Medical Overdiagnosis and Overtreatment - Do Physicians Want Cost Control?

Truth is more absurd than fiction.  Mayor Michael Bloomberg’s wacky ban on certain sizes of sugary beverages, a scheme which was riddled with inconsistencies and exceptions, was properly squashed by a New York judge.  The mayor’s next play was to order all establishments that sell cigarettes to hide them from patrons.  I hope that this policy is examined in the same courtroom that ruled that the leaky soda ban was illegal.  Is this guy a mayor or an emperor?  Who can legitimately defend the government dictating to private businesses how they can display legal products to its customers?  Where would candy, potato chips and other poisonous snack foods be sequestered? 

Speaking of sequestration, which the president warned would crush the country, the earth still rotates, the sun rises in the morning and congress has a 15% approval rating.  In other words, not much has changed. 

We learned that there was not enough cash to fund White House tours for school kids.  Yet, we learned that Vice President Biden and his entourage spent $585,000 for a single night in a Paris hotel last month.  The VEEP & Co. were more frugal when they stayed in London on the same gig when the price tag for one night was a mere $459,000.  This seems a smidgen extravagant during such economically lean times and conveys a message of prodigal excess to the hoi polloi.   Is it possible that some of the expense for these 2 nights was excessive?  Was every government official on this junket essential to advance American interests?  While I don’t suggest that the VEEP stay in a Bed & Breakfast or a youth hostel, I’ll bet that these obscene hotel costs could have been reduced without jeopardizing our foreign policy interests.

 

$585,000 + $459,000 = Lots of White House Tours for Kids

 Motel 6 Next time?

I know from my own profession how many zillions of dollars are wasted that generate income for various constituencies but don’t advance the greater good.  I have admitted repeatedly that I and my colleagues are one of these constituencies.  While the phrase cutting waste is an attractive populistic utterance, the substitute phrase cutting income is more provocative.   Every dollar of waste is someone’s income who likely doesn’t view his earnings as wasteful spending.  Of course, this is not particular to the medical arena; it’s true of every profession, trade and institution.

I have railed in this blog about the explosion of unnecessary radiology testing in medicine.   CAT scans of the abdomen have largely replaced physicians’ examining abdomens, similar to how echocardiograms have replaced actual physicians discerning subtle heart sounds and murmurs with the antiquated medical instrument known as a stethoscope.   While those who overdiagnose and overtreat, including gastroenterologists, justify their practice patterns as sound medicine, watch these practice styles screech to a halt once punitive payment policies against medical overuse are implemented. 

This week I saw a patient with abdominal pain who had a normal ultrasound of the abdomen 2 days prior to hospitalization at another institution.  The dictated report was on the chart for all to review.  The attending physician had ordered a special gallbladder test, but the radiologist had insisted that an ultrasound be repeated first.   Did we expect that a 2^nd ultrasound 48 hours later would show new findings?

I see this stuff every day and it is these observations that led to the creation of this blog.  There is waste in the care of every patient, including mine, but the system has been immobile and immutable.  The medical industrial complex is a lumbering ocean liner whose course extraordinarily difficult to alter.  Every real reform threatens powerful, highly motivated and well-funded players. 

Obamacare has smashed through the barricades and promised to be the panacea that eluded us for over half a century.  I have been a deep skeptic and my skepticism has deepened with time, along with the rest of the country.  Let’s watch what actually happens to medical costs and quality as the government rules and regulations coerce doctors, patients and employers.  When the myths of Obamacare are exposed, will the president come clean to our kids when they are finally allowed to visit the White House?

Sequestration Closes the White House

Fortunately, the sequester did not incinerate Caribou Coffee, where I suck down several hot chocolates each week.  Luckily, Cleveland hasn’t passed a Big Government Big Edict against Big Beverages, as Mayor Michael Bloomberg rammed through last year in New York City.  Recently, a New York state judge refused to drink the mayor’s Kool Aid and ruled against the absurd, loophole-ridden government intrusion.  

Sorry, Mike.  I suggest that you console yourself with a beer, which apparently is much safer than soda since no restrictions were placed on sizes of alcoholic beverages that may be sold.     

I will try to crank out at a blog post now, but my heart is ponderous as I contemplate the plight of our nation’s children.   The barricades have been erected at 1600 Pennsylvania Ave.  White House tours have been cancelled, yet another apocalyptic consequence of sequestration.  It’s not clear to me who was responsible for this.  The White House?  The Secret Service?  Personally, I think it must be George Bush’s fault and expect that Harry Reid and Nancy Pelosi will soon declare this publicly. 

Sorry kids.

The Obama administration faults the GOP for failing to ‘compromise’ on what they describe as a balanced approach to our nation’s fiscal situation.  Let me elucidate the meaning of the word compromise.  It means surrender and cave.  The Dems want more revenue, aka taxes, although the GOP just consented to a gazillion or so dollars of tax increases on the wealthy, which took effect on January 1^st.  Wasn’t that a compromise?  If the GOP cave again now, or should I say compromise, does any breathing American believe that they won’t be asked to do again and again?

One thing is for sure.  Both sides have only one issue on their minds – the 2014 midterm elections.  I predict that the GOP will retain the House and that the intransigence will persist.  Then, for the next 2 years, both sides will calculate every uttered syllable and act toward prevailing in the upcoming presidential election.  Remind me, why is the world laughing at us?  There’s something to be said for benevolent dictatorships.

Who can help to diffuse the hyperpartisanship and tamp down the political hyperventilating?   Who can cut through the Machiavellian maelstrom to bring sanity to chaos?  There is a singularly gifted individual has the requisite diplomatic skills to triumph in this mission impossible.  America needs Dennis Rodman now more than ever. 

Who’s going to break the news to our kids that the White House is off limits?  We may need to recruit professional counselors to manage their grief, but there may be a dearth of therapists who have been decimated by the sequester.  A spoonful of Haagen Dazs can help ease the bitter medicine down our youngsters' gullets.  (I mention the word gullet so I can justify this rant in a medical blog.)   Let’s give each of our neglected kids a milkshake to calm and comfort them, while this beverage is still legal.

Metatstatic Medical Regulations and Health Care Reform - Job Security for Bureaucrats

This week I promised you specific examples of dumb rules that we doctors must comply with. Here are just a few.  There are enough ridiculous regulations to fill multiple blogs devoted only to this issue posting hourly around the clock.  Yeah, I sound a mite cranky now.  The truth is that I still enjoy the work of doctoring.  I love my time with my patients.  There is, however, an increasing burden of stuff thrust upon us that takes time, energy and money away from our healing mission.   Perhaps, these regs are solving someone’s problem somewhere.  I suppose that this should comfort me knowing that somewhere in a government cubicle, a bureaucrat is smiling.

Floor Plan of Cubicles Where Health Care is Reformed

•        We are required to ask patients their ethnicity.  Of course, many of them including myself are uncertain how to respond to this accurately.  I’m sure that our staff conveys an impression of knowledge and professionalism when they shrug their shoulders in cluelessness after patients ask the purpose of this inquiry.      
•      A few times per week, I am given a several pages of forms to sign off on.  This lists all the patients whom I have joyously performed procedures on recently and the sedation that I administered.  Of course, I cannot recall any of these interactions days later.  I have been told that signing this complies with some requirement issued from a windowless government office located somewhere within the Milky Way.  I can assure readers with total certitude that this act helps no living or deceased human being, or provides any beneficial function for the medical profession or any other occupation.  It is possible that this provides employment for a government sinecure, so perhaps my signature helps to contain unemployment.  Call me a patriot.
•       We have to report to Medicare on every single patient we perform a procedure on if he suffered a burn or fell down.  Let me come clean with readers and disclose our stats on these two misadventures.  After successfully probing tens of thousands of patients, none has taken a tumble or been singed by lightning.  We are also required to report if pre-operative antibiotics were administered on time.  Sounds good except years pass before we ever give a patient antibiotics before a colonoscopy.  The government, hungry for data, makes us send in a code on every patient that didn’t receive antibiotics, which is 99.97% of them.  So, why the reporting mandates?  Because our endoscopy center is lumped into the same category with facilities that perform actual surgeries.  Ever hear the phrase ‘one size fits all’?  Where do these right wing ideologues get the idea that there’s any waste in Medicare? 
•       We cannot discuss off label use of medications with pharmaceutical representatives, a silly rule that I discussed in a prior post.  Like many regs, there’s a rational basis for it, but it morphed into OperationOVERKILL.  This reminds me of the anecdote of a young boy who was punished when he kissed a girl in school.  An innocent romantic gesture?  Hardly. This was a brazen violation of an ironclad sexual harassment policy.  Luckily, the third greater only planted a buss on the cheek.  If there had been unwelcome lip contact, then the youngster may have been whisked out of the country to endure extraordinary rendition and enhanced interrogation techniques. 

If a principal of a school is fed up with kids running in the halls, should all kids be required to have their ankles shackled so that compliance with school policy cannot be violated?  If you don’t regard this hypothetical as silly, then please stop reading this blog.  You were probably one of those kindergarten miscreants who played pat-a-cake with a kid of the opposite gender.  Touching another kid’s skin is verboten and is a clear stepping stone to playing tag, flag football and other delinquent activities.  I think that all children under the age of 10 should be required to wear mittens while on school property.  Boys who cannot control their lips should be fitted with muzzles.  Let’s do this for our kids. 

If anyone out there has their own rules and regulations tales, pray tell.

Medical Regulations Run Amok!

This post is a two-parter.  Readers, forgive me.  When I completed it in one of Cleveland’s finest culinary establishments, a building adorned with two arches, the word count approached 1000, and I couldn’t subject readers to a post of this length.  This is not a sneaky device to lure you back next week for the stunning conclusion, reminiscent of the old Batman TV show where we would have to wait for the 2^nd episode to witness Adam West and Burt Ward save themselves from a seemingly fatal fate. 

Using Sonar to Detect Gotham City Villains

I don’t love rules and regulations, though I’m hardly a lawless renegade.  I was an obedient youngster who reliably colored inside of the lines.  I went through adolescence with barely a squeak of rebellion and earned a college diploma without plagiarizing.  In my personal and professional life, I try to maintain a comfortable distance separating my conduct from looser behavior that would still be considered reasonable.

But, some rules are so enigmatic that we need to recruit our greatest minds to explain their existence.  Many of these edicts are usually wild over-compensations addressing some narrow conflict or minor offense.  Instead of acting surgically, these bureaucratic blunderbusses aim everywhere hoping that one of their lead balls will find the desired target.

These absurdities are not restricted to the medical arena.  I stumbled across this piece this very week describing a young boy who was suspended from school for two days.  I have attached the link here so that readers can appreciate how nefarious and dangerous this young man is.  It’s a chilling vignette that reinforces the need to adopt zero tolerance for weapons on school grounds.  Frankly, I think the kid should have been expelled and his irresponsible parents prosecuted for providing their child with weapons-grade material that he clandestinely secured in his lunch box.  While I have been skeptical with regard to gun control, this tale of horror has caused my position to shift.

In medicine, we have rules and requirements that would make patients’ heads spin with such acceleration, that they might actually become airborne like helicopters.

The hoops that we jump through daily with respect to billing and coding are an adventure that I suspect no other profession can relate to.  In our office, have a team of dedicated professionals who each day enter the byzantine, labyrinthine hall of mirrors which can test the nerves of the most hardened warriors.  While the ‘paperwork’ is all electronic, if the wrong punctuation mark is entered, it risks destroying western civilization, or disrupting the nation’s energy grid, at the very least.   Next week I will offer just a few specific examples of senseless regulations that our practice faces every day.  If any reader suspects that I made stuff up for effect or amusement, I assure you that my imagination isn’t that developed.   So much of the new and improved health care system has become towering arcade of insanity that was designed and enforced by those who marvel at the inferno of frustration that they created.  All I know is that nearly none of it helps doctors or patients, whom I still think are the essential players in the medical arena.

Think of your own lives and occupations.  Is there dumb stuff you have to do that makes no sense?  Let us hear from you now.  Sharing is caring.  

Obama or the Whistleblower - Which One Has Hubris?

I love words.  Call me a logophile as well as a blogophile.  When I write, I never resort to a thesaurus.  I enjoy the struggle of trying to find the right word.  There’s not a day that passes that I am not in the dictionary looking up a new word, or more likely, looking up the definition of a word for the 3^rd or 4^th time whose meaning I cannot retain.  I find that until I use the word, the definition is dangling out of reach.   There are many words that I think I use correctly, yet when I verify the actual definition, I find that I have been using the word more creatively than, perhaps, I should. 

Indeed, recently I engaged in some verbal sparring over the word responsive.  I had thought that this word could be used to describe a response to an inquiry that was on point, not evasive and forthrightly addressed the matter at hand, yet I did not find this meaning included in the definition of standard dictionaries.

Here’s how I have used the word.

“Have you read the latest Whistleblower masterpiece?  Doesn’t that guy have a great wit?”

“I think his blog is part of a vast right wing conspiracy and he should be thrown over the fiscal cliff!”

While the response above may be true, I would describe it as not responsive to the initial inquiry.

Here’s the dictionary entry:

re·spon·sive  

/riˈspänsiv/

Adjective 1.      Reacting quickly and positively. 2.      Responding readily and with interest or enthusiasm. While my meaning is not included above, I’m not ready to wave the white flag here.  Being quite sure that this term is used regularly by lawyers when attacking a witness’s answer as being not responsive, I consulted informally with an attorney acquaintance of mine.  I will keep his identity private as if his colleagues discover that he rendered any advice without a clock ticking, I would fear for his personal security.  This officer of the court confirmed that my usage is proper. So, I am not prepared to concede and am girding my loins for further verbal lexical combat.

In days of yore, there were several hard cover dictionaries strewn about the house, and another in my office. I am reluctant to admit publicly that it was a delight for me to slowly turn the pages and scan word entries, lest if my kids read this, they may erroneously conclude that their father is a nerd.  There’s not a nerd bone in my hip & groovy body.  Yes, I read our encyclopedia from cover to cover as a youngster.  Didn’t everybody?    And so I turn C-SPAN on from time to time...

What All the Cool Kids Read

Consider the word hubris.  What does it mean precisely?  Is it arrogance?  Smugness?  Superciliousness? 

Here’s Merriam Webster’s definition:

Exaggerated pride or self-confidence.

One could say that there is plenty of hubris in this blog, although I deny that the author suffers this flaw.  I am but a modest and humble scrivener.  I agree, however, that there is hubris contained within the Whistleblower pages.  When I post on Obamacare and its Democratic cheerleaders, one can’t ignore their hubris.  When I describe a plaintiffs’ bar that asserts that the tort system is a paragon of justice, it is beyond a reasonable doubt that these guys are guilty of hubris.  When I write of physicians who defend their parochial interests over the greater good, readers rightly sense an overdose of hubris. 

Perhaps, I am truly the smug one here.  Indeed there have been comments over the past few years that have diagnosed me with Smarmyitis.  If you are not familiar with this malady, see below.

Here's the definition:

Definition of SMARMY

1

: revealing or marked by a smug, ingratiating, or false earnestness smarmy

 self-satisfaction 

2

: of low sleazy taste or quality <smarmy eroticism>

Do current readers concur with this diagnosis?   Should I seek a second opinion?  Kindly leave comments which I hope will lack hubris and be very responsive. 

Shout out to NZ and to LSP for being players in a responsive repartee.

Do Probiotics Work? Marketing Mania Tramples Science

My kids know that I enjoy a spirited argument.   During the days when the dinner table was our public forum, I tried hard to offer a responsible voice of dissent on the issues before us.  I admit now that the view I espoused was not always my own, but one that I felt merited inclusion in the discussion.  I still do this with them and to others in my life who are willing to succumb to probing of the mind.   I willingly subject my own mind to the same process. 

Because I am a gastroenterologist, folks assume that I have special expertise in nutrition.  I should, but I don’t.  Perhaps, medical education has evolved since I was in medical training, but in my day, a soft subject like nutrition was bypassed.   I am hopeful that I can remedy this knowledge vacuum in the years ahead.

These days, nutrition is part of the burgeoning tsunami of wellness medicine, a discipline that races beyond known science as it seeps into the marketplace.

Several times a week, I am queried on my view of probiotics, which are bacteria that confer health benefits on the human who ingests them.   If you were to survey the public, I suspect that a majority would express that probiotics promote health and are effective in treating or preventing various maladies.
  

These products are included in the billion dollar enterprise of alternative medicine that is not subjected to any Food and Drug Administration (FDA) oversight.  Their claims are very difficult to study and there is no standardization in the industry of what constitutes probiotic treatment. This a different universe that conventional drugs inhabit.  These medicines, prescribed by physicians, are subjected to rigorous oversight by the FDA and must demonstrate safety and efficacy.  Alternative product purveyors, free from these constraints, can appeal to our New Age beliefs with promises that are seductive but unproven.  They promise better health but don’t have to prove anything. 

If you were in the business of selling medicine, would you choose to spend gazillions dollars and several years praying your drug gets through the FDA, or promote a probiotic that a public is ready to swallow on faith?   If you’re stuck on this question, then consider my alternative blog MDWhistleblower for Dummies for remediation.

Do probiotics treat or prevent disease?  Are these companies overpromising?   Clearly,  the marketing claims are a light year or two beyond verifiable and supportive science. 

I know that many of us want probiotics to be the panacea for what ails us.  I know that wellness and preventive medicine have become a religion for many of us.  I suggest that we need some Old Fashioned wisdom to restrain New Age converts.

Don’t misunderstand me.  I’m not dissing Alternative Medicine acolytes.  Does their stuff really work or is  belief of efficacy sufficient?   Why aren’t these companies utilizing the scientific method to determine if their potions are just placebos?   Kick this issue around your own dinner table and make sure that dissent is on the menu.