MD Whistleblower

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.   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 or taught.   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 the dangers of seeking a s

One thing that gastroenterologists know about is stool.   But, I’m not referring to that kind of stool in this post.   Follow along . When we do a colonoscopy, for example, we are relying upon stool, or more accurately a stool, as in a three-legged stool.    This metaphor illustrates that the three legs must be equally strong or the stool will not stand.   The three pillars of support that a colonoscopist needs include: Knowledge Skill Judgment All 3 Legs Needed As the gastroenterologist guides the colonoscope along your long and winding colon, he may discover a lesion.    He needs knowledge to identify the intruder.   Is it a cancer or a benign polyp?   Could it be Crohn’s disease or some other form of colitis?   Is it a normal structure that simply appears atypical? Obviously, the more experienced the gastroenterologist is, the more likely he will be able to identify the abnormality. But, every gastroenterologist, regardless of experience, confronts lesions

Consider these behaviors.    A newborn calf nurses from his mother.    A robin places a worm into the gaping mouths of her offspring.    Cats know how to hunt. These behaviors are examples of instinct.   The creatures do not even understand why they engage in these acts.   They are inborn behaviors.   Animal Instinct Humans have instincts also.    Unlike most professional standards and qualifications, instincts cannot be easily quantified or tested.   But, under certain circumstances, they are invaluable assets.   We learned last week that the Transportation Security Administration (TSA) has been pursuing a program called Quiet Skies, when passengers who have met certain criteria are monitored for various behaviors that might suggest that closer scrutiny is warranted.    I am making no comment here on the merits of the program, but I am supportive of TSA using instincts of air marshals as a tool to evaluate threats.    Some have criticized this as an infringement

I write to you now from the west side of Cleveland in a coffee shop with my legs perched upon a chair.  Just finished the last Op-Ed of interest in today’s New York Times.  Do I sound relaxed? I rounded this morning at both of the community hospitals that we serve.  There is not a day that goes by that doesn’t have blogworthy moments.  If I had the time and the talent, I would post daily instead of weekly.   Read on for yet another true medical insider’s disclosure. Gastroenterologists, as specialists, are called upon by other doctors to address digestive issues in their patients.  For example, our daily office schedule is filled with patients sent by primary care physicians who want our advice or our technical testing skills to evaluate individuals with abdominal pain, bowel issues, heartburn, rectal bleeding and various other symptoms.  The same process occurs when we are called to see hospital patients.   If a hospital admitting physician, who is usually a hospitalist, want

Professional training and development are critical.  Police officers, educators, orthodontists, painters, chief executives, musicians and chefs all need ongoing training to remain current.  Job requirements evolve, and we must adapt.  An accountant who hasn’t kept up with new or anticipated tax law changes might not account for much when computing your tax obligation or refund. Physicians need to be dedicated to ongoing professional development as much as any other occupation.  Patients often wonder if their doctor is up to date.  Does your primary care physician know about new medications for your condition?  Does your orthopedist use the latest medical hardware when replacing your hip joint?  Is your anesthesiologist using the same old laughing gas to put you asleep?  Is your dermatologist’s knowledge of his field only skin deep? In the medical profession, there has been a paradoxical emphasis on reducing professional training.  Here’s what I mean.  In hospitals, it is no lo

Last week, I offered up an argument on why medical judgement means more than medical knowledge.  In other words, being a really, really smart doctor is not the essential qualification for practicing excellent medicine.  I ended last week’s post with some examples of medical ads that are familiar to all of us.  Here are some ads and slogans that you won’t see on highway billboards or in press advertisements. ·        Bring your back pain to our orthopedists.  They probably won’t operate on you since most back pain is not effectively treated surgically.  You don’t want unnecessary surgery, do you? ·        Wanna lose weight?  Consult with our bariatric surgeons who will refer you to one of our certified dieticians so you can endure yet another diet.  Who wants a trigger happy surgeon anyway? ·        Come to our oncology center for a second opinion.  Don’t expect any new treatments, since ‘promising’ experimental treatments are exactly that – experiments.  We’re not roll

Would you rather that your doctor have excellent medical knowledge or medical judgment?  Answer this question before reading on. Patients are drawn to doctors and medical facilities who boast ‘cutting edge’ medical knowledge and techniques.  Medical judgement, which is much more important in my view, is barely mentioned.  Good doctors have great knowledge, but great doctors have superb judgment.  Consider the following vignette that I hope illustrates why judgement means more than knowledge. A patient is comes to the emergency room with abdominal pain.  The physician refers him to two different physicians, Dr. Knowledge and Dr. Judgment.  Which of these physicians would you rather see? Is the gallbladder the culprit here? Dr. Knowledge:  I recommend that your gallbladder be removed.  I have trained in advanced robotic surgery which leaves only one very small scar.  My complication rate is extremely low.  Our operating room team is excellent.  I am the only surgeon

Years ago, I was having dinner with 2 members of The Cleveland Orchestra, one of the finest orchestras in the world.  I asked them, with my kids present, how much time they devoted to their craft.  As many parents know, getting kids to commit to practicing a musical instrument is about as easy as splitting the atom in your garage.  The musicians told us how much time they practiced, which was mind boggling, as one would expect.  Any artist, athlete, Green Beret or similar professional, has to demonstrate extraordinary commitment to maintain a superlative level of excellence and preparedness. I asked one of the musicians, the violinist, how long he could refrain from playing his instrument before he noted some professional slippage.  Guess your answer.   At the end of this post, I will relate his reply. How many hours are enough? How long can you be away from your job before your performance ebbs?For most of us, we can take weeks or longer on holiday and return back to ou

Years ago on Cape Cod, my kids and I stumbled across a man who had spent the day creating a sand sculpture of a mermaid.  It was an impressive piece of art.  “How long did it take you to make it? ” we asked.   While I can’t recall his precise words, the response was something like “25 years and 7 hours”.  I’m sure my astute readers will get his point. We are transfixed now watching Olympic athletes performing in Rio.  So much depends upon their brief routines which can last seconds to a few minutes.  While a diver’s acrobatic plunge may take 2 seconds, it would not be fair to leave aside the years of work and training that prepared the athlete for this moment. The same point can be made for anyone who has worked and trained hard to reach a point where the action performed seems easy to a spectator or a customer.   If an attorney prepares estate documents, we can assume that the fee for this reflects the prior training and research that the lawyer has done on this issue, as it

Patients are amazing creatures.   The current breed is hyperinformed on medical information and has an ever expanding reservoir of physician data to trove through.  I’m not just referring to physician reviews on Angie’s list.  Soon, the public will be encouraged to review our success and failure rates with respect to medical treatments, how much cash the drug companies grease us with, all disciplinary actions, comparison with peers, complication rates, medical malpractice entanglements and how much Medicare reimbursement we have received. There will be published quality benchmarks on physicians so that the public can see how their physicians scored on these various quality measurements.  I have opined throughout this blog that I feel that these measurements are tantamount to taurine excrement.   Sadly, reimbursement will be tied to these results with physicians who don’t rate high enough having some of their income confiscated.  Physicians who don’t make the grade may game the syst

Years ago, I was having dinner with 2 members of The Cleveland Orchestra, one of the finest orchestras in the world.  I asked them, with my kids present, how much time they devoted to their craft.  As many parents know, getting kids to commit to practicing a musical instrument is about as easy as splitting the atom.  The musicians told us how much time they practiced, which was mind boggling.  Any artist or athlete or Green Beret or similar professional, has to demonstrate extraordinary commitment to maintain a superlative level of excellence and preparedness. every day. I asked one of the musicians, the violinist, how long he could stay away from playing his instrument before he noted some professional slippage.  Guess your answer.   At the end of this post, I will relate his reply. How long can you be away from your job before your performance ebbs? For most of us, we can take weeks or longer on holiday and return back to our positions seamlessly.  A few examples.

This afternoon, as I write this, a professional football player was ejected from a game for committing the transgression of unnecessary roughness.  This infraction should be taken seriously in a game where violence is not only legal, but desirable.  I’ll leave it to the reader to imagine how unnecessary the roughness was if it resulted in an ejection.  It is self-evident to any thinking person that the human body is not designed to withstand the punishment of this game.  Keep in mind that most of us are only seeing the actual games, and not the hundreds of hours of brutal practicing.  I take care of an octogenarian who played for the Cleveland Browns decades ago.  While this profession lifted him out of a Pennsylvania steel town, it is challenging for him to identify a part of his body that is working properly.   The National Football League (NFL), which showed us all last year how they fumbled their domestic violence issues, has belated admitted what most first graders would readi

Racism and prejudice are endemic in America.  Many of us reflexively answer, No , if we are asked if we are prejudiced.  I don’t.  I say yes. While I do my best to give everyone a fair shake, I grew up in a white suburban family in the latter decades of the last century.   My friends, my parent’s friends and all those we associated with were all the same color.  In elementary school, there was but a single black girl in our classroom. Is it possible for a white kid to grow up surrounded by all of the overt and covert prejudicial and stereotypical influences and somehow emerge pure?   I don’t think so.   Prejudice today among those of us who consider ourselves to be enlightened is more subtle and often hard to recognize. I don’t want to overplay this here.  I often feel that a charge of prejudice with regard to race, gender, age or religion is spurious and is launched to advance a personal or a political agenda.  We all know this to be true and these instances deserve condemna

Everyone likes to be recognized for a special achievement or accomplishment.   Every career has special awards and commendations for everything.   While there’s no reward that matches cold hard cash, many of these honorable mentions have no tangible value whatsoever.  Pull into a fast food parking lot and you may see a parking space designated with a sign proclaiming, Employee of the Month!  Such an award conveys appreciation but does little to enhance the standard of living of the recipient. It seems that every other week there is some award show on television for the arts and entertainment industry.  99.44 Pure! I’d like an award, or at least a citation, for the work that I do as a gastroenterologist.   Fortunately, there are many awards and honors that I am eligible for.   Here are some of the prestigious honors that would illuminate any curriculum vitae. Fellow of the American College of Flatulence Honorary Doctorate of Hemorrhoidology Election to the Sphincter Pr

Medicine is an art, not a science.  We’ve all heard that maxim before, but what does it actually mean for living, breathing patients? Physicians rely upon knowledge and experience when we advise patients.   We try to stay current on relevant medical studies to guide us, knowing that the latest medical ‘breakthrough’ may be debunked in a few years.  Seasoned physicians resist the temptation to abruptly change their medical advice based on a single study, even if published in a prestigious journal. Knowledge and experience are important, but judgment trumps them both, in my view.   The best clinicians are those who consistently exercise excellent medical judgment. A knowledgeable physician may be able to recite a dozen explanations for your high calcium level. An experienced doctor can expertly perform a colonoscopy having mastered the technique. A physician with a high level of medical judgment knows that surgery is wrong for a particular patient, even though medical t

We’ve all heard or used the phrase, ‘leave it to the professionals’.  It certainly applies to me as the only tools that I can use with competence are the scopes that I pass through either end of the digestive tunnel.  Yeah, I have a ‘toolbox’ at home, but it is stocked similar to the first-aid kit in your new car, which contains a few BandAids, adhesive tape and, hopefully, the phone number of local doctor.  My home tool box has an item that can practically fix anything – the phone number of a local handyman. Nothing for Hemorrhoids Here.      Photo credit It is essential to know one’s limitations, regardless of one’s profession.  Politicians shouldn’t speak authoritatively as if they are climatologists. Gastroenterologists should not prescribe chemotherapy, even though we are permitted to do so. Bloviating blowhards on cable news shows are likely not military experts. The guy who fixed your toilet might not be a top flight kitchen remodeler even though his business

If you are a physician like me who performs procedures, then rarely you will cause a medical complication.  This is a reality of medical life.  If perforation of the colon with colonoscopy occurs at a rate of 1 in 1500, and you do 3000 colonoscopies each year, then you can do the math. Remember that a complication is a blameless event, in contrast to a negligent act when the physician is culpable.  These days, for many reasons, an actual complication is confused or misconstrued as an error. Some complications are more difficult on physicians than others.  For example, if I prescribe a medication and the patient develops a severe rash, I do not feel personally responsible.  It’s the drug’s fault.  However, when I perforate someone’s colon as a medical complication, I feel responsible even if this act was a blameless event which will occur at a very low but finite rate.  (Of course, there are perforations of the colon which result from medical negligence, but I am leaving these as

Is your doctor a hammer and you're a nail?  Here's some insider's advice coaxing patients to be more wary and skeptical of medical advice.  Should you trust your doctor?  Absolutely.  But you need to serve as a spirited advocate for your own health or bring one with you.  Ask your physician for the evidence.  Sometimes, his medical advice may result more from judgement and experience as there may not be available medical evidence to guide him.  Make sure you have realistic expectations of the medical out me.  And most importantly, try as best you can to verify that the proposed solution is targeted to your problem. Is Your Doctor a Hammer? Consider a few hypothetical scenarios. A 66-year-old patient has chronic right lower back pain.  Physical therapy has not been helpful.  Radiological studies show a moderate amount of hip arthritis.  A hip replacement is flawlessly performed.  The orthopedist discharges the patient from his practice.  The pain is unchanged.

I read recently that the left coast state of California is contemplating requiring physicians to submit to alcohol and drug testing.   Citizens there will be voting on this proposal this November.I do think that the public is entitled to be treated by physicians who are unimpaired.  Physicians, as members of the human species, have the same vices and frailties as the rest of us. Traveling leftward I have no objection to this new requirement, if it passes. This will not be a stand-alone proposal on the ballot, but is a part of the ballot initiative.   Why would trial lawyers in the Golden State want to include it?  The meat of their ballot effort is to reverse effective tort reform that had been in place there for several years.   Click on the Legal Quality category on this blog for a fuller explanation of why the medical malpractice system has been screaming for reform, and is slowing getting it.  Sure, there are always two or more sides to every issue.  But, when the different

A few days before this writing, a 32-year-old woman came to see me for an opinion on stomach pain.  Why would I refuse to see her again?  Abdominal pain is an everyday occurrence for a gastroenterologist.  She was accompanied by her mother.  I had never met this woman previously.  She had suffered abdominal pains for as long as she could remember.   She recalled frequent visits with the school nurse when she was a young girl. The Stomach - Usually Not the Source of 'Stomach Pain' She has abdominal distress of varying severity every single day. Despite this medical history, she was not ill and appeared well. Why did I refuse to take on her case?   She seemed like a very appropriate patient for my practice.  I have expertise in evaluating and treating abdominal pain.  The patient was pleasant and cooperative.   I believe she would have been comfortable with me as her gastroenterologist. I learned that the patient lived in another state and was only in Cle