Sunday, September 19, 2010

The Healing Power of Prayer: Faith vs Reason?

Our society thrives on tension and competition.
  • GOP vs Democrats
  • Civil Libertarians vs Eavesdroppers
  • Ohio State vs Michigan
  • Creationists vs Darwinists
Ideas, like sports teams, compete to win. We are the referees of these contests. Many of these competitions in the public square are ongoing. Some of these duels are locked in a dead heat. Others are in overtime. Some are ‘challenge matches’ when a vanquished idea wants another shot to change the original outcome. Many of these controversies may never be resolved.

In addition, the outcomes may change because we – the referees – have changed. What was considered to be a foul years ago may now be regarded as fair play.

The medical profession is riddled with many internal conflicts that will not be easily resolved. Here are a few, and I’m sure readers could add generously to the list. 
  • Primary Care vs Medical Specialists
  • Physicians vs Insurance Companies
  • Obstetricians vs Medical Malpractice Attorneys
  • Fee-for-Service vs Salaried Medicine
  • Evidence-Based Medicine vs Alternative Medicine
A patient I saw some months ago in the hospital illustrated another conflict that we physicians face, from time to time. Although the case was a typical case of internal bleeding, it could be classified as a Case of Faith vs Reason. Here’s a brief synopsis of the case.

An 81-year-old male was hospitalized with rectal bleeding. I had treated this man years ago, and was requested to assist in his care once again. Gastroenterologists are typically consulted on patients with internal bleeding. A day later, I performed a colonoscopy and determined that the bleeding was originating from pouches in the large intestine called diverticula. This is a common scenario and the bleeding usually ceases spontaneously. Each day, he continued to bleed, but never to an alarming degree. He received only 2 units (pints) of blood over the first few days, indicating that he was not in urgent danger. Then, he had an abrupt event when he bled suddenly and dropped his blood pressure. At that point, he was transferred to the intensive care unit for closer observation. He was given additional blood transfusions and a 2nd bleeding event occurred. We performed an urgent angiogram, which is useful in acute, ongoing bleeding to identify the leaking artery and to seal it. The result was completely negative.

Most physicians at this point would advise the patient to consider surgery, to remove the section of the large intestine that is continuing to bleed. I requested that surgeon evaluate the patient and anticipated that he would perform surgery on that very day. My assumption was incorrect. The surgeon, a careful and compassionate physician, agreed that surgery was indicated, but no operation would take place. The patient preferred a different therapeutic plan, which I will paraphrase here.
“I think I’m just going to pray. If I’m still bleeding after the weekend, then we can talk again.”
This is a man who knows something about faith. He has been a priest for longer than I have been alive. He also knows about reason. He has more post-graduate formal education than nearly anyone I know. After earning his baccalaureate undergraduate degree, he earned a masters and doctoral degree. But for a dissertation, he would have earned a second Ph.D.

I would have opted for the surgery for myself, and would have enthusiastically supported his decision to undergo it. But, I wasn’t the referee in this contest, he was. He listened carefully to the medical professionals, and then viewed this information through the prism of his own life experiences and beliefs. I’m sure there was a contest occurring in his own mind, but he was able resolve it calmly and confidently. He didn’t say that he wouldn’t have surgery, only that he wanted to try something else first.

The bleeding stopped and the patient was discharged. The surgeon remained idle. Did the patient know something that the rest of us trained physicians didn’t? Clearly, he knows that choosing the best answer on the gastro board exam may not be the right answer for him. It’s refreshing to watch someone who can choose a different direction defying convention and momentum. Again, this man is not an idealogue. He was willing to call the surgeon back.

I was so honored when he presented me with an inscribed copy of his autobiography entitled, I Looked Up and Heard God Calling Me. At the end of the book, Father Pittman writes:
Even now as I look back, I believe that I reached a stage of prayer that I have not yet equaled in fifty years of training and practice as a religious. I can still see the goodness of the Lord in all that happened.  
I am honored to care for many priests and nuns in my practice. They are wonderful human beings who exude peace and contentment. They tell me that they pray for me, and I’m glad that they do. Who would turn down prayers from Father Pittman?

What do readers think?

Sunday, September 12, 2010

Electronic Medical Records, Surgery or a Grand Canyon Hike - Which Hurts More?

Two weeks ago, I did what had to be done. Months of procrastination had to end. Fears had to be put aside. Anxiety and misgivings had to be overcome. Second opinions always confirmed the need to proceed. So, when the excuses ran out, I jumped.
What decision did I make?

Did I…

(a) Finally have rotator cuff surgery?
(b) Begin electronic medical records (EMR) in the office?
(c) Retire from medicine to be a full time ‘Whistleblower’?
(d) Agree to a family vacation when we will hike up and down the Grand Canyon sans mules?
(e) Agree to become an expert witness for a medical malpractice plaintiff’s attorney?
(f) Apply an Obama 2012 bumper sticker on my car?

Two weeks ago, our office entered the paperless universe. The era of ink on paper was over. The manner that I had seen office patients for 20 years suddenly evaporated. And, I wasn’t happy about it. For our small group of gastroenterologists, even though we are aware of the potential advantages of computerized charts, we adopted EMR because we had to. For me, I was perfectly satisfied seeing patients in the office the old fashioned way, similar to how physicians have treated patients throughout history. Prior to 'point & click medicine', I had lots of time for eye contact and observing patients’ body language and facial expressions. I have previously expressed my concern about EMR adversely affecting the doctor-patient relationship. My written chart notes were in my own unique verbiage, code words and phrases that could convey my precise meaning when reviewed months or years later. True, I couldn’t access patient records from remote sites, but somehow we managed to get the job done without tragic consequences. EMR is a cure, but I wasn’t aware that my practice was diseased.

So, now I face patients with a laptop, loaded with software that I don’t fully understand. I am clicking, pasting, free typing and spending minutes searching for some common term like hemorrhoids to insert into the history of present illness. During the first week, I have sorely tested my patients’ patience, and my own.

Since, I don’t want to communicate to my patients my frustration, annoyance and trepidation, I try to make the experience seem like it's all jolly-good fun. I maintain a fixed smile of delight that must make patients think I administer an hourly Botox injection. Looking deliriously happy when I want to smash my laptop to shards is hard for someone with no acting skill or talent. Therefore, I \prepared some cue cards to assist me. Here’s a sample.

  • Do Not Say: I hate this system and so will you.
  • Say: Isn’t this wonderful? I can now search my whole practice for all of my porphyria patients.
  • Do Not Say: Remember how you used to wait a half hour in the waiting room for your appointment? Those were the ‘good old days’.
  • Say: My partners can view your medical history even at 3:00 a.m. Try it out this weekend when I am not on-call.
  • Do Not Say: I wonder who can hack into these records?
  • Say: Of course, this will really improve your medical care. I already clicked that you are feeling better.
  • Do Not Say: I can check my email during office visits and patients think I’m looking at their EMR charts!

Of course, it will deliver many improvements for patients and physicians, as pointed out by ├╝berblogger Musings of a Distractible Mind . I am excited to have access to my patients’ records from anywhere. It has been vexing to receive phone calls at night from my partner’s patients with stomach pain, when I do not know them, and have no access to their records.  E-prescribing will save time and screen for important drug interactions and allergies. Letters can be sent to referring physicians at the time of the office visit automatically, although the software writes them in a robotic fashion. Ultimately, all  EMR systems will communicate with each other, so that a patient seen in an emergency room can have medical records accessed from any EMR system. By then, patients should be carrying a flash key or a microchip containing all of their medical history, radiology images, EKGs, etc.

While on balance, EMR is a true reform that will improve medical quality, it won’t make everything better. It will take great effort by physicians to prevent EMR from dehumanizing our personal interactions with our patients. This is a formidable task, and many of us will not fully succeed. We should not simply consider the medical outcome, but also the path and the experience that precede it.
For example, we would sustain ourselves on Ensure or Meals Ready to Eat (MRE) for life. This would save us time and money. But would it be worth it? When we focus only on the medical outcome, then our humanity is at risk. While the nutritional analogy above isn’t a perfect fit for the EMR issue, I hope you will agree that there is a connection.

What do other physicians think about EMR? More importantly, I am interested in the views and experiences of real, live patients. For those who are dissatisfied, how can we physicians do better?

If I do end up at the bottom of the Grand Canyon, and the National Park Service adds WiFi service there, should I take my laptop with me?  While my feet are dangling in the Colorado River, I can refill prescriptions.

Sunday, September 5, 2010

Gastric Bypass Surgery: Cure or Disease?

Last week, a female patient saw me in the office for the first time to discuss her chronic digestive issues. Luckily for her, my recommendations did not include probing into her alimentary canal with the endoscopic serpents that we gastroenterologists rely upon.

As the visit concluded, she advised me that she intended to have a gastric bypass (GIB) procedure performed, and even used the medical term of bariatric surgery. I suppose that she mentioned it because the issue falls within my specialty, and she wanted my reaction to her plan, although she didn’t directly solicit my opinion. Nevertheless, she received it.

I am not surprised anymore when the critical medical issue emerges at the end of the office visit. Every physician has this experience regularly.

“So, Mrs. Fleets, I think that this new medicine will really help your constipation. My nurse will be happy to arrange your next appointment. Do you have any questions?”

“How come I now have trouble breathing when I walk up stairs?”

What struck me about my bypass seeker was that she didn’t appear to have the bulk that would justify weight loss surgery. Sure, she was overweight, but she was thinner than many patients are after undergoing a gastric bypass operation. She was in her thirties and was not suffering from any pulmonary, cardiac, endocrine or rheumatologic consequences of obesity. She simply wanted to be thinner.

I asked her what other treatments she had pursued, since clearly surgical treatment of obesity should be the last option. A patient’s typical response to this inquiry is a narrative describing a series of diets and medications that produced only modest and transient benefit. When no other means can peel the pounds off, and the health consequences of the heft are significant, then surgery is worthy of consideration. But, this is a very weighty decision and the scales should not be tipped too easily in favor of surgery.

This patient had never been on a serious diet or enrolled in a weight loss program. I suggested Weight Watchers, a legitimate, effective and affordable program that encourages the client to make lifestyle changes that are sustainable. Of course, we live in an era of short cuts and gimmicks where infomercials promise us potions that will transform us from Michelin Men into taut lifeguards in a matter of weeks. She responded that she doesn't have the time for the meetings.

Doesn't have the time? My patient had no clue how much commitment and discipline gastric bypass surgery demands. If she couldn’t accommodate a weekly meeting, then how would she ever accommodate to her new intestinal anatomy? She was exactly the wrong candidate for the operation.

I explained to her that gastric bypass is major surgery with all of the risks of any abdominal surgery. More importantly, I emphasized to her that even when the operation is successful, it changes your life every single day forever. The dining experience, one of society’s most important social and familial forums, would be irrevocably altered. Bypassed patients knowingly forego gastronomical pleasure to serve a greater good.

Moreover, a gastric bypass procedure can redirect the internal plumbing, but it cannot unravel the psychological aspects of the disease. If the latter is not properly treated or screened for, then patients can undergo a bypass and actually gain weight. There is no bypass that can restrain a patient from ingesting several milkshakes a day.

Removing an appendix or a gallbladder won’t change your life. GIB profoundly disrupts nature’s digestive system. Only very small meals can be ingested. There are a host of nutritional deficiencies that can arise, because there may not be sufficient intestine available to absorb necessary nutrients.

Do I favor the operation? Yes, but only for a proper candidate who has been carefully vetted by medical and psychiatric professionals. Hundreds of thousands of Americans will have the surgery this year. The medical threshold for determining eligibility for bariatric surgery is becoming steadily lower. I wonder if the acceptance criteria have become too lenient. Of course, the operation is being marketed hard across the country to keep operating rooms humming. Bariatric surgery is big business.

Will this patient get the operation? I hope not, because I don’t think she has the mettle for her post-operative life. If I were the consulting surgeon, I would certainly ‘bypass’ her and direct her back to some treatment options that really work and have no risk.

Once again, I know that GIB is the right choice for many patients who are suffering and have no other remedy available. But, we live in a ‘cut & paste’ society where we often opt for short cuts and secret passageways to success. GIB is no short cut; it’s a surgical incision that may create a deep wound that will not heal.

Sunday, August 29, 2010

Hospital Medicine: Out of Order

Physicans in Reverse Gear!

Here is some inside dope on the medical profession for patients to ponder.

We are all reading these days about improving the process of delivering medical care. This effort aims to raise the level of medical quality, and to minimize errors of omission and commission. This is why all surgeries and medical procedures begin with a ‘time out’, when there is a brief huddle confirming the identity of the patient and the intended operation. This is to prevent scenarios, such as:

“Mr. Patella, we replaced the wrong knee, but you would have needed a new one at some point. No need to get out of joint over this – the rehab is on us.”

Numerous medical specialties are now using checklists for medical procedures that include a series of steps. For example, if every heart bypass patient needs to proceed through 24 pre-operative steps, including laboratory studies, diagnostic tests, specialty consultations and an informed consent discussion, then a checklist is an effective tool to ensure compliance. Indeed, without a tracking mechanism, it is easy to understand how important steps can be omitted, with serious consequences. Chec-lists have been standard operating procedure in the airline industry, which have an excellent safety record.

Of course, there is a risk that physicians will become numb to all of these warnings and ‘time outs’. How carefully, for example, do we listen to flight attendants’ warnings and instructions prior to take-off?

This issue is relevant to how we physicians approach hospital patients. Here’s how we were taught to do it by our professors and mentors. See the patient first. Take the medical history personally, before you review the results of the CAT scan and other diagnostic tests. After taking the history directly from the patient, proceed with a methodical physical examination, which may provide important diagnostic clues. A medical condition that was considered probable after the history may be rendered unlikely after the examination. Additionally, an unexpected abnormality found on the physical examination, may lead the physician to pursue a different line of questioning that was not considered initially. After these two fundamental steps, the H & P, have been completed, the physician creates a differential diagnosis, a list of reasonable diagnostic considerations that can explain the patient’s condition. The doctor does not need to consider every diagnostic possibility, only those that are reasonable. For example, if you were to search diagnoses such as abdominal pain or fatigue on the internet, you could create lists that contain over a hundred entries. Sometimes, our patients bring us these lists convinced that their symptoms are explained by an obscure parasite, not present in this country, because the parasitic disease description matches the patient’s symptoms exactly.Obviously, physicians will expand the list of diagnostic possibilities, if the working list proves to be inadequate.

At this point, additional medical data are reviewed or tests are ordered to narrow the list, hopefully down to the correct diagnosis. Sometimes, the H & P is sufficient to make a reasonable diagnosis, and no further tests are required. For example, a patient who sees me with 6 weeks of heartburn that is consistently relieved with antacids doesn’t need to swallow my scope to make the diagnosis. I already know it, or I should.

This is how we were taught to see patients. Here's how it's done in the real world, particularly in the hospital. Every day, we physicians commit medical heresy, by seeing the patient last, after x-ray results, labs and specialist consultations are reviewed. I know this is true because I am one of these medical heretics. It is standard practice today to do what our medical school faculty beseeched us to avoid - seeing the x-rays before seeing the patient. Nowadays, when physicians enter patients’ rooms, we often already know that the CAT scan shows diverticulitis, or that there is a kidney stone, or that a cardiac stress test is abnormal.

What is wrong with this? Don’t physicians still get to the right answer, even if today’s diagnostic path is reversed?

I am hostile to this approach, which I practice, because it devalues the history and physical examination, which is the core of doctoring. When the physician greets a patient, and already believes that he knows the diagnosis, then the H & P became a diagnostic afterthought, a formality that must be performed more for documentation than for diagnosis. This means that the doctor will not take a broad and probing history, as he no longer feels the need to construct the classic differential diagnostic list. If the doctor meets a patient after viewing a CAT scan suspicious of appendicitis, he may take a cursory history and miss the correct diagnosis, which may not require surgery. It is in patients’ interest for physicians to think broadly at the outset, narrowing down the possibilities over time. It is harder to reverse this process. Once a patient is labeled with a diagnosis, it can be difficult to peel it off. This is why diagnostic labels should not be affixed prematurely. Seeing the patient out-of-order risks this outcome.

Internist to gastroenterologist: "Please see my patient, Mr. Calculus, in room 304 with vomiting. This is his 3rd gallbladder (GB) attack in 6 weeks.

This patient has now been labeled with GB disease.Will the gastroenterologist be open-minded enough to take a full history? Will he discover, for example that this patient ‘borrowed’ pain pills from a friend to relieve his back discomfor? Perhaps, his symptoms are a side-effect of these medicines. If so, then removing the gallbladder is the wrong move.

The out-of-order approach also has eroded physicians’ physical examination skills. If I already know from viewing a CAT scan that a patient has an enlarged spleen, then I will be biased when I palpate the abdomen at the bedside. Sure, I might feel the spleen, but will I examine the rest of the patient with necessary diligence? What if the spleen is not the critical finding? Physicians who examine hearts, lungs and abdomens – when they already know of abnormalities in advance – cannot be fully objective.

Finally, the out-of-order strategy reinforces to patients and the medical profession that testing and technology are more important than the initial human interaction with hands-on contact. This is not true, and yet this is increasingly the way of the medical world.

I maintain the medical history is the most valuable diagnostic took that exists, and it is at risk of being included on the endangered species list. Beyond its medical value, it is a foundation of the doctor-patient relationship, which is already under threat on so many fronts.
Here’s the checklist I wish I used without exception:

___ History
___ Physical
___ Other Stuff

Why do doctors like me who know that the H & P should come first, use the reverse gear istead?  The response to this question should be of great interest to the public, and I hope that this inside dope will appear below in the comments section.   OK, physicians, come clean.

Sunday, August 22, 2010

Stop Medical Malpractice: The White Coat Wall of Silence

Photo Credit

Leisure Guy, one of my most faithful commenters, opines that I am omitting an important aspect of the tort reform argument. He has implored me repeatedly to read a particular book that I suspect buttresses his views, but this worthy pursuit is simply not near the top of my priority pyramid. Since he’s retired, he enjoys the luxury of burrowing deeply into the base of his priority pyramid. With 4 tuitions to go, retirement is a distant mirage for me. I’m can be a ‘leisure guy’, but only in my dreams.

I have written throughout this blog and elsewhere that there are too many frivolous lawsuits against physicians. I have admitted that caps on non-economic damages are not ideal, because they deny some worthy plaintiffs of complete compensation, but I support them because I believe they serve the greater good. I have ranted that there is no effective filter to screen out physicians who should never be invited to the litigation party in the first place. I believe that the current liability system encourages the practice of defensive medicine, which wastes billions of health care dollars and exposes patients to unnecessary risk and expense. I believe that the system is unfair and needs to be reformed. I stand by these views.

Leisure Guy (LG), in between sipping pi├▒a coladas on his deck, sent me a personal e-mail. Here’s his correspondence in its entirety.
It does seem that, given the goal of reducing the number of lawsuits for medical malpractice, the simplest, most direct, and most effective action is preventing incompetent MDs from practicing, regardless of the source of the incompetence (alcoholism or other drug dependency, dementia, and so on). In fact, it would seem to me that this is much more obviously a course of action than going after lawyers and tort reform: stop the malpractice, and the lawsuits will stop. (That was the experience of anesthesiologists.) But you continue to focus on lawyers and the courts, and I’ve never read a post in which you go after the MDs for protecting incompetents and keeping them in practice---that seems inexplicable.
MDWhistleblower is not like the Sunday evening CBS news program 60 Minutes, where an unsuspecting guest is accosted by a journalist who intends to humiliate the individual publicly and irrevocably. In contrast, I have come not to bury LG, but to praise him. He has an important point that merits inclusion in the tort reform conversation. Is it fair for physicians like me to rail against the unfair medical liability system, while we remain mute about medical negligence? No, it is not.

Reading plaintiff lawyers’ blogs, one would think that medical incompetence is spreading across the medical landscape like a wildfire. We read the ubiquitous assertion that there are 98,000 preventable deaths every year, a statistic that is trying through repetition to become transformed into a fact. In my 20 year career, I have only occasionally witnessed medical negligence. I certainly see and participate in plenty of adverse outcomes. I see every day colleagues who make medical judgments that differ from my own. I am informed by patients about physicians who lack important communication skills and would benefit from a week’s retreat at Doctor Charm School. I see on occasion physicians who are rude to nurses. I regularly see physicians who, along with patients, over utilize medical testing and treatment. I see too often physicians who order medical tests for the wrong reasons.

In some of the above cases, the physician is me.

None of these examples, however, represent negligence. If there is an epidemic of medical incompetence, it either doesn’t exist in my world in northeast Ohio, or I am too incompetent to recognize it. I am interested in the views of other physician readers on this issue. How much true medical negligence and incompetence do you witness?

Nevertheless, my friend LG correctly points out that we physicians are not effective or serious at holding our members accountable. Sure, every state has a medical board, but we all know how egregious an offense must be to result in a serious professional sanction. It is not part of medical culture to identify colleagues who have demonstrated competency lapses, committed a negligent act or may be impaired. Recall the adage, ‘friends don’t let friends drive drunk’. Physicians don’t turn in colleagues who may be in need of remediation and rehabilitation, except in extreme circumstances. What stops us? Are we scared that we will be stigmatized as a squealer and ostracized? Do we rationalize that we might not know all the facts about a practitioner who may appear to be missing the mark? Do we look the other way hoping that some other corrective mechanism will descend from the sky to address the issue? Do we allow our empathy for a fellow colleague to corrupt our judgment? .

I don’t retract a single syllable of my views on the need for tort reform. But, we physicians should also heal ourselves. This is our professional obligation and would also deepen the trust between us and the patients we serve.  Not only is it the right thing to do,but it's a smart move also.  Haven’t we learned over and over again what happens when we don’t act proactively to solve a problem?  The White Coat Wall of Silence will become yet another target for 'reformers' to shoot at.  Let's take this target off the field.

Sunday, August 15, 2010

Plagiarism and Academic Integrity: Annals of Internal Medicine Caves

We have a classroom in our home. It’s called the dinner table. This is the locale where over the years, my wife and I have tried to teach 5 kids right from wrong. As we parents ourselves still struggle with these issues, it is clear that integrity remains an indefinite element of life’s curriculum.

There was a time when this table was an actual classroom, when my wife and I home schooled 2 of our youngsters for about 3 years. I could devote an entire blog to this adventure.

Many of our family dinners were seasoned with discussions about integrity. We have discussed and debated the lapse in integrity that has seeped into our educational culture, as well as into society at large. We have reviewed dozens of news accounts detailing ever more resourceful methods of cheating and stealing ideas without attribution. This phenomenon has no boundary and has permeated the medical profession. Euphemisms like ghostwriting cannot camouflage the practice for what it often is – cheating.

Yes, I know that times have changed, and many of yesterday’s values have been retired. But, I don’t regard personal integrity to be an elastic virtue that is subject to modification based on popular culture and demand. Honesty and personal probity are absolute, not relative values that can be shifted or sanded down.

Indeed, it is my view that diluting the definition of integrity has damaged every level of our society. Once this occurs in one sphere, such as education, it is impossible to contain the practice there. It seeps out and spreads. We must forcefully identify it when we see it and strive to reverse its propagation. This endeavor is often a tough slog upstream, but the objective merits the effort. I think that it is a fight than we can win.

The July 20th issue of the Annals of Internal Medicine reported that 5% of applicants to residency programs plagiarized portions of their personal statements. Presumably, all of these individuals will become physicians, and some will become academic researchers. Isn’t personal integrity an absolute requirement for these professions? One could argue that plagiarism should be a disqualifying offense. An editorial on the journal article in the same issue states that:

If the integrity of the personal statement is increasingly polluted by Internet samples of hired consultants, perhaps the personal statement is ill-suited to this era and best left to history. In 1 stroke, this action would solve the problem of plagiarism on personal statements substantially more effectively that a nationwide campaign.

I vigorously reject the editorialists’ view. The proper response to unethical behavior is to denounce it, not to escape from it. If our profession is stained by plagiarists who are cheating on their applications to medical residency programs, we should hold these individuals accountable and strive to raise the ethical bar of all applicants. To ‘reassess’ the need for the personal statement as a response to plagiarism is itself cheating. Every year, high school kids are caught cheating on standardized tests. Is the cure for this to abandon the test or to work harder to teach our kids about raising their IQs, or integrity quotients? Ethical goalposts should be firmly rooted.

In a prior post, I have lambasted the legal profession for dumbing down academic standards in an effort to burnish the credentials of law students.  Our profession should not emulate this approach.

I am dismayed that one of our most prestigious medical journals has gone soft, when a firm hand is required.  I'd like to invite the editors to my dinner table so my kids can teach them right from wrong.