Sunday, March 9, 2014

Can Private Practice Survive?



Just read another article forecasting the demise of private practice, which is the model I practice in.  We certainly feel the squeeze here in Cleveland, where our small gastroenterology (GI) practice is suffering from some breathlessness as surrounding health care institutions suck up oxygen in the community.

Now, being deprived of oxygen isn’t necessarily fatal.  Many patients suffer from diseases that result in low oxygen levels in their blood.  Folks who live at high altitudes don’t have the same concentration of oxygen available as do those who reside at sea level.  Yet, they live active lives.

How do these folks survive?  Do they have lessons for my GI practice?

Take a Deep Breath...

Here are some options that help individuals with low oxygen levels breathe easier.
  • Receive supplemental oxygen using an oxygen tank.  No analogous solution for my medical practice here.  For us, the ‘oxygen level’ can’t be artificially increased.
  • Reduce activity level to minimize oxygen requirement.  This is why folks with respiratory conditions tend to remain sedentary so they can function at a lower oxygen level.  Not sure if there’s a lesson here for our practice.  Do we move more slowly in the office?  Do we see fewer patients?  If we doctors used oxygen tanks, would this inject more vitality into the practice?
  • Attack the root cause of the oxygen assault.  If the cause of a patient’s low oxygen is pneumonia, then prescribe the right antibiotic to reverse the injury.  If the doctors in our practice attacked the proximate cause of our oxygen deprivation, we could go to jail. 
  • Train at a high altitude locale for athletic competition in the lowlands.  Marathoners seek out high altitude training courses to build endurance in preparation for the big race down below.  Perhaps, we should move our practice to high altitude Colorado for a year.  After doing colonoscopies there for a year, imagine the increase in our performance when we returned to Cleveland?  I will place this on the agenda of our upcoming practice meeting. 

Great choices for us.  Breathe less, do less or move.


Sunday, March 2, 2014

Feed a Cold and Starve a Fever? Not on my Watch


Physicians and patients collaborate to treat symptoms.   This is not newsworthy and even sounds appropriate.  Isn’t that what doctors are trained to do?   It is but I’m not sure this should be a central focus of our healing mission.  Treating a symptom is not the same as treating a disease. 

For example,  if an individual is having abdominal discomfort, pain medicine should not be the first responder, even if this would bring the patient relief.  Physicians try to understand the cause of the pain which would then guide our therapeutic response. The treatment would differ substantially if the cause of the pain were appendicitis or an ulcer or a kidney stone.

Is Fever the Enemy?

Often symptoms are regarded as diseases themselves that need to be treated.   Over the years, I have been called by nurses hundreds of times to prescribe medicine for patients who were nauseated.  Nurses are exceptional professionals, but they are not physicians.   They are preoccupied with the patients’ comfort and welfare and are vigilant about symptomatic treatment of nausea, diarrhea, headaches, constipation and insomnia.   This is one reason, but not the only reason, that hospitalized patients routinely receive sleeping pills, Imodium, laxatives and acetaminophen.   Most of us at home do not reach for antacids or other symptomatic remedies as often as these elixirs are dispensed in the hospital, where the culture of medicating is more pervasive.  In fact, medical interns and residents often include several ‘standing orders’ for patients they admit to the hospital so that nurses will not have to contact them for advice if these common symptoms develop.  

Standing Orders

If patient develops constipation, then give laxative A.
If patient develops diarrhea from laxative A, then give Metamucil.
If patient develops gas and bloating from Metamucil, then give simethicone.
If simethicone does not relieve gas, then double the dose.
If patient complains that high dose simethicone is causing sleeplessness, then give sleeping pill Y.
If patient complains of lethargy after receiving sleeping pill Y…

Interns who didn’t use standing orders would be guaranteed to receive nurses’ pages around the clock alerting young, tired physicians with scores of symptoms to respond to.  Standing orders were an intern’s insurance policy against paging assault.  This collaboration between interns/residents and nurses is where we physicians first learned to pull the symptomatic trigger so reflexively.   I think even seasoned physicians often casually prescribe anti-nausea medicine rather than aim to understand the cause of the symptom.  It's a tidy response to nurse's concern about a patient, which is often relayed to the doctor after hours on the phone.

In addition, not every symptom should demand an immediate pharmacologic response.   Yet, in the hospital, and often in our offices, this may be our modus operandi.

And finally, are we so sure that symptoms should be squashed?   Why do we treat every fever, for example?   Could it be that fever, diarrhea or vomiting are actually bodily defense mechanisms that are combating disease and illness?  Could it be that an infected person develops a fever in order to make his body less hospitable to germs or to sharpen his immune system?   Are today’s medical professionals really much smarter that millions of years of natural selection?   Let’s dose ourselves with a tincture of humility.  We’re not all that smart.

Even writing about this stuff gets me worked up.  I feel some heartburn developing.   Where are my Tums?

Sunday, February 23, 2014

Do Doctors Practice Evidence Based Medicine?

I advocate evidence based medicine.  We should restrict our medical recommendations to those that have a reasonable underlying scientific basis.   On the opposite end of this spectrum is quackery, when snake oil and other potions are hawked that either have no scientific support or have been shown scientifically to be ineffective.


I do not offer snake oil here as a historical reference.  We have more snake oil and its congeners today than ever before.  People who are sick want to believe the man who promises them healing, particularly when conventional medicine has not succeeded.  This belief goes to the core of human nature, at least as I have observed over the past 3 decades. 

Of course, in the medical world, we don’t have enough science yet for all of the medical issues that we physicians confront.   That means that we guess a lot.  How often does this occur?  Every single day.   Patients would be quite surprised to learn that there is usually scant or conflicting medical evidence to guide the issue that has brought them to our offices.   This does not mean that your physician is rolling the dice on you.  He relies upon available medical knowledge, if there is any, and his judgment and experience, two invaluable assets that are not measured in the various pay-for-performance schemes.   These invaluable assets are not measured and rewarded by the government and insurance companies because they cannot be easily measured.  Does that mean that they don’t count?  Absurd, of course.

If you doubt the presence of non-evidence based medicine, consider the promised health benefits of yoga, probiotics, medication, massotherapy and the latest gluten free rage.  I’m not stating categorically that these and related techniques do not work; I am pointing out that there is no persuasive medical evidence supporting their claims.   Our airwaves are clogged up with snake oil disguised as medicines promising ‘good prostate health’ or ‘healthy bones’.  These sound like health claims to me, but their language is carefully selected and is followed by the disclaimer ‘not designed to diagnosis or treat any medical disease’.   Would you rather believe the false promise or the true disclaimer?

Of course, these prostate potions do not want to be subjected to rigorous scientific scrutiny.  Why would they?  They do not need FDA approval like prescription medicines.  They can freely and legally use the phrase ‘clinically tested’ (whatever that means) and empty their warehouse shelves to clogged prostates across the country.   These companies only have to spend funds on marketing, unlike true drugs that must spend millions demonstrating to the FDA that their products are safe and effective.

There are many products on the market today that don’t want to be tested to confirm or determine efficacy.   Guess why.

Sunday, February 16, 2014

Mammograms Under Fire in New Study: Trash the Study?

Sometimes, we play a little politics on this blog.  I am a student of current events and enjoy following the dysfunction and absurdities in American politics.  To paraphrase the legendary former British Prime Minister, ‘never has so little been done by so many to benefit so few’.

Legendary Former British Prime Minister

Which of the following recent events is the most politically charged?
  • Speaker of the House John Boehner passed a clean extension of the debt limit without conditions. (Nothing like a colossal failure on this issue months ago to guide the speaker today.)
  •  Obamacare received its 27th extension, another ‘tweak’.
  • A new study questions the value of mammography. 
Readers know how skeptical I am about medical dogma.  When I was an intern a quarter century ago, I didn’t grasp why routine measurement of Prostate Specific Antigen (PSA) was standard medical practice since it was true back then that more men were harmed than helped by its use.

A recent study in the prestigious British Medical Journal (BMJ) has concluded that mammography does not save lives.  This study will become political dynamite as breast cancer is as much a political issue in this country as it is a medical subject.  Remember Mammogate?

I have no agenda here beyond a search for the truth.  I favor any reasonable endeavor that will prevent disease, treat illness effectively and deliver comfort.  If persuasive scientific information informs us that a medical treatment or test is not effective or is harmful, our reaction should not be to attack the test as flawed. We should also note if the criticizers have a personal stake in the test’s survival.   When colonoscopy is supplanted by a better test – which it will be – gastroenterologists will need to separate our own interest from the public interest, in accordance with our professional ethical standards and the oath that we all took. 

This new view on the old breast test mammography emerged from a randomized trial, which is a rigorous method of scientific study.  Ninety thousand women participated.  When there are a large number of subjects in a medical study, it strengthens the conclusions for mathematical reasons. This is why investigators strive to recruit a large number of patients in their studies.   The BMJ study concluded that women who underwent mammograms had the same death rate from breast cancer as women who only underwent breast examinations.   Additionally, ‘non-invasive’ mammography led to unnecessary invasion on many women.  Twenty percent of cancers found were felt not to be a medical threat and yet led to surgery and other unpleasant treatments.

Even when prior mammography data is viewed in its most optimistic light, the benefit to an individual woman is extremely modest.  This point is so often misunderstood by even an informed public.  When a study performed on a large population shows a 10% benefit, for example, the benefit to an individual participant may be trivial.  This is why headlines such as, “New Drug Strengthens Bone Density by 20%”, are so deceptive.  Patients need to know what the benefit of a particular treatment is for them, not for a large study group.

Get ready for the Mammography Zealots to mobilize for their three pronged approach: Pitchforks, Placards and Protests!

My question for them is do they want to save mammography or save women?


Sunday, February 9, 2014

Does is Matter if Your Doctor is Liberal or Conservative?


In the medical world, when a physician, a scientist, a hospital, a drug company or a panel of experts issues a report, the games begin.  If one agrees with the statement or benefits from it, then the report is heralded as breakthrough brilliance.  If, however, the report suggests a new medical pathway that diminishes your relevance or reimbursement, then the report and its authors are regarded as misguided.  Yes, I am generalizing somewhat here, but you get the point.

As readers of this blog know, I am a conservative medical practitioner.  I do not mean conservative as in supporting the NRA, prayer in public schools, self-deportation of illegal aliens (or should I say ‘undocumented residents?), ‘clean coal’ and lower taxes for millionaires and billionaires.  Conservative physicians describe those who are extremely judicious with regard to medical treatment and diagnostic testing.  We don’t lurch to treat or test unless a high threshold of necessity and effectiveness is crossed.  Before ordering a medical test, two questions should be considered.

Will the results of the test under consideration potentially change the medical management of the patient?

Is the change in medical management referenced above in the patient’s best interests?



Gallstones

Let me illustrate why the 2nd question above is so critical.   For example, assume a surgeon orders an ultrasound on a patient with abdominal pain to determine if gallstones are present.   This test seems reasonable as the result of the test may change the medical management of the patient – the point raised in question 1.  So far, so good.  If gallstones are present, then the surgeon removes the gallbladder.  But, if this is not the correct treatment (because the pain is not caused by gallstones), then the principle in question 2 has been violated. In this example, the physician feels that the ultrasound  test was needed as it led to gallbladder removal.   He feels that the test changed the management of the patient – which it did – but it led him down the wrong path. So, the test was not reasonable and should not have been ordered in the first place.

I make this point as for years during medical training and afterwards, I have been told and have read that tests should only be done if they might change medical advice.  This is true but not the whole story.  Left out of this medical maxim is the more important point that the new medical advice must advance the patient’s medical interest.

An oncologist may recommend a CAT scan because if new cancer is found, then new treatment will be prescribed.  Does this strategy pass the two question test I have raised here?  Sometimes yes, and sometimes no.

Is there anyone out there who doesn’t believe that we are testing and treating patients excessively? 

This same two-question strategy can be applied to a medical commentary blog to assess its worth. 

Does the blog potentially change your point of view?
Is this new viewpoint enriching you?

As always, readers’ views are earnestly solicited.  

Sunday, February 2, 2014

Should this Jehovah's Witnessed have been Transfused Blood?

Autonomy is a bedrock ethical principle in medicine that has supplanted medical paternalism.  Patients have a right to make their own medical decisions and are entitled to know the advantages and drawbacks of all reasonable options.  Clearly, informed consent cannot be given if the patient is only partially informed or has been given a slanted presentation by the physician.

When a patient does not have the capacity to provide consent, then a surrogate is used.  This individual is charged to make the decision that the patient would have made if the patient were capable of doing so.  Some argue that the surrogate should decide on what he feels is in the patient’s best interest, which may be different than what the patient would have preferred.

Can Christian Scientist parents deny lifesaving treatment to their children? The courts have properly ruled for the children in many of these cases.   These decisions may be traumatic for loving parents who feel that conventional medical treatment may cause an irrevocable spiritual catastrophe.  Is the situation more complex if the child is 15 or 16 years old and does not want surgery or chemotherapy?  What about a 17-year-old?

I was asked to see a patient recently who was profoundly anemic, having lost about 2/3 of her blood.  Ordering blood transfusions would have been a reflex for any physician.  The patient was a Jehovah’s Witness.  Practicing Witnesses will refuse blood transfusions even at the risk of their lives.  I have treated many of these individuals over the years and respect their right to make informed medical decisions.  This patient, however, was mentally retarded and her sister was making decisions on her behalf.

Red Blood Cell, White Blood Cell and Platelet

At the sister’s request, no blood transfusions were administered and the patient survived.  I wondered if this case was ethically problematic as the sister was denying care that may have been lifesaving to a patient who could not express an opinion on the issue.  Perhaps, she would not have wanted to die or might not have been a practicing Witness at all.  Should the sister, despite noble intentions, have been entrusted with this decision?


I think that had we decided to ask a court to rule on this issue, that blood may have started to flow.