offering their advice on choosing a physician. If you review the piece, make sure to peruse also through the deluge of readers’ comments, including one from your humble blogger. While the Times piece is informative, it does not offer a surefire prescription for selecting a high quality physician. There simply is no easy formula to assess physicians’ competence, like the magazine Consumers Reports might use to rate microwave ovens. Nevertheless doctors are being evaluated and compared by insurance companies, employers, the government and now even on Angie’s List! The reason that this task is so challenging, and the results so suspect, is because tw