Sunday, August 9, 2015

When Does Life End? Ask a Humble Doctor.

About a week before I write this, I met a man for the first time.  Though it is unlikely that I will see him again, it is unlikely that I will forget him.

This was a side trip for us, as we meandered for a weekend through the beauty and nostalgia of Ohio.  Once you find yourself about an hour south of Cleveland, you are in a Land of Barns, where cornfields and cattle punctuate the countryside.  There are miles and miles of open roads unblemished by Starbucks, CVS or Big Box Retail.  Is the air truly fresher or does it just seem that way?

On the Open Road in Ohio

We drove out to meet this man to examine his wares.  The GPS faithfully led us to the desired location, but we assumed that we were misled as there was no business sign to alert customers like us.  Not quite the marketing strategy we know from city life where advertisements will soon appear on toilet paper.   He has an unusual profession, which I will not identify, as this might be enough to identify him which would violate his privacy.

We looked over his shop and he then invited us into his home to show us how his stuff might look in an actual home.  When he learned what I did, he then told me that he had seen several gastroenterologists on a medical odyssey that started 3 years ago.

The man’s profession is not important.

The medical facts that resulted in a delay in his diagnosis of cancer are incidental.

His Christian faith, evidenced by numerous crucifixes adorning his property, would likely be deemed to be paramount by the man himself.

The doctors told this man that he had 3 months to live.  That was 3 years ago.  As a trained medical professional, it is my considered judgment after decades of medical training and experience, that he is quite alive.  Not just alive, but alive and well.  Not just well, but downright inspirational. 

When he was given this dire news, his response was that ‘it’ll have to kill me’, as he intended to fight back.  He did.  He has one final surgery remaining this fall.

The doctors were wrong, dreadfully wrong.  Perhaps, they were relying upon textbooks, which my new friend didn’t read.  He had his own playbook, which helped him to find a pathway back to life. 

Of course, doctors, as members of the human species, make mistakes.   We give wrong advice.  Sometimes, we give the correct advice, but something unexpected happens, as I suspect happened in this case.   Arrogance is the enemy of good medicine.

Sir William Osler, one of medicine’s preeminent physicians of all time, implored physicians to have ‘the grace of humility’’  No second opinion needed here.

Sunday, August 2, 2015

Planned Parenthood Videos Threaten Truth

While we have all heard the adage, any publicity is good publicity, I don’t agree.   See if you agree that the subjects of the following hypothetical headlines would have preferred anonymity.

Local Surgeon Loses Scalpel – in Patient’s Abdomen
Teacher Pursues New Career as Porn Star
Restaurant Owner Claims Rats are Really Pets

Planned Parenthood is in the news.  Several videos, surreptitiously taken, have been released showing discussions between Planned Parenthood personnel and folks who were pretending to be interested in procuring fetal parts.  It is illegal under federal law for Planned Parenthood to make a profit selling fetal parts.  More fact gathering will be necessary to determine if a legal line has been violated.  Legalities aside, the videos have generated revulsion across the ideological spectrum by how unseemly and casual the Planned Parenthood folks discussed a subject with huge ethical and legal ramifications.  The public heard how the abortion technique could be ‘adjusted’ so that fetal organs would not be damaged so they could be harvested.  The faux venders were told by Planned Parenthood that they prefer that the surrendered organs would be considered for ‘research purposes’, rather than as a typical business transaction as this would give the organization some ethical and legal insulation. 

One’s ultimate view on the legality and propriety of Planned Parenthood’s behavior should be independent of one’s view on the abortion question.  I am always agitated when an individual or organization’s views on an issue are tainted to conform to an ideology.  For example, if you are a Democrat who believes that Hillary Clinton’s email practices are entirely proper, then you should have the same view if Dick Cheney were substituted in her place.

If Dick Cheney says the earth is round, some folks will say he's wrong.

Regrettably, this is not the standard that operates in the public square.  Pro Life believers are clamoring to defund Planned Parenthood, an organization many of them loathe.  Pro Choice adherents, sidestep the videos’ content and focus instead on the deceptive techniques used to obtain them.  Both sides are missing the point on purpose.

If Planned Parenthood broke the law, then this fact should not be mitigated or expanded depending upon one’s abortion views.

This story has various medical ethical dimensions.
  • Must an abortion provider obtain consent from the patient for giving away fetal parts?
  • Is it ethical for an abortion provider to modify the procedure in order to preserve specific organs?
  • Is informed consent necessary for an abortion provider to use a different technique for a purpose unrelated to the medical task at hand?
  • Could the patient charge the vendor for fetal parts?

 I have not given my own view on the abortion question here.  It shouldn’t matter.  This issue should be judged separately from one’s view on the abortion question.   Call it straight. Support your adversaries and rebuke your own team when the facts demand this.  Telling the truth is good publicity.  

Sunday, July 26, 2015

Warning! Cell Phones Can Kill You!

In medicine and beyond, folks just want stuff to be true.  Sometimes, we believe stuff that is unproven, but might be true.  We doctors recommend such treatments to patients every day.  On other occasions, a benefit of a drug or food item is extrapolated way beyond the data.  For example, if Nexium is known to be effective against stomach ulcers, then why not use it for patients with stomach aches who are ulcer-free?  There’s not a gastroenterologist on the planet that hasn’t engaged in this therapeutic mission creep.  More interestingly, folks often persist in beliefs that have been disproven.  The notion, for example, that certain vaccinations can cause autism has been thoroughly debunked by rigorous scientific study, yet there remain diehards who defy the science. 

Curiously, many unproven or disproven practices have gained a fair measure of street cred in the Court of Political Correctness.  Keeping a gluten-free diet today is downright chic.  Colonic cleansing is the bomb.  Kale is king. 

If we want to generate some heat in the green crowd, just mention the word ‘radiation’.  Ingesting irradiated food, for example, is believed to be tantamount to swallowing strychnine.  No persuasive evidence necessary.  Faith will suffice.   Nuclear reactors are regarded as atomic bombs in waiting, as if burning coal or hydraulic fracturing (fracking) are as clean and pure as the first snowfall.  The sun’s radiation, which assaults us daily is somehow not demonized, nor are cosmic rays, high energy radiation which bombards our atmosphere and can reach down to earth itself.

Cell Phone-Free Zone!

The City of Berkeley, the epicenter of New Age Goofiness, has just passed an ordinance that requires retailers to warn customers about the medical risks of devices that emit radiation, such as cell phones.
Here’s an excerpt from the caveat.

If you carry or use your phone in a pants or shirt pocket or tucked into a bra when the phone is on and connected to a wireless network, you may exceed the federal guidelines for exposure to radio frequency radiation.  This potential risk is greater for children...

Luckily, I'm mostly in the clear.  I am not a child and do not don female underwear.  I secrete the phone into the left inside pocket of the sport jackets I wear each day to work.  The phone, therefore, rests above my heart.  Perhaps, the gentle radiation from my beloved iPhone is conferring a cardiac benefit on me?  While it's just conjecture, perhaps, if my heart gets tempted to beat out of step, that my iPhone's rays keep my rhythm sure and steady.  

If I were the cell phone companies, here's how I would fight back.  Forget about litigation or trashing the fiends who fear all radiation, foreign and domestic.  I would sell my theory of cardiac protection to the American Heart Association. For a proper donation, they might consider cell phones to be 'Heart Healthy'.  

If your adversary argues without facts, then shouldn't you?

Sunday, July 19, 2015

Should Physicians Profile Our Patients?

Profiling in this country is highly discouraged and is illegal in many circumstances.  Anti-profilers decry this technique which, they argue, unfairly targets innocent individuals violating their rights.  Our beloved Transportation Security Administration, or TSA, is charged not to use profiling as a screening tool.  Personally, I object to this prohibtion.  While an individual’s rights are important, it must be weighed against the rights of the community.  Our cherished rights to free speech and assembly are not absolute.

I have flown on El Al airlines, whose personnel actively profile in an effort to keep its passengers safe.  Anyone who has been a passenger on this airline will likely agree with me that he has never felt safer on an airplane.  I have a right not be blown up, and if profiling further minimizes this risk, then call me a fan.
Last year, my mother, who appears as threatening as a school librarian, was patted down twice when she traveled to visit me in Cleveland.  I’m sure that the patter-downers were following the rules and regs, but this doesn’t seem to be a well targeted effort. 

A Non-controversial Profile

I’m familiar with the argument against law enforcement using profiling to reduce crime and protect public safety.  I understand that this can lead to abusive practices by overzealous police officers.  But I wonder if, as El Al believes, this can be a legitimate tool in law enforcement’s armementarium.  I’m open to the debate here.

I’m a physician and I certainly profile my patients.  I don’t have a single template for treating abdominal pain in all  patients.   For example, if I see a recent immigrant from China with stomach issues, a part of the world where gastric cancer is relatively common, this may affect the speed and intensity of my evaluation.   If an American born patient comes to my office with the same complaint, my response might differ.   If breast cancer is more common in Ashkenazi Jewish women, shouldn’t we factor this in when we are advising them on risk reduction?  Certain populations have different health risks.  Physicians are always trying to separate out patients who might warrant special attention. 

If you are trying to reduce a certain disease that is largely restricted to one segment of the population, doesn’t it make sense to target this segment rather than everyone?

I realize that health and law enforcement may not be analogous.  I also realize that profiling in law enforcement is a very sensitive issues, particularly for minorities who have been victimized by this technique.   But, if we abandon the procedure entirely, are we forfeiting a tool that could keep us all safer? 

El Al has a different view.  Here, in America, TSA is trying to detect evil stuff. El Al is trying to detect evil people.  Which makes more sense?

Sunday, July 12, 2015

When to Call the Doctor After Hours

Patients are entitled to receive medical advice 24 hours a day.   If you call your doctor at 3 a.m., you will reach a physician who will advise you.   Of course, it may not be your own personal physician as this individual cannot be expected to be available 365 days a year until he retires.  Physicians partner with colleagues who share on-call responsibility for evenings, holidays and weekends.   For example, my gastroenterology group has 3 physicians who take turns during the off ours to be available for our patients.

Here are some tips for patients who are seeking advice after hours from the on-call physician.

When possible, call your doctor before sundown.

I advise against calling the doctor after hours for a question that only your own physician can answer, unless an emergent situation is suspected.   For example, the on-call physician will not know what the next step will be if next week’s colonoscopy is negative.

If you call after hours for advice on a medical issue that has been present for weeks or months, then don’t expect a magic bullet response.   When my partner’s patient calls me after hours because he has had 2 months of nausea, it’s unlikely that I can solve this on the phone with a patient I don’t know, when my partner hasn’t figured it out after  a month of office visits and diagnostic testing. 

Have mercy on us!  Reserve after hour phone calls for truly urgent matters.  Realize we may have been awakened multiple times throughout the night with hospital phone calls, or even made a midnight run to the emergency room.  Sunday morning is not when your doctor will welcome a conversation on flatulence. 
Be reasonable.  If you call thinking that your college student who is home for winter break needs some Nexium to calm his overheated stomach,  don’t expect a prescription if your kid is not our patient.

It’s best to direct your inquiries during daylight hours to the physician who knows you best.  Of course, emergencies can occur at any time.   If you develop a medical urgency, or you are uncertain if the issue can wait until the office is open, then please call us.   We never want you delay contacting us about urgent condition, which might delay your treatment.   If the medical matter ends up being non-emergent - no foul.  You guys aren’t doctors.  What’s routine to us may understandably be concerning to you.

Let’s see what you’ve learned. Which of the following hypothetical scenarios merit a late night call to the doctor?
  • My hemorrhoid doesn’t feel right.  I know it’s 2 a.m., but I thought I should call  now when it will be easy to reach a doctor.
  • I had 4 episodes of rectal bleeding since dinner and I’m feeling a little dizzy.   I think it will pass.  If I call the doctor he might make me go to the hospital and miss the family BBQ party tomorrow.
  • Wow!  This Wellness Festival is awesome!  I know it’s Sunday, but I’m going to call my doctor now to ask which probiotic-fortified kale chips to buy.
If you enjoyed this post, call me.  Day or night.

Sunday, July 5, 2015

No Confederate Flag This Fourth of July

It’s the birthday of the nation, the Fourth of July.  John Adams proclaimed in a letter to his dearest wife Abigail that this day “will be celebrated by succeeding Generations, as the great anniversary Festival…with Pomp and Parade, with Shews, Games, Sports, Guns, Bells, Bonfires and Illuminations from one End of this Continent to the other from this Time forward forever more.”

Years later, in an amazing twist of historical fate, John Adams and Thomas Jefferson would each ascend to heaven on the very same Fourth of July.


These days, many of our historical figures and symbols are under review, judged in the context of current mores and sensibilities, always a process to be undertaken with care.  The Confederate flag is being banished from government property, as it should be.  During an earlier part of my life, I was sensitive to the argument that this flag properly honored the heritage of Confederate forefathers.  A little wiser now, I now realize that my ‘sensitive’ southern viewpoint was wholly insensitive.  The offense that this symbol has for most of us clearly outweighs competing arguments to brandish the flag on public lands.  If you want to display this image to honor the gallantry and heroism of your ancestors, your home is still your castle and you may adorn it as you wish.   Or, put on a T-shirt, get a tattoo or apply a bumper sticker. 

As expected, many who are now decrying the flag are doing so for political and economic reasons.   I don’t think that Amazon or WalMart have suddenly experienced a moral revelation as they scour their shelves to remove Confederate merchandise from their inventory.  Similarly, presidential candidates who weeks ago would finger-wag that these issues were ‘better left to individual states’, are now racing up the flagpoles themselves to be the first to tear down the flag.  Sounds like an electoral epiphany. 

My worry is that this will initiate an avalanche of a politically correct cleansing of our historical icons and symbols.   What should the standard be for us to publicly honor our historical and modern figures?  If the standard should be moral purity, then we will be spending the next decade carting away statues, demolishing monuments and changing the names of schools and streets throughout the country.  Who could make the cut?   We can’t even agree on if a female portrait should appear on the ten or twenty dollar bill, let alone who should be selected. 

It’s not easy to define a hero.  Name half a dozen Americans whom you think are our nation’s best, and I guarantee that there will be folks who see it through a different lens.  Same is true for the revered legends in American history.  Should we admire Robert E. Lee for his deep sense of honor, while he took up arms against his government?  Should we honor Henry Ford, who changed the world, but was a viscous anti-Semite?  Should honor Harry Truman as one of the most popular presidents in modern times, even though he dropped two atomic bombs on Japan within 3 days of each other?  

This nation emerged from a crucible in which virtue and vice cohabited.  We cannot expect that those who created and sustained the nation would be perfect.  Indeed, the preamble to the Constitution begins with the phrase ‘in order to form a more perfect union, acknowledging that we can never achieve the ideal state, but must strive toward it. 

Those men were also not perfect.  Thomas Jefferson, who penned the immortal phrase ‘all men are created equal’ into the Declaration of Independence, was a slave holder and a miscegenist.  George Washington owned hundreds of slaves.   Should the Jefferson Memorial be converted into a Museum of Tolerance?  Should our nation’s capital be given a new name?  If we sanitize every corner of the public square, what will we be left with?