MD Whistleblower

Last week, I presented the U.S Services Task Force’s (USPSTF)recent revision on its mammography guideline.  I agreed with the assertion that lives will be saved.  There is a little more to the story.  When a task force or an organization is devising a preventive medicine guideline, lives are not the only consideration.   First, mammography is a screening test – an exam performed on an individual without symptoms to prevent illness.   For clarification, a mammogram, unlike screening colonoscopies, is not designed to prevent cancer.   The objective is to detect breast cancer at an early phase which should result in a more favorable prognosis. Whenever a screening test’s target population is widened, as just occurred with USPSTF’s mammography revision, more lives will be saved.  For example, if we started performing screening colonoscopies at age 30, of course we would save lives since colon cancer can arise in folks in their 30’s.  However, what...

Recently, the U.S. Preventive Services Task Force (USPSTF) issued a groundbreaking draft revision of its screening mammography guideline for women at average risk of developing breast cancer.  The new guideline advises women to undergo screening mammography every other year starting at age 40, ten years earlier than it previously recommended – a major modification.  This will be a two-part blog post. If you find this post of interest, I encourage you to return next week when I will share some ‘inside baseball’ on   mammography and medical guidelines. The USPSTF issues an array of preventive health advisories which it revises periodically.   I have always admired the task force’s measured and conservative recommendations, which reside within the boundaries of medical data and evidence.   The task force is comprised of experts who strive for objectivity, even though none of us are entirely immune to external influences.   They are a sober voice of reason ...

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...

A female patient came to see me with some difficulty swallowing, a very routine issue for a gastroenterologist.  I performed an scope examination of her esophagus and confronted a huge cancer occupying the lower portion of her esophagus. Life changes in an instant. I expected a benign explanation for her swallowing issue.   She was relatively young and not particularly ill.  She had seen my partner years in the past for a similar complaint, which he effectively treated by stretching her esophagus.  I expected that I my procedure would be a re-run.  I was wrong. Prior to the procedure, we chatted and I learned that she had recently undergone a CAT scan of the chest ordered in response to some respiratory symptoms, which were not severe.  After I had completed my scope examination of her,  I was amazed that no mention of this tumor was related to the patient, who had told me that only a hiatal hernia was seen. I requested a fax o...

Sometimes, we play a little politics on this blog.  I am a student of current events and enjoy following the dysfunction and absurdities in American politics.  To paraphrase the legendary former British Prime Minister, ‘never has so little been done by so many to benefit so few’. Legendary Former British Prime Minister Which of the following recent events is the most politically charged? Speaker of the House John Boehner passed a clean extension of the debt limit without conditions. (Nothing like a colossal failure on this issue months ago to guide the speaker today.)  Obamacare received its 27 th extension, another ‘tweak’. A new study questions the value of mammography.  Readers know how skeptical I am about medical dogma.  When I was an intern a quarter century ago, I didn’t grasp why routine measurement of  Prostate Specific Antigen (PSA) was standard medical practice since it was true back then that more men were harmed than helpe...

Breast news is booming.   Mammography is in the news again.   We have legions of breast lobbyists that have agendas that are far beyond the true medical value of mammography.  Even legislators have entered the mammographic arena in a clumsy effort to show their pro-women bona fides.  Politicians should not practice medicine.  It’s absurd that they try to do so when they can’t even perform their own jobs competently. In 2010, the government overturned its own panel the United States Preventive Services Task Force (USPSTF), in response to an outcry from politicians and mammo-cheerleaders. The USPSTF is not anti-mammogram, and neither am I. I’m pro medical evidence. Mammogram enthusiasts often champion positions that are beyond the science.  Beyond the Kool Aid drinkers, there are billions of dollars at stake here.  Medical evidence is massaged by companies who manufacture conventional and emerging imaging breast techniques and by radiologists w...

This blog is about freedom and personal responsibility.  I have opined that cigarette smokers should not be permitted to transfer total responsibility for the consequences of their choices to the tobacco companies, even if this industry has committed legal and ethical improprieties.  I do not support the politically correct beverage ban in New York City, sure to spread elsewhere, where the government decides the content and dimensions of beverages that the public desires to purchase.  With regard to Obamacare, don’t get me started or I’ll never get to the intended subject of this post. First, let me refute a point in advance that is sure to be leveled against me by the pro-breast crowd.   I am zealously pro-breast and want all breasts foreign and domestic to remain free of disease. I am against breast cancer and support the goal of striving for early detection of this disease and medical research to prevent it.  Indeed, I am against all cancer an...

A hundred bucks doesn’t buy much these days. A crisp Ben Franklin can be exchanged for 50 Big Macs A Broadway show ticket A night in a New York City hotel (just joking) A college textbook (paperback) Your life Your life? Yes, 5 crumpled Andy Jacksons can save your life, as was reported earlier this year in a front page article in The Plain Dealer, Cleveland’s only daily newspaper. University Hospitals is now offering a $99 spiral computed tomography (CT scans) of the chest in individuals who are at increased risk of developing lung cancer. The rationale is that if cancers can be detected early, then the cure rate for surgical removal is very high. Gary Schwitzer, medical blogger and press watchdog, tries to bring some balance to the distorted media coverage of CT lung cancer reportage. The test is not covered by insurance, so consumers will have to hand over 10 Al Hamiltons to get in the door. I’m a deep skeptic of this effort, and predict that with some more time, the ...

I still marvel at the accomplishments of CAT scans and imaging studies.   These technologies have revolutionized the medical profession.   Imagine foretelling 50 years ago that a new technology would emerge that could perform ‘exploratory surgery’ without an incision.    This prediction would be greeted with disbelief, if not scoffing.   Of course, there would be similar reactions if decades ago other technological feats, such as fax machines, personal computers, emails and internet, were predicted. CAT scans save patients’ lives, prevent surgeries, make accurate diagnoses and refine treatment plans.   This is the good news.   However, as expressed repeatedly on this blog, there is a darker side of the story. Without doubt, too many CAT scans are performed. Accumulated medical radiation has health consequences. Resources expended on unnecessary CAT scans could be devoted to worthy health care endeavors Radiologists suffer from litigophobia and ide...

Many patients erroneously believe that x-rays and CAT scans have no risk. In their minds, they are non-invasive studies that can cause no harm. Since there are no incisions or anesthesia, they regard the experience as having the same risk as taking a family photograph. How wrong they are.  In my mind the danger from non-invasive radiology studies may surpass the risk of hard core medical treatment. True, radiology tests won’t puncture an organ or a blood vessel, as a surgeon or a gastroenterologist can. Imaging studies do not cause direct damage, but they may lead patients onto the medical battlefield. These diagnostic tests are an insidious force that draws patients into a spiral of direct risk and medical overutilization. Is this post a shot at radiologists? No, it’s a shot at all of us. Remember, radiologists never order CAT scans; the rest of us physicians do. I certainly am distressed with the obsessive manner that my radiology colleagues interpret studies today, identi...

Folks across the country are paying hard cash for total body scans, abdominal aortic aneurysm testing, CAT coronary artery scans and carotid artery evaluations to prevent disease or find important lesions early. It’s a seductive argument, and it’s a scam. Ordinary patients don’t understand about pre-test probability and positive and negative predictive values. Indeed, all physicians were taught to consider Bayesian theory when ordering diagnostic tests. This is very tough concept for patients to grasp. A critical principle of proper diagnostic testing can be summarized in a single sentence. If an individual is unlikely to have the medical condition under consideration, then a diagnostic test that yields a positive result is likely to be a false reading. Here is an illustration demonstrating why patients need to understand this issue. While the forthcoming example is hypothetical, I guarantee that every physician has seen very similar patients in their practices. While the...

If we are ever to prevail against the CAT scan cascade, we must understand why these tests are ordered. Here are 7 explanations of why doctors scan their patients. Talk to your own doctor and see if I’ve missed a few. While some physicians have financial conflicts of interest, most order scans for other reasons. This is not a ‘choose the best answer’ multiple choice test. Physicians often have more than one reason to scan you. The physician orders a scan to follow trivial lesions identified by accident on prior scans. A patient or the family want a medical test believing that a diagnosis has been missed. The physician orders a CAT scan hastily, without sufficient thought if it makes medical sense. The physician has a financial interest in ordering CAT scans. The physician correctly believes that the scan is medically necessary. The physician orders a CAT scan defensively for his own legal protection. The physician orders a scan to bypass a difficult discussion of a patient’s chronic co...

The last few postings in the Radiology Quality category have detailed the risks of pursing trivial CAT scan abnormalities. Physicians created the term incidentalomas to describe these lesions that were discovered incidentally, or by accident. There is an epidemic of these lesions today as the volume of CAT scanning increases each year. When a scan uncovers an abnormality, the healthy patient is dragged into the medical arena. This unlucky patient may not be healthy for long. These scans are a potent accelerant that fuels the vicious cycle of unnecessary and excessive medical care. Medicare expenditure for radiologic imaging tests, including CAT scans, is exploding. John Iglehart analyzed this trend in the March 5, 2009 issue of The New England Journal of Medicine. Medicare Expenditures for Imaging Studies Year 2000 Annual Expenses: $3.6 billion Year 2006 Annual Expenses: $7.6 billion The government capped fees paid for imaging studies performed in out-patient facilities and doctors’ o...

The superscan in the prior posting, which showed a ‘freckle’ in the right lung, has now created an anxious patient and family. This patient’s worry will be heightened when he is sent to a pulmonologist, or lung expert, to evaluate the ‘abnormality’, which was found entirely by accident. The lung specialist will then advise the patient to have periodic CAT scans over the next 2 years to assure that they lesion does not enlarge. Obviously, this exercise diminishes quality of life and costs plenty of money that could be used to help truly sick people. And, if the nodule does increase in size – which even benign lesions can do – then the doctor may recommend surgery just in case it is cancerous. Consider what tens of thousands of Americans endure evaluating abnormalities that should never have been discovered or investigated. Millions of us are walking around with innocent imperfections in our internal organs. In other words, if any of us were to undergo a CAT scan, many of us would have a...

I am astonished at the diagnostic accuracy of today’s radiologic technology. CAT scanners today, for example, can detect lesions that were invisible 5 or 10 years ago. As a gastroenterologist, I am routinely referred patients with subtle abnormalities seen in their livers, pancreases and digestive tract. Indeed, every medical specialty has been similarly affected. Pulmonary specialists see patients with tiny lung nodules that would not have been seen with older technology. Oncologists see patients with borderline abnormalities that can only be detected with the latest generation of scanners. Shouldn’t we celebrate this futuristic diagnostic accuracy? I’m not so sure. I believe that these phenomenal technologies harm many more patients than they save. Follow my reasoning. Most of the abnormalities that scans detect today are innocent lesions that will never make a patient sick. Our internal organs are not smooth and perfect. New scanners, like the satellites in space mentioned in the pr...

One of the most vexing events for patients is when they are told that there is an abnormality on a radiology study. These discussions in doctors’ offices create palpable anxiety for patients and their families, even when physicians try to reassure them that the abnormalities are likely to be trivial. Patients today are frightened that they have cancer. They all know anecdotes of individuals who were falsely reassured and were ultimately diagnosed with a malignancy. I have heard fears of cancer related to me by teenagers who have seen me as a gastroenterologist to evaluate a few drops of blood they observed on the toilet tissue. Their fear is not rationale, but it is real. A few weekends ago, I was asked to see 2 patients on my hospital rounds to offer an opinion on abnormal CAT scans. The first patient’s scan showed an abdominal mass the size of a grapefruit that the radiologist suspected was related to the patient’s prior diagnosis of colon cancer. The second patient’s scan sh...