Sunday, February 10, 2013

New York City Soda Ban is a Hard Swallow

New Yorkers are headed toward leaner times.  The New York City Health Board recently approved a ban on large sized soft drinks proposed by Mayor Michael Bloomberg.  Is Big Government now targeting Big People’s Big Drinks?  Does the government have the right to restrict free choice 0n what we eat or drink?  Does the argument that this is a necessary public policy initiative pass the smell (or taste) test?  Will this edict result in measurable weight loss?  Do we know as fact that weight loss saves health care dollars or do we assume so simply because the conclusion appears logical?
First, the policy is riddled with nonsensical exceptions.  If banning large drinks is right and proper, then why not ban them all, not just certain sizes at certain establishments.  Does it make sense to ban large drinks at movie theaters, but permit continued guzzling at convenience stores and vending machines?  If the product is evil, then shouldn’t any size of these life threatening beverages be poured down the drain?  Does it make sense that unlimited refills of smaller size sodas are permitted?  So far, does the policy seem rational and coherent?
Once the measure takes effect in March, movie patrons can still live dangerously and stay within the law simply by ordering several smaller sizes of the poison potions.  Thirsty customers can outfox the ban by purchasing multiple smaller sodas.  These folks who are carrying 3 or 4 small size drinks, rather than a supersize beverage, could easily spill them placing themselves and other moviegoers at risk of serious injury.  Those who adhere to the letter and spirit of the new policy by purchasing only a single small beverage may not have sufficient liquid to wash down the palm oil coated popcorn.  As a gastroenterologist, I foresee several cases of clogged esophaguses with popcorn gumming up gullets. I think the government will have huge legal exposure on this issue.
Popcorn - An Innocent Victim
Do we think that New Yorkers who are forbidden to purchase large size drinks at certain locales will seek out celery stalks and carrot sticks? 
Folks who try hard to lose weight have a hard time doing so.  Folks under the ban won’t get slimmer just because the government restricts one food class at a certain size at some locations. 
Why stop at soda?  If pop is the enemy, then shouldn’t ice cream, candy, cake, doughnuts and fried foods be prohibited?  I am sure there are those who would support a government mandated menu that we would all be forced to swallow.  For these do gooders, government knows best.
Explain to me please why banning soda is necessary public policy while liquor and cigarettes are legal in any quantity.
I want to drink what I choose.  But I'm not drinking the Kool Aid.

Sunday, February 3, 2013

Same Day Doctor Appointments? Read the Fine Print

Cleveland and northeast Ohio are not hospitable to private practice medicine.  I should know.  I’m one of them.  Private practice is fading as health care reform suffocates it by design.  When this occurs, the public will have lost physicians who, in my view, have practiced patient advocacy and service at a higher level than our employed counterparts.  Keep in mind that the first half of my professional career was spent as an employed physician and the latter half as a private practitioner.  So, I know the advantages and drawbacks of each model first hand. Of course, there are employed physicians who are outstanding doctors and private practitioners who are not, but I maintain that a physician who owns his business has a stronger incentive to provide excellent service to patients and to referring physicians.  This just makes sense.  Don’t we find that when we shop or dine out or stay at a Bed and Breakfast that there is a different level of service from those who own these businesses?  If a store closes at 5:00 pm and you arrive at the locked door at 5:05, would your chances of gaining entry inside be greater if the boss were there rather than an employee?  Get the point?

I recognize and have expressed in this blog that there are advantages to the employed physician model which eliminates and reduces conflicts of interest that confront those of us who practice in the private arena.  However, doctors on salary and the institutions that employ them face their own unique conflicts and challenges that can interfere with their healing mission.  Fee-for-service medicine leads to over-utilization while models that restrain costs may restrict care, access and service to patients. 

One service that our small gastroenterology practice offers is rapid access for patients who need or desire an expeditious appointment.  This is tough for sprawling and expansive group practices, as we have in our neighborhood, to duplicate.  Yet they try.  The big dog medical institution in town is now advertising that they guarantee a same day appointment to any patient who desires it.  Sounds good so far.  I wondered how they could pull this off since it’s a vexing task for me even to reach these docs on the phone, let alone try to arrange a timely appointment for one of my patients.  Here’s the sleight of hand.  Sure, the institution will grant the patient an appointment, but it’s not with his doctor and may even be across town in a satellite location.  Is this what most of us have in mind for a same day appointment?  While it’s a tricky marketing ploy, it’s a poor play at customer service.  These patients would do better to present to a local urgent care, which offers a same day visit with a doctor who is likely less than 10 minutes away.

Years from now, when we are all enjoying Cadillac care at Chevrolet prices, where will I be?   Private practice will be long gone, but my skills will still be useful.  I’m hoping I can land a position as a docent in the Fee-for-Service wing in the Museum of Medical History.   I’ll be paid on salary, of course, like doctors will be everywhere. 

Sunday, January 27, 2013

Serenity Prayer Can Ease Chronic Pain

One of the toughest parts of treating patients is managing their expectations.  We wish that everyone could enjoy a perfect recovery with complete healing, but the medical profession is imperfect and life is unfair.  Some folks cruise by decade after decade without a scratch, while others sag under the weight of chronic illnesses.   Accepting reasonable expectations can change the game for patients and their families.  If the patient’s expectations exceed what is possible, then the patient will never be satisfied and the dissatisfaction may assume a life of its own, which can torment with virulence equal to the disease.   Second and third opinions may be sought, which usually lead to more testing and frustration.  Learning to accept what is possible – though enormously challenging – creates a path toward leading a fuller and more satisfying life.   While I haven’t been burdened with a chronic disease, I do personally understand that acceptance of a situation opens a path toward healing. 

You have just experienced the joy and delight of a colonoscopy.   The physician approaches you afterwards to inform you of the results.  Which of the following  hypothetical responses would you prefer?

We found a lesion in the large intestine that we are very concerned about.  The biopsies will be available in 48 hours. 

The colonoscopy was completely normal.

Of course, I am not entirely serious here.  We all hope and pray for the second response.  Yet, often, when I reassure patients that their colons are pristine, many react with frustration and disappointment.  This usually occurs with patients who are suffering chronic abdominal pain and distress and are desperately seeking a concrete explanation for their symptoms.  They enter the colonoscopy suite with stratospheric expectations that my scope will crack the code of what has stymied other physicians for years.  These expectations are fueled when other doctors they have seen advised that their pain is clearly coming from their stomach and intestines.  So, when the CAT scans and ultrasounds and blood tests and emergency room visits are all non-diagnostic, they want to believe that the light of the colonoscope will illuminate the diagnosis.

The light of my scope is really quite limited.  It’s an accurate tool for many conditions, but is a clumsy diagnostician for chronic pain.  Of course, the pain is real.  But, our tools to identify its cause are often crude and inaccurate.  In some instances, of course, there may be an occult diagnosis that the physician has overlooked.  In most cases, however, the pain has no identifiable medical explanation. 

At some point, a patient with chronic, unexplained pain must veer away from the quest to find its cause and onto the journey of living as full a life as possible with the condition.  The choice may be ruling over the disease or being ruled by it. 

Blogging about this is easy and comfortable, particularly when your humble scrivener is not suffering chronic pain.  But I have seen patients who summon grit and moxie to stay in charge of their symptoms and their lives.  They might not reach the end zone in one play or two, but they are steadily moving the ball downfield.  Their efforts and successes are inspiring.  I hope I have learned something from them.

Life is unfair and unpredictable.  Which path do we choose when we are challenged?

God grant me the serenity 
to accept the things I cannot change; 
courage to change the things I can;
and wisdom to know the difference.

Sunday, January 20, 2013

Medical Malpractice, Tort Reform and James Bond? Let Me Explain.

Sometimes, I feel like I belong in law enforcement.   There was a time in my life that I seriously considered a career where I would haul in the bad guys and make society a better place.   Of course, every American male youngster fantasized that he would one day drive the Aston Martin, get the girl, defuse the bomb, and sip on a martini that was shaken, not stirred.  I was no different.  I was 10 years old then when my pal Lewis and I were secret agents with the requisite weapons, invisible ink and secret codes.   At the risk of disclosing that I have a tincture of obsessive compulsiveness, I still retain the files of our secret organization.  While Lewis has expressed concern that these files in the wrong hands could threaten international order, I have reassured him that the enemies of mankind will be unable conquer our layers of sophisticated encryption.  At risk of being accused of hyperbole, Israeli and American intelligence agencies studied our secret files as a template for the Stuxnet worm.   

I have had many patients who are law enforcement professionals.  I respect them and the work they do.  I have had patients who served in the FBI, the Secret Service and all levels of local law enforcement. I feel a kinship with these folks.  Like a community gastroenterologist, much of what they do is routine.  We both endure endless paperwork that often seems to serve no useful function.  We both are exposed to extremes of the human condition.  We both get scared.  We both serve a public that is sometimes skeptical of our biases and motivations.  We both may need to make urgent decisions relying upon our training, experience and instincts.   We both deeply understand that sometimes the right decision leads to a dark result.

Last November in Cleveland, 2 people were killed by police after a harrowing high-speed chase.  It was a tragic finale that left many painful and raw questions.  Thirteen officers fired 137 rounds that killed two citizens who were ultimately found to be unarmed.  Understandably, there was outrage in the communities, and the matter continues to be under investigation.  As expected, the initial facts were murky and in dispute.  Anger and haste are poor catalysts to develop the truth. 

I have no opinion at this time if law enforcement personnel should have held their fire and pursued a non-lethal strategy of capturing these two individuals who were fleeing from them at high velocity.  A dispassionate investigation will determine this.

But, while it absolutely necessary to investigate this tragic episode, as a doctor, I am very sensitive about being judged after the fact by investigators who have endless manpower, resources, audio and video evidence and months of time to evaluate the propriety of a split second decision.   A catastrophic outcome is not evidence of negligence, despite the ease of reaching this conclusion, particularly by those who have been injured and their families.  In addition, a fair judgment on what transpired must consider the context of one who had to make an immediate decision to act.  If an investigation requires a 4 month inquiry involving dozens of professionals to conclude that an officer erred, could the policeman be expected to reach the same conclusion in 2 seconds in the field? 

When football referees review a call on the field, sometimes the call is reversed.  Of course, the review offers instant replay in slow motion at various angles, none of which were available to the official who first made the call.  Get the point?

None of us envies a cop who faces a situation where he must discharge his weapon.  Sure, there is training, but as every professional knows, one can’t train for every contingency.  This is not a board exam; this is real life with lethal consequences and no time to ponder the alternatives.   Was the suspect reaching for a weapon or an innocuous item?  I can’t imagine the lifelong trauma one would endure after killing another person, even if this was a necessary act.  I suspect it would be a greater trauma if a policeman didn’t pull the trigger when he should have, and missed the opportunity to save innocent lives. 

I was raised to respect law enforcement, and I do.   While their job is tougher than mine, I can personally relate to their profession.   We both serve and protect the public.  We both make decisions based on what we know at the time, which is often less than we want to know.  We agonize when something awful happens and wonder if we contributed to the outcome.

There’s something else that binds our professions.  We both are often judged retrospectively by those who weren’t there when we were blinded by white heat and couldn’t see then what later seems to be in such clear focus. 

We learn from our errors and misadventures.   As readers know, I believe that the negligent must be accountable for their actions and resultant consequences.  The process to determine this, however, must operate at the highest level of fairness and integrity.   Too often, this standard is not achieved or even reached for. 

And now, my thoughts wander back to Miss Moneypenny, ‘Q’, boat chases and ejector seats, when I contemplated a profession that I know now is better left to other others.

Sunday, January 13, 2013

Is Colonoscopy the Best Colon Cancer Screening Test?

The medical arena, like society at large, is permeated with self-interest. This reality makes me very skeptical that comparative effectiveness research, which I support, will get airborne. In medicine, every heath care reform, new medicine, new medical device or revised medical guideline is at some constituency’s expense.  Recognizing and dismantling conflicts of interests is one of our greatest challenges and threats. 

When I was a gastroenterology fellow over 20 years, our department was active in new technologies to crush and dissolve gallstones and stones that had wandered from the gallbladder into the liver pipes. Millions of dollars of R & D were spent and the procedures were done in specialized centers in the U.S and abroad. The treatments were cumbersome and only modestly effective, but the treatments continued year after year. Then, laparoscopic cholecystectomy arrived, a new operation that could remove gallbladders with much less pain and recovery time. At that moment, the gallstone dissolving business dissolved. As endoscopic techniques improved, gastroenterologists could safely and easily remove stones from the liver pipes, which became the preferred method for accomplishing this objective.  These outcomes served the public good, but this is not always the case. .

New medical developments are often pursued for both marketing and medical reasons. Large medical institutions will spend mightily for the latest high-tech robotic laser shooting burger-flipping tumor ray gun, even if (especially if) the competitor across the street already has one. Here in Cleveland, I suspect we have a mind numbing duplication of medical services in a very tight geographic reason. Since availability correlates with usage, I surmise that we are a model of overtesting and overtreatment. I am not assigning blame. Indeed, I need to be reeducated as much as anyone since we all practice medicine in a culture of excess.

The prism that should be used to view new medical development is if it serves the greater good. Many folks, however, define the greater good to be any outcome that coincides with their own parochial concerns. Conversely, if a particularly group is threatened by a medical advance, then it will be alleged that the greater good will surely suffer.

To a gastroenterologist, 50 is a milestone year. This is the age that we pounce upon you to scour your colon to remove cancers-in-waiting. While we champion this test, and sincerely believe in its worth, it is not ideal. Here are some drawbacks.

  • The pre-colonoscopy cathartic cocktail
  • Anxiety
  • Discomfort (no it’s not always painless)
  • Cost
  • Risk of complications
  • High rate of negative results
  • Loss of a day’s wages or personal enjoyment
  • Need for a driver
What will gastroenterologists' reaction be when a better test threatens to retire our colonoscopes? Will we defend colonoscopy against a simple analysis of a person's stool which is just as effective? Will we claim that the research behind the new development is flawed? Gastroenterologists have successfully prevailed against CAT colonography, a competing test which examines the entire colon for polyps using a CAT scan. We have the edge in this duel since patients who pursue the CAT scan option must still take a vigorous laxative and, if polyps are discovered, they cannot be removed. Colonoscopy’s unrivaled advantage is that it can remove nearly all polyps discovered. It’s one stop shopping.  If radiologists perfect the technique of performing a CAT colonography without any required laxatives, then the scales may tip in their favor. 

The above vignette is not a futuristic hypothetical creation. I suspect that colonoscopy and CAT colonography will be properly forced out during my own career as colon cancer screening techniques. Colonoscopy will still be performed, but only when some kinder and gentler screening test indicates that an individual has a high probability of harboring polyps. It will no longer be wielded in a buckshot fashion.  The number of colonoscopies being performed will be decimated.

When that happens, it will not be good news for the Kirsch family. But, it will be greater good news for everyone else’s family.

Sunday, January 6, 2013

Medical Quality: Myth or Science?

On the morning that I began this post, I read in our local newspaper that Tennessee is soon expected to have a law that would permit public school teachers to offer views on climate change and evolution that are counter to orthodox doctrine on these subjects.

No, I don’t think that creationism is science and it should not be disguised as such. Global warming, or climate change, however, is more nuanced. While it is inarguable that temperatures have been rising, it is not certain and to what extent human activities are responsible for this. Clearly, this issue has been contaminated by politically correct warriors and those who have an agenda against fossil fuel use. Science, like all scholarship, should be a pursuit of the truth, without a destination in sight. Believing or wanting to believe that man is turning the world’s heat up may sound plausible, but it may not be true.

Just because something sounds true and logical, doesn’t make it so. In addition, repeating an opinion like a mantra isn’t sufficient to confer legitimacy on a view. Zealots and partisans gainsay these inconvenient truths.

In the medical universe, much is presented as true, which may be either false or unproved. Consider how many established medical procedures and practices have no underlying science to buttress them. Consider the following examples and decide if you agree that each is a good idea that makes sense.  Do they sound right or are they truly sound?

  • Patients should have regular physical examinations as an integral part of preventive medicine.
  • Patients should undergo a CAT scan of the chest and abdomen at age 50 in order to detect any silent lesions that may be present, before they have an opportunity to grow and threaten the patient.
  • Medical care is superior in large medical centers because physicians there have access to the best minds and technology.
  • If you have fever and a cough, it’s best to begin antibiotics early before pneumonia can develop.
  • Everyone should restrict their salt intake.
  • Probiotics facilitate good digestion and should be part of a healthful diet.
  • Placing stents in narrowed arteries helps patients live longer by allowing for increased blood flow.
  • Cardiologists are more skilled at managing high blood pressure than general internists because of additional training and experience.
  • A back x-ray is important to evaluate new back pain to exclude a fracture or other serious condition.
  • Everyone should receive medication to lower their cholesterol levels, even if the levels are ‘normal’, as this will reduce risks of developing heart disease.
  • Alternative and complementary medicine are safe and effective and should be incorporated into mainstream medical practice.
  • Colonoscopy is a fun and exciting event that everyone should enjoy often.
  • Medical bloggers who spew forth sarcasm need to be chastised and publicly humiliated.
So, let’s not label the backwoods Tennessee folks as backwards too quickly. Medicine and climate change have common elements. Both are suffused with politics, to their detriment. Remember Mammogate? Proponents of both make spirited claims without scientific basis, and attack principled dissenters as outlying heretics. Count me as one of them. Someone has to blow the whistle here.

I have something in common with climate change myself. When I read about myth masquerading as fact, I find that my own temperature starts rising.