Sunday, September 9, 2012

How to Take a Medical History: A D-Day Approach

One of the joys of being a physician is learning the patients' histories. A joy, you say? Isn't taking the history simply part of the doctoring routine? You've all been there.







When did the pain start?
What made it worse?
Did it move around or stay in one place?

I agree that inquiries like these are not intrinsically joyful, but this is not my meaning here. I refer to history here in the conventional sense. I am interested in who the patients are as people, what they did and what they saw.

It is amazing how many seemingly ordinary folks have extraordinary tales and vignettes that they are quite willing to share, if they are asked.  I have a sense that they are a reservoir of wisdom that we must actively draw from, as they may not volunteer their advice.

I recall a science teacher whose prior occupation was serving as a commander of a nuclear submarine. Even years later, his secrets remained tightly held, despite my gentle entreaties. He was, to borrow a phrase, a tomb of confidentiality. Perhaps, the sedation I would be administering prior to a future colonic violation might loosen his tongue. Oh, the secrets I've extracted in the endoscopy suite!  Relax, patients. What's uttered in the endoscopy suite, stays in the endoscopy suite, our own version of the Vegas Rules.

Another patient, now elderly participated in a historical event that changed the world. He took a leisurely boat ride across the English Channel on June 6, 1944 reaching the shores of Normandy. I've been to beaches many times in my life, but his experience was quite different. I was mesmerized as he recalled the fear that he and his men suffered as their craft approached the French shoreline. He told me of a chilling order that he never had to carry out. If any soldier refused to leave the craft, he was to shoot him. When I was an 18-year-old, I was a comfortable pre-med student. When he was the same age, he walked through the valley of the shadow of death and, unlike the psalmist, he did fear evil.

Another patient, now a nonagenarian, was a scrawny 17-year-old kid who awoke up one morning to hear bombs bursting in air. This quiet and modest man, several decades ago, was stationed in Pearl Harbor on the date that lived in infamy. I was tingling.

Just a few weeks back, an old man came to see me wearing one of the veteran baseball- style caps that many aging vets wear. For me, these caps are a reliable sign that there will be more to talk about than just heartburn and hemorrhoids. "Where we're you stationed," I asked. "Iwo Jima," he answered. You know what's coming now, readers. This man witnessed the marines raising the flag on Mount Suribachi in, perhaps, the most iconic image ever captured in American military history.

Over the years, I have related these treasured vignettes to the kids, who rightly wondered if I actually performed any medical work in the office. For the years that we home schooled the 2 boys, my patients' experiences became part of their curriculum whenever possible. On more than one occasion, these gracious individuals met with us so that we could hear history directly from the folks who made it happen.

Seasoned physicians may not know the answers.  But, they know what questions to ask.  When your doctor is taking your history, is he asking the right questions?  Am I?

Sunday, September 2, 2012

Medical Device Approval Process Under Fire

All parents have heard their kids complain that but for 1 or 2 percentage points, they would have achieved a higher grade.


“This is so unfair! My average is 89.9999 and he is still giving me a B+!”

Every kid should receive an A, of course, since psychologists are now professing that every kid is a prodigy in some new measure of intelligence. Academic intelligence, the conventional and obsolescent notion, has been sidelined to make room for other types of smarts, such as musical intelligence, existential intelligence, interpersonal intelligence, spatial intelligence and many others.

I agree that there’s a lot more to being smart than conquering number theory and linear algebra, but I wonder whether this effort to broaden the definition of intelligence is simply so more parents can have smart kids. Personally, I think that the conventional definition of intelligence is too rigid and we should be open to where rigorous research leads.

Fortunately for me, I did not discover that there is a category of navigational intelligence, which would have cost me at least 40 revised IQ points.

In my day, a grade of 94% was a solid A, and we strived to reach this threshold. Were our teachers too lenient? Should a grade of A required that at least 99% of our answers were correct? Where do we draw the lines to separate excellence from acceptable? Who makes the decision?

Last year, a public fight erupted over an Institute of Medicine (IOM) report that had not even been issued that argued for tougher rules for medical device companies. The report had been commissioned by the FDA and was in response to several recalls of medical devices that had malfunctioned and harmed patients. Advocates of medical device companies cried foul claiming that the 12-member panel was biased. Look for a lot more of this strategy when comparative effectiveness research (CER) goes forward. If a CER panel’s conclusion is against your interest, then attack the panel. Lawyers have mastered this technique generations ago. If the facts are on your side, attack the law. If the law is on your side…


IOM Report Targets Medical Device Industry

Is the IOM on target or is the aggressive pushback from the industry legitimate?  I do know that is an easy task to make medical device companies and pharmaceutical companies appear callous, avaricious and indifferent to human suffering, when this may be entirely false. Can you say ‘demonization’?

Of course, we want medical devices and pharmaceuticals to be safe and effective. We expect that artificial hips, pacemakers, defibrillators and stents will perform superbly. Safety and testing policies should be made by experts independent from industry, but I believe that industry is an important voice at the table. Indeed, several constituencies should be represented, including the public. If we strive to eliminate every real and potential conflict of interest, then we will lose many voices of medical experience from the real world.

I'm not suggesting that reform in the device approval process is unnecessary. But, there are truths that must be acknowledged.

  • No medical device or drug is 100% safe or effective.
  • A percentage of medical devices will fail which may result in injury, reoperation or death.
  • A failed medical device is not tantamount to corporate misconduct
What percentage of medical devices should perform as intended? 90%? 95% 98%?

How much testing and clinical trials should medical devices be required to undergo before they can enter the market? If the device is similar to an existing device, or is an existing device that is applying for a new use, should the testing process be the same as for a new product?

A grade of 98% sounds like an A+ to most of us, but this may not be sufficient in the medical device universe. Would we be content on an airplane knowing that we have a 98% chance of landing safely?

If we all agree that the medical device industry needs tougher standards so that their safety and effectiveness levels approach 100%, then we will need to accept higher medical costs and a reduction in innovation. Will this trade off serve the greater good?

I’m sure if the federal highway speed limit were lowered to 50 miles per hour that lives would be saved. No one is hollering for this reform. What should the medical device speed limit be?

Sunday, August 26, 2012

Improving Patient Satisfaction: Lessons from 18,000 Feet

First Customer Service Representative?

Your call is important to us.  Please listen carefully because our options have changed.

Reader query: During your current or any prior lifetime, has any phone menu option ever changed?

I have more than once experienced an option not offered on the robotic phone menu option choices - a dead phone line after a 30 minute wait.

Have you tried this customer plea as I have?  Could you pretty-please jot down my cell phone number in the event that we are disconnected?  Here are some of the responses one might expect from such in insolent request.

• Are you joking?
• I would but I think it's illegal.
• Sorry, our phone bank only receives incoming calls.
• No, but if you prefer, I can transfer your call to our grievance hotline. Just click on option #17.
• Uproarious laughter from the entire phone bank who heard my request on speaker.

As I write this, I am at 18,000 feet in a propeller plane that I trust will land safely in Cleveland.  Hopefully, the air traffic controllers are all awake and alert. I'm flying in from Canada where my mom and I observed how indifferent the airline and customs personnel were to the plights of the passengers.  Regrettably, this level of  'customer service' isn't restricted to our neighbor to the north.  Air travel isn't much fun these days for anyone anywhere.

I'm sure the airline folks are as hassled as we travelers are.  Would you want to face angry and frustrated passengers each day when you are powerless to remediate their complaints?  At times, the lines of happy travelers at the customer service desk in the airport for lucky folks who have missed flights or lost luggage reminds me of the lines I endured at Disney World.  This analogy is apt since both sets of lines lead to adventure!

Here are my observations as an airline customer.

• I do not feel that my business is appreciated.
• Reaching a living, breathing human being on the phone should only be attempted if a physician has cleared you for this activity. Cardiac patients need not apply.
• Flexibility to adapt to customers' needs or to changes in circumstances have been left out of the playbook.
• Fees charged to make even the most trivial change in ticket reservations are unconscionable.
• No obvious regard for the value of customers' time with regard to flight delays.
• Service on board?  Now we passengers can ask, 'are you joking?'
• Dissatisfied customers have no recourse.  In other spheres of the marketplace, if we are not treated well, we dump them and walk down the street to a competitor.

There are lessons here for the medical profession and for our patients.  Fortunately, patients and physicians enjoy much better partnerships than do airline industry have with its customers.  But, our relationships with patients have been challenged from many internal and external forces. How are we doing in with regard to patient satisfaction?   What do our patients say?  While there are many legitimate reasons why high levels of patient satisfaction are more diffiicult to achieve today, patients still deserve our best effort and outcome.  I am skeptical that pay-for-performance and similar efforts are the right tools to get this job done.  When your only tool is a hammer, than physicians start to look a lot like nails.  Haven't we been hammered enough?

While it is a generalization, I believe that private practice medicine - like any private business - has stronger incentives to provide high levels of patient satisfaction.  Employed physicians, the emerging dominant model for doctors, may not be as vested in catering to their customers, although I know there will be disagreement here.  For employed physicians, their sense of patient satisfaction may be feedback survey results from patients, which will be reviewed by their supervisors and placed in their personnel files.  Private practitioners, in contrast, may be more concerned with pleasing the patient directly than in pleasing the survey. This difference may appear subtle, but I believe it is substantive.  In the same way that teachers are criticized for teaching to the test, physicians who must answer to bean counters may be practicing medicine with an eye toward the survey.  This can lead to gaming the system. 

As I noted on a prior post, the airline industry has taught the medical profession important lessons on medical check lists.  I don't think, however, they have much to teach us about customer service.  If you disagree, give them a call for some pointers on how to soothe seething passengers.  Remember, your call is important to them.

Sunday, August 19, 2012

Unnecessary Antibiotics in Livestock: What's My Beef?

I’ve already written about the overuse of antibiotics in this country. This overutilization costs money and causes medical complications. It also is believed to be the cause of a new generation of superbugs, that can attack us with impunity as we may have no effective antibiotic to defend ourselves with.


As an aside, I remember when I first learned the meaning of the word impunity. Here’s the opening paragraph from the short story written by a nineteenth century master.

THE thousand injuries of Fortunato I had borne as I best could, but when he ventured upon insult, I vowed revenge. You, who so well know the nature of my soul, will not suppose, however, that I gave utterance to a threat. AT LENGTH I would be avenged; this was a point definitively settled -- but the very definitiveness with which it was resolved precluded the idea of risk. I must not only punish, but punish with impunity.

Without resorting to Google, can any readers name the work and the author?

Digression over. Antibiotic (ATB) overutilization is not just an issue that affects man; it affects beasts also. Farmers have been prescribing antibiotics to fowl and cattle for years to make their animals heartier. This issue falls under the jurisdiction of the Food and Drug Administration (FDA), who have imposed restrictions on ATB use in livestock over the years. There is tension between those who feel that ATB should be banned and those who favor a more permissive policy.

Surprisingly, more antibiotics are prescribed to animals than to humans in this country.

Farmers and veterinarians feel they should be free to prescribe ATBs to keep their animals in good health. Antagonists claim that ATBs should not be allowed simply to prevent infections that result from unsanitary conditions. Moreover, there is a widespread view that overutilization of ATBs in cattle creates superbugs that can threaten humans. Farmers counter that these fears are hyped.

These are real issues that need real science to separate facts from politically correct arguments.

(1) It’s true that ATB use in cattle and livestock have increased.

(2) It’s true that superbugs are on the rise.

(3) This does not mean that (1) has caused (2).

The FDA has tightened the rule requiring now that farmers will need veterinarians' prescriptions for antibiotics, a requirement that is expected to substantially decrease their use. 

I’m inclined to agree that both animals and humans receive more ATBs than they need. But, I wouldn’t want to create new mandates based on a hunch or even a logical belief. Before we adopt policies that affect industries, livelihoods and jobs, let’s ask ‘where’s the beef?’

Sunday, August 12, 2012

How Much Does A Colonoscopy Cost?


One would think that a physician who earns his living billing patients would be conversant with the prices of his services. Not this doctor. I am queried periodically by patients asking how much I charge for a colonoscopy. Of course, every physician recognizes that this question is not phrased properly. It doesn’t matter what we charge; it’s what an insurance company determines we will be paid. I might believe that your colonoscopy was worth a thousand bucks, but those who pay the bill have a different sense of its value. Many ordinary folks think that we doctors can simply raise our prices to enrich ourselves. Physicians cannot do this. The hardware store and the supermarket can raise prices in response to rising overhead and market forces, but we physicians cannot. While I realize that the public does not sympathize with physicians who are lumped in with the 1%, a pejorative term popularized by the Occupy movement.

The reality is that many private medical practices are struggling financially and have closed. Many of these practitioners have retired and others have become physician employees. Our practice in the Cleveland suburbs is feeling the squeeze and I cannot estimate how long we will remain viable. Personally, I believe that private medicine is being targeted by design, and when it becomes extinct, the public will lose an important health care resource. While I am not opining that private practice is the only model that can offer high quality medical care, I maintain that when the physician is also a business owner, that he has a strong incentive to satisfy his patients and his referring physicians. Employed physicians are given incentives, which are metrics that reward or punish them depending upon how the measure up on various ‘quality’ schema. Throughout this blog, I have railed against pay-for-performance and its cousins which claim to measure medical quality, but will fail in the mission. It’s like assessing the quality of a chef’s culinary creation by weighing the plate of food. Get the point?

Pay-for-Performance is in the lowest tier of the bottom 99% of quality control measurment. It was not designed to increase medical quality, but to control costs, which is a legitimate goal. At least have the guts to say so out loud.

I don’t have a clue what a colonoscopy costs. This is partially because I have never been interested in the business of medicine. However, colonoscopies are like airline tickets; no two passengers pay the same fare. Insurance companies have different rates. If we obtain biopsies or use a nurse anesthetist to administer the Michael Jackson juice before colonoscopic take-off, then there will be additional charges that cannot be firmly stated in advance.

When I do see what we are paid for a colonoscopy, it certainly doesn’t seem exorbitant considering the years of physician training and experience we have, the outstanding nursing care we provide, the immaculate and modern facility and equipment we use and our devotion to providing the highest quality service possible.

Who can put a price on an experience like this? Not us.

Sunday, August 5, 2012

The Plague of Unnecessary Antibiotics

With regard to antibiotics, physicians and the public have each been enablers of the other. Patients want them and we doctors supply them. There’s nothing evil about this arrangement. Antibiotics are one of medicine’s towering achievements and have saved millions of lives. Shouldn’t we prescribe them to patients who need them? Of course we should. But why do we prescribe them to patients who don’t?


Before you race to the comment section to accuse me of being a self-righteous preacher, realize that throughout this blog, I have confessed my own mistakes and shortcomings, and will continue to do so. (Yes, many commenters have enthusiastically assisted me in this effort.) So, when I throw a stone at the medical profession, I am also in the line of fire.

I have since the heady days of medical internship, been a conservative practitioner, preserving my soul even after completing training where medical overtreatment was worshiped. In medicine, less is so much more. I wish that more patients and more of us subscribed to the philosophy of medical parsimony.

Why would a physician prescribe an antibiotic (ATB) that is not needed?

First, there are times when the medical situation is murky, and the physician may be unsure if an ATB is truly needed. If there is concern about this patient, then the doctor may understandably prescribe the ATB, just in case the illness is a bacterial infection. (ATBs are effective against bacterial infections, but are not effective against more common viral infections including common colds.) Doctors often must make recommendations and decisions based on incomplete information. Wouldn’t it be nice if we knew with 100% certainty if a sick patient needed surgery, as many medical malpractice attorneys believe?

However, I am not referring to prescribing ATBs when the clinical situation is unclear. I refer to situations where they are clearly not indicated, and should not have been prescribed.

Over the years, I have seen numerous cases of ‘diverticulitis’, ‘sinusitis’, ‘touches of pneumonias’, upper respiratory infections, coughs, colds and various sore throats all treated with ATBs. Many of these patients received a 2nd course of ATBs when the condition persisted or recurred. In many of them, these drugs were simply not needed. Don’t think that ATBs were mere placebos. Unlike true placebos, ATB have real medical risks and can cause harm.

Of course, it’s possible that my medical judgment is flawed and that these patients truly needed ATBs, and it was lucky these folks had sharper physicians who recognized this. However, ask any doctor – including yours – if the ATB trigger is pulled too quickly. If the doctor says no, then get a second opinion.

So, why does this happen?

  • Patients demand it, convinced that they need it. This belief is strengthened if prior physicians have provided them with ATB ‘Kool Aide’ for the same viral symptoms.
  • Patients who are told only to rest and drink fluids may not believe they received sufficient medical care. “He did nothing for me. Who needed this appointment? For this I took off work?”
  • It may take 15 minutes to convince a patient that ATB are not needed, and only 10 seconds to prescribe one. Additionally, some patients can’t be convinced by any argument.
  • Physicians want to keep their patients satisfied. This will become more relevant when patient satisfaction reporting will be tied to physician reimbursement. Won’t that be ironic if lower quality care that patients approve of will reward doctors?
  • Physicians may falsely believe that prescribing an ATB reduces their legal vulnerability, arguing that the ATB is evidence of active treatment against the condition. For some reason, physicians don’t fear being sued if an unnecessary ATB causes a medical complication or a serious side-effect.
Overutilization of ATBs costs money and exposes patients to unnecessary risks. I’m also philosophically hostile to any treatment or medical test that is not needed. Additionally, medical experts have warned us for a few decades that the tsunami of ATBs that are prescribed so casually is breeding out superbugs that resist our available ATBs. It is tragic when a patient is severely ill from a true bacterial infection, and the necessary ATBs won’t work because the germ overpowers it.

So, the next time you have the sniffles and you’re in your doctor’s office, make sure you demand the right treatment. And, if you leave without a prescription, don’t feel that the doctor did nothing for you. He may have done quite a lot for you. And, that's nothing to sneeze at.