Sunday, November 7, 2010

Can CAT Scans Prevent Lung Cancer? Smoke and Mirrors

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 identify every tiny abnormality, which generates patient anxiety and more medical tests chasing these trivial results.   Off the record, radiologists will confide that these ‘abnormalities’ are inconsequential, but their formal dictations always suggest that these lesions may be ominous.  Their dictated recommendation?  Mores scans!
  • CAT scans can provide patients with false security, which is the premise behind total body scans that are scamming the public.
  • CAT scanning and other technologies have eroded physicians’ bedside physical examination skills.   Does anyone think we are as skilled using a stethoscope as our predecessors were?  Of course, one can argue that we don’t really need these antiquated skills anymore. 

Recently, the press went ga ga over a new study that concluded that screening CAT scans on cigarette smokers could save lives. They hyped headline of The New York Times was CT Scans Cut Lung Cancer Deaths.   The study concluded that annual chest CAT scans on smokers could reduce the risk of death by lung cancer by 20%.   Why is my reaction so cynical to what was heralded a groundbreaking development in oncology? 
First, I am always wary when study results are presented in relative terms, such as a 20% decrease in the number of deaths.  Relative percentage terms always exaggerate the clinical benefits and are misunderstood by the public, as well as the press.  For example, assume that a new cholesterol-lowering medication is prescribed to 500 people who are compared with a control group of untreated individuals to determine if the drug can prevent heart attacks.    If 4 folks in the medication group develop a heart attack, and 5 control patients do also, then the drug company can correctly claim it lowers heart attack rates by 20%.  This sounds impressive, although the true benefit that an individual realizes is trivial, since 99% of all patients suffered no cardiac event.   Can’t you just see the headline Drug Cuts Heart Attack Rate by 20%?
In the chest CAT scan study, 300 people must be screened to save one life.  Is this worth it?  Of course, if the lucky individual is in your family or mine, then any cost would justify the outcome.  However, we cannot make public policy based on anecdotes or rare favorable outcomes.   For those who argue that saving lives is worth enormous expense at the expense of others, do they also support the following positions which would save lives?
  • Lowering the highway speed limit to 40 mph
  • Outlawing air travel
  • Prohibiting swimming
  • Eliminating skiing
  • Forbidding contact sports
Assuming the CAT scan study’s conclusions are correct, 299 smokers have to be screened to save a fellow inhaler.  Twenty-five percent of the scans had ‘abnormalities’ discovered that led patients into the medical labyrinth described above.  So, in the group of 300, 1 life was saved and 75 were targeted for subsequent medical assault.  When you consider that there are nearly 50 million smokers in America, imagine the billions of dollars that will be spent and the hundreds of thousands of patients who will be subjected to medical care evaluating harmless lesions.   
In addition, as doctors who have been around a while know, one study shouldn’t change the course of medical practice.  Over the past decade or two, many other groundbreaking studies were subsequently refuted.   I’m sure that physician readers can cite many examples of these medical retreats.  In six months’ time, we could learn of new study that concludes that smokers who are screened with CAT scans have a higher death rate.
A better strategy that is considerably cheaper and more effective is to try to reduce the number of cigarette smokers.  The CAT screening study cost $250 million.  What if those funds were used instead to treat nicotine addiction?  Would this have saved more lives than annual CAT scan screening?  The low tech approach, at least, is more focused on low hanging fruit, rather than aiming buckshot style at every smoker.  Moreover, I would imagine that if a smoker is told that his annual CAT scan is negative, that he will have less incentive to consider quitting.  For him, a negative scan may reinforce his belief that he will avoid a malignant fate.
Other bloggers, including KevinMD and Gary Schwitzer didn’t drink the CAT scan Kool Aide.  My advice?  When the press is serving up Kool Aide, hire a food taster.
Do I think there may a reasonable role for CAT scans in smokers?  I’m not holding my breath on this one. 

Sunday, October 31, 2010

Plagiarism and Medicine: Should We Care?

Recently, I wrote a post on plagiarism in medicine. I advocate a stringent code of ethics for our profession. Once our integrity becomes squishy, then the whole tapestry starts to unravel. We physicians are charged to search for and guard the truth.

In 1910, Sir William Osler wrote:
No human being is constituted to know the truth, the whole truth, and nothing but the truth; and even the best of men must be content with fragments, with partial glimpses, never the full fruition.
Of course, we physicians don’t always succeed in enlightening the truth, but we try. Every day, every one of us faces choices that test us. Some are easy. Most of us would not falsify billing submissions. Other choices are murkier. For example, do we coax a symptom out of a patient so that the procedure or visit becomes a covered benefit? Have we informed a patient whom we are recommending a colonoscopy about the radiologic alternatives? When a patient informs us that his primary care physician has referred him to a surgeon whom we do not hold in high regard, do we speak up? Some folks believe that dispensing medication samples to patients is improper because it encourages the use of expensive medications and raises drug prices for everyone.

I am not writing this because I am a paragon of ethical behavior. I have made some wrong choices in my career. I am also not suggesting that personal integrity is of greater worth for physicians than for others. However, although every individual and business should use honest weights and measures, personal integrity is a fundamental value of the medical profession. This is why I am so troubled about ethical lapses of pre-medical students, physicians-in-training, practicing physicians and academic researchers. Medical plagiarism targets the soul of the profession

There’s new twist on plagiarism, which makes the offense even more complicated. Which of the following scenarios do you find more troubling?

A college student deliberately enhances his research paper with someone else’s work and then submits the paper as his own. He hopes that his plagiarism will not be detected.

A college student appropriates information from various websites and ‘pastes’ liberally into his research paper without attribution. He would readily disclose his research technique as he does not recognize it as ethically problematic.
In my school days, when pterodactyls flew overhead, we all knew what plagiarism was. We didn’t need introductory college lectures to define it. When we ‘borrowed’ someone else’s work without attribution, we knew it was wrong. These days, kids, and even many grown-ups, don’t even know what plagiarism is, or when they are committing it. They have diluted the definition to such an extreme, that only a verbatim extraction of whole paragraphs from the holy bible would be considered plagiarism.

Consider two points from a recent New York Times article.

  • 40% of surveyed undergraduates admit to have plagiarized on written work
  • Only 29% of students believe that copying from web constitutes serious cheating
Many cheaters today do not even regard the offense as an impropriety. Somehow, they believe that the internet and other sources are public domain information reservoirs to be ‘cut & pasted’ and presented as one’s own work. A student caught cheating in my day would be punished. Today’s offenders are likely to deny that any ethical breach has occurred. Counseling these individuals is much more difficult task. We all know the first step of a 12-step program.

Medicine, along with the rest of society, has suffered some ethical erosion. If premedical students, for example, have a relaxed ethical attitude, what kind of medical students will they become? Can we expect that these students, who plagiarize in college, would undergo an ethical metamorphosis when they become grant-seeking academic researchers or practicing physicians? What kind of role models will these researchers and academic faculty be for younger physicians and investigators?

Plagiarists, idea thieves, have chosen personal gain over the truth. If the plagiarist seeks to enter the medical profession, what is our response? Do we close the gate or escort him inside?

I don’t believe that an isolated episode of plagiarism should permanently disqualify someone from becoming a physician, or remaining one. I do think, however, that this is a serious offense that merits a designation of impaired. The offender would need to admit the failing and submit to a process of reeducation and rehabilitation, similar to what is required for other afflictions. The most critical time to address any ethical lapse would be during the undergraduate years and during medical school, with the hope that early detection could change the game.

I’m interested in the readers’ views, particularly those who disagree with me. If you like this post, feel free to ‘cut & paste’ it into your own blog, under your own name, of course.

Sunday, October 24, 2010

ABIM Board Recertification Exam: Threat Level Green

Two Thursdays ago, I took the American Board of Internal Medicine (ABIM) recertification examination in gastroenterology (GI).   Whistleblower readers have already digested some of my musings on this event.  The good news is that there was no penalty for incorrect answers.  The bad news is that I submitted many incorrect answers.  Every one of these standardized tests that we all take becomes a mind game, where the examinee (us) tries to penetrate the psyche of the test makers (them).  We’ve all been there.   We torture ourselves between what we think is the right answer, and what we think that the questioners think is the right answer.   Sometimes, I thought that the ‘correct’ answer on the list is out of date, which confused me.  Or, what I felt was the truly correct answer, wasn’t included in the answer choices.  For example, I am a very conservative practitioner, who often advises observation, rather than tossing patients into the diagnostic arena.  In a few of the exam’s clinical management questions, I would have chosen ‘wait and see’, but on the test I was forced to scope, scan or operate. 
I didn’t invest even one nanosecond to prepare, which I think was the proper strategy.  I’ll find out in a few months. This is clearly a test that one cannot study for.
Many of the questions were reasonable.  Physicians’ define reasonable as an easy question that we know the answer to.  Unfair questions are all the rest.  Many questions do not relate to typical GI community practice, or they ask the examinee to resurrect an arcane medical fact, that was last known to us during the heady memorization days of medical school. 
Years ago, I submitted sample GI questions to the ABIM, at their request, to be considered in the internal medicine board certification exam.  This wasn’t an easy task, and I recall it took considerable effort to create just a few questions.  Here are some of the hurdles.  Is the question’s content reasonable for an internist?  Should the question test medical knowledge or judgment?  Is the clinical narrative realistic?  Is sufficient information included to lead the examinee to the correct answer?  Should I insert an irrelevant piece of data to distract the test taker, as occurs in the real world?  Has the question been sanitized of ambiguity so that examinee doesn’t develop bulging neck veins and a paroxysmal surge in blood pressure?
Is an exam question reasonable if you could find the answer by consulting a reference, as we do in everyday practice?  Of course, we do not need conventional text books or journals  any longer, now that we have 24/7 access to the world’s most authoritative medical resource – Wikipedia.  I think that internet use should be permitted during the exam to replicate actual medical practice.   Do physicians have to know the right answer immediately or simply know how to find it?
I think that creating exam questions is a useful exercise for medical students and residents, and even for practicing physicians.   Try it yourself.  Devise a few board questions and show them to colleagues. Be prepared for some critical reactions.  It’s not as easy as it looks.
However, many medical standardized exam questions are downright silly, and are of marginal clinical relevance.  On every one of these tests that I’ve ever taken, there are always a slew of patient vignettes that are literally foreign to American physicians.  Patients on these exams do a lot more foreign travel than my real patients do.
Here’s a sample question, which is solely the product of my imagination.  I will never divulge, even under hypnosis or interrogation, any of the copyrighted materials on the GI board exam.  I do not want the ABIM enforcers to snatch me in the middle of the night and escort me on a perp walk, cuffed and shackled, while reporters blind me as their flash cameras detonate.  

A patient returns home from Southeast Asia and develops a series of wacky symptoms. Chartreuse colored fluids are being ejected from various bodily orifices. He has a rash in the right nostril (see Figure A) and noticed some tingling in the ring fingers of both hands. For the last week, he has been speaking in rhyme and has developed a craving for guacamole. There is stridor present, which is quite ‘inspirational’. (Click Audio) Labs are notable for the abnormal trace element levels listed below.

Which of the following diseases that you’ve never heard of is the likely diagnosis?
The most impressive aspect of the experience was the security.  When I arrived, I had to show 2 forms of identification.  The testing administrator didn’t simply glance at them, he studied them.  I had my palm vein pattern recorded and my photograph taken.  I was advised that I would be monitored by video and audio devices.  I wondered if an examinee read questions softly aloud to himself, and was caught on audio, that a trap door might snap open underneath him.  Poof, another physician prematurely retiring! Every time I entered the sacred exam room, I had to empty my pockets and roll up my sleeves.   You could not enter or leave the room without a photo ID check and a palm vein scan.  When I returned for the final session after lunch, the proctor nabbed me trying to sneak my wristwatch into the exam room, which I forgot to remove.   “It was an accident,” I protested.  Was my medical career over?  Fortunately, this major ethical lapse did not constitute ‘irregular behavior’.  I’m sure after this incident, that I never left her site. 
Of course, I agreed to the Pledge of Honesty, and was given a list of admonitions afterwards that promised to send me to the gulag if I gave any test info away.
I am not here to criticize these security personnel, but to praise them.  I felt a lot more secure there than I do at the airport.   In fact, the Homeland Security Advisory System assigned a Low threat level in my testing center.   There were no free peanuts, but there was peace of mind.

Sunday, October 17, 2010

Advanced Cardiac Life Support and Tort Reform

Photo Credit

Two days from this writing, I will go mano a mano with a computer screen.   This will be my second gastroenterology (GI) board recertification.   Last week I suggested that the 490 minutes of unfettered fun might not be money well spent.  A reader could infer my view that the $1200 fee has more to do with securing the finances of the American Board of Internal Medicine than it does to enhance my knowledge of GI.   Perhaps, I was hyperventilating about the cost.  When I calculate the GI board CPM (cost per minute), I determine that the exam only costs $2.45 per minute   In other words, a full minute of quality board testing time costs about the same as a slice of pizza.  Clearly, the test is a bargain, and I retract any prior Whistleblower whisperings that contradict this. 
Yesterday, I took another exam, this one to recertify me as a qualified Advanced Cardiac Life Support (ACLS) practitioner.  An excellent paramedic instructed me and my 2 GI partners on new developments in basic life support, medication strategies to resuscitate the moribund, airway management and proper use of a defibrillator. 
Since my internship and GI fellowship,  I have never  had to administer life support.  This is fortunate for me, and for the patients, since I am unqualified to perform ACLS, despite my certification, which I am required to have..
You recall the 3 important initial steps of basic  life support.   These lifesaving ABCs are
  • Airway
  • Breathing
  • Circulation
I have my own 3 step emergency plan that I am always ready to implement.  They are
  • 9
  • 1
  • 1
Practicing physicians are simply not skilled advanced  resuscitators. If an individual collapsed, many physicians nearby would hope that paramedics would arrive before the doctor would have do any doctoring.   Indeed, many physicians are reluctant to identify themselves as doctors in emergency situations.   I’m not suggesting that any of us would stand aside if there was a person in dire need of urgent medical care.   However, if there are 20 physicians in a theater, and a frantic call is issued for a physician, some doctors might hesitate hoping that there is an ER doctor or a cardiologist who will step up.
The public wrongly believes that a medical degree includes lifelong lifesaving skills.   If someone drops while she shops, she might fare better if there is a boy scout nearby, instead of an allergist, dermatologist, psychiatrist, family doctor or even a gastroenterologist.
Jewish law mandates that an individual intervenes to save someone’s life.  The Talmud teaches, "...if  one sees his friend drowning in a river, or if he sees a wild animal atacking him, or bandits coming to attack him, that is he is obligated to save [his friend."   This concept is not part of American jurisprudence.   It is legal to stand idly by when someone needs to be rescued, even if such a choice would be morally reprehensible.   While there is no law requiring that we act to save someone, there are laws in all 50 states and the District of Columbia that try to encourage us to do the right thing.
We are all familiar with the Good Samaritan legal doctrine.  These laws provide immunity to folks who provide good faith emergency care to people who are at risk of death.  If a man suffers cardiac arrest and needs cardiopulmonary resuscitation, the Good Samaritan law protects the rescuer from being sued if the individual dies or survives with a devastating result.   We do not want fear of a lawsuit to restrain an individual from stepping in to save someone’s life.  It would seem difficult to argue against this concept, but nothing would surprise me in the irrational and unfair medical liability arena. 
In my medical practice and yours, if an adverse event develops, despite good faith and proper medical care, there is no Good Samaritan shield to protect me.   To paraphrase an oft quoted line from the New Testament, the truth may not set me free, at least not right away.
I think that the medical liability system needs to be defibrillated, wiped clean to allow society’s moral pacemaker to generate a new rhythm.    I’m ready to charge the paddles.  Are you?

Sunday, October 10, 2010

Board Recertification in Gastroenterology: More Fun than Colonoscopy

Photo Credit

This coming Thursday, I will have the joy and pleasure of taking the gastroenterology (GI) board recertification exam.   There will be many entertaining elements to the experience, as other board certified physicians already know.  Although there will be many fun delights, some will clearly be more amusing than others.
Which of the following features of the GI board examination will be most fun?  While more than one answer may be correct, choose the best answer.
(1)    A 490 minute all day exam is a thrill, by definition
(2)    Losing a day of income
(3)    Paying the American  Board of Internal Medicine (ABIM) $1200
(4)    Pleasing my partners who will cover my practice
(5)    Having my palm vein recognition scan to verify my identity every time I reenter the room
During this exam, each giddy examinee will be provided with a computer station.  I am nostalgic already for the proctor of yore announcing, ‘pencils down!’, as there will be no pencils permitted in the examination room.  In fact, many items are forbidden in the sancta sanctorum, the examination chamber. For example, portable phones, wallets and watches are classified as contraband by the ABIM Security Police.  While I understand that my phone could be a secret repository of important facts on the life cycle of the hookworm, a likely exam topic on a parasite that no American gastroenterologist ever sees, what’s the fear about wearing a timepiece?   Are they worried that my watch might be an upgraded version of Maxwell Smart’s shoe phone, allowing me to quietly ‘phone a friend’ whom is poised to Google my urgent request?   
At the present time, the ABIM is still permitting test takers to take the exam fully clothed, although this policy is under review.   Security professionals are concerned that examinees might have secret wires and antennae woven into their underclothing, which could transmit stealth information on hemorrhoids and flatulence –key board topics – to the GI board certified wannabee.   Perhaps, the ABIM intel pros fear that a ‘wristwatch’ might actually be a monitor where such improper information could be displayed.  This would explain the wristwatch prohibition.  The solution, of course, is to require that all examinees take their recertification exams naked.  While this appears to violate established social mores, this is outweighed by ABIM’s desire and obligation to secure the exam.  This should be acceptable to medical professionals who confront nakedness every day.  After all, we are doctors.  The proctor, however, who does not have a medical degree, would have to be blindfolded throughout the exam.
I now mention a specific ABIM board examination restriction in its own paragraph to set it apart.  I, MDWhistleblower, solemnly affirm that the following sentence is true and is paraphrased from the ABIM web site.  Examinees are not permitted to bring suitcases in the exam room.  I wish I were funny enough to make stuff like this up.
Of course, we will be warned that any ‘irregular behavior’ will be reported to the authorities, which can result in severe professional sanctions.   We gastroenterologists know more about irregularity than any other physician, and we should have been consulted on this issue.   We would have suggested that any first offenders be subjected to a rigid sigmoidoscopy performed by a first year surgical resident.   I suspect this would serve as an adequate deterrent against temptation, and would guarantee very regular behavior.
Before the examination begins, I will have to agree to a Pledge of Honesty.  I’d like the ABIM to agree to a Pledge also.  Do they pledge that this examination, and the 5 required home study modules that preceded it, will make me a better gastroenterologist?    I have already opined on this issue.
Do any other physicians believe that board recertification is ‘irregular’.  If so, I propose a rigid response to the ABIM.

Sunday, October 3, 2010

The Myth of Electronic Medical Records

Painting of Paul's Damascus Road Conversion

Electronic Medical Records (EMR) promises to be the holy grail of modern medicine.   It aims to deliver us from the Smith Corona era into the digital age.   I’m a gastroenterologist who has already been practicing digitally for two decades.  I guess I am way ahead of my time

Is EMR progress?    Consider these two hypothetical  patient assessments.  The assessment is a critical section of the medical record where the physician shares his thinking on the patient’s condition.   The assessment answers the question, “What do you think is going on here and why?” 
The Old Fashioned, Archaic, Fossilized and Sclerotic Assessment
The quality and timing of the patient’s abdominal pain is strongly suggestive of mesenteric ischemia (lack of blood supply to the guts), as the pain consistently develops  45 minutes after meals.  The patient has numerous risk factors for this condition.   Peptic ulcer disease is unlikely as the patient has been on an effective anti-ulcer medicine for months.   The frequency of the pain is not typical for gallbladder disease or pancreatitis…
The New & Improved EMR Assessment
Abdominal pain, unspecified
Our office manager admonished me earlier this week because I was free typing the medical history section, rather than use ‘point and click’ ( P & C).  Apparently, if I free type and forego the template entirely, it stymies the coding process.  (For non-physicians, coding = getting paid.)  While EMR vendors are convinced that medical histories can be recorded using P & C technique, I’m a deep skeptic.  The medical history is a narrative, a record of a fluid, and sometimes meandering dialogue between patients and physicians.   The history probes in all directions.  It wanders.  It creates new passageways. The patient’s response to a question often opens up a new avenue of inquiry, a function that cannot be reproduced on a rigid template.   
Imagine how our personal conversations would be if we communicated using a P &C template.

Steve:  “Jim, it’s great seeing you?  It’s been a while.  How’s it going?”
Jim:  “Samantha’s having a rough time with chemo and I was just laid off.”
Steve: “Fantastic!  Are you free to golf this weekend?“

I do believe that EMR systems in time will fulfill their early promises.  They will incorporate excellent voice recognition software.  The myriad of EMR systems will be integrated so that a recent emergency room visit will automatically be transmitted to my patient’s EMR record.   Patients will have their medical histories, EKGs, medical images, etc., recorded on flash drives, which will load into any EMR system.  When this occurs, it will no longer be possible to be an EMR non-believer.
But, some of today’s EMR whistles are whistling in the dark.  For example, we physicians all nodded like bobble-head dolls when we were told that we could have access to patient’s records at home after hours.  This meant that when we received weekend phone calls from our partners’ patients, whom we did not know, we could access their medical record and give better medical advice.   Of course, this makes sense, but is it really true?
First, it’s tough for cyber neophytes like me to boot up the laptop when a patient calls while I am behind the wheel.   Secondly, I have been handling patient calls at all hours for 20 years, and I have somehow managed to handle the issues with few catastrophic consequences.  Indeed, all practicing physicians have developed this important skill set of triaging patients by phone.  Our role here is not to make a diagnosis; it is to decide if a patient needs an emergency room visit or can be seen electively in the office.   I’m not suggesting that reviewing record is not useful, only that the benefit of instant access may be exaggerated in certain circumstances. 
I’m sure that EMR 2.0 and its descendants will ultimately deliver.  So far, it hasn’t surpassed ink on paper in my practice, although it's only been a few weeks.  So far, as expected, EMR has not brought me closer to my patients.  To paraphrase a past U.S. president, it's a divider, not a uniter.

I realize that there are some physician EMR users who worship the new technology. There are indisputable advantages that they can and will bring to medical care.  Some EMR systems may be better than others.  However, this has not a downhill sleigh ride for many doctors and patients, at least not yet.  Interestingly, the majority of physicans are still content to use paper charts.  In the near term, they will transition to EMR, not so much because of a Damascus Road conversion, but because payers will require it.

I admit that with each passing week, it is getting smoother for us.  But, it has taken an enormous investment of T & T (training & tweaking) time, which is ongoing.  And, we haven't yet incorporated our endoscopy practice into the system.   At the start, it may take longer to document a colonoscopy than to do one.
For me, blogging is the EMR antidote.  It’s open terrain.   There are no moats or fences.    It’s unpredictable and spontaneous.    It’s emotional and creative.   It has a point, but not a single click.