Sunday, January 10, 2016

Why My Patient Left the Office

A patient came to the office and refused to see me, although I was quite willing to see him.  I’ll present the scenario followed by the patient’s reason he took an abrupt U-turn.   Then, if you are inclined, you may offer your own advice and comment.

I performed a colonoscopy on this patient and found a large polyp in the upper part of the large intestine, or colon.  The upper part of the colon, or right side of the colon, has been receiving a lot of press in gastroenterology in recent years.  Medical studies have observed that cancers in this region are more easily missed for reasons that don’t need to be explained here.  For this reason, gastroenterologists are particularly vigilant when examining this region.

The polyp was large and somewhat hidden behind a fold of tissue.  I suspected that this was a benign lesion.  I removed the polyp using one of the gadgets in our bag of tricks, but knew at the time that I had left some polyp tissue behind.  I was unable to remove the entire lesion because of its tricky location.  In addition, because the polyp seemed to be embedded in the wall of the colon, I wasn’t certain that I could safely remove the remaining fragment without causing a complication.  First, do no harm.

The Large Intestine - Where Polyps Hang Out

I advised the patient to return to the office in 3 weeks so that we could review the options.   In the meantime, the pathology report from the specimens confirmed that the polyp was benign, but pre-cancerous.  The remaining polyp tissue would have to be removed.   Our practice has a No Polyp Left Behind policy.

There are 2 options that make sense.
  • Have a surgeon remove the R side of the colon, which would guarantee safe and complete removal of residual polyp in one session.
  • Refer the patient to an expert colonoscopist at one of our nearby teaching institutions.  There are advanced techniques and skills that could complete the task that I left unfinished without surgery.  This is certainly easier to go through than an operation, but there is a lower probability that all of the polyp will be removed in one session.  Therefore, future colonoscopies would be needed to reexamine the site to verify that it is clean.  Colonoscopies have risk and inconvenience.   This approach, in my view, affects quality of life as for a long period of time, the patient has concern about polyp tissue left behind.

Discussing these two options, with their respective risks and benefits, is a long conversation.  I would anticipate many questions from the patient and any family member who might be present.

The patient came to the office at the appointed time, but then balked when he was asked for his $40 co-payment, as required by his insurance company.   Of course, we have nothing to do with setting co-payment rates.  While I have respect for the sum of $40, I think it can be argued that this is not excessive for receiving a full presentation of medical options from a physician on how best this patient can prevent colon cancer from developing.    

He left the office.  How should I react?  Should I call him and provide a ‘free office visit’ on the phone for 15 minutes so he doesn’t have to fork over the forty?   I make dozens of phone calls to patients every week, but these are generally to resolve simple issues.  If during one of these calls, I decide that a phone call is not appropriate for resolving the issue, then I ask the patient to make an appointment.   While a patient might think, for example, that I can diagnose and treat diverticulitis on the phone, I prefer a hands on approach here.

Should I write to my PPP (petulant polyp patient) and advise him that he needs to see me face to face as the issue is more than a phone call can handle?  What if I do so and he doesn’t show up.   If a few years from now, the lesion turns malignant, then will this be my fault?  When does my responsibility end and his begins?  

Sunday, January 3, 2016

Whistleblower Looks Ahead to 2016

At the end of every year, the airwaves compete for our attention on programming that ‘looks back’ at the past year. 

People we’ve lost in 2015.
The 10 biggest news stories of 2015.
The greatest gaffes of the past year.
Stories that made us cry in 2015.

Year-end magazine issues follow the same playbook.

Whistleblower doesn’t look back.  

Whistleblower Eschews Rear-view Mirror

I suppose there is a public appetite for retrospectovision since, as we all know, the media’s mission is to serve up what we demand.  The newspaper adage, ‘if it bleeds, it leads’, is more a comment on us than it is on the journalism profession.  We are vampires who look to media for our next blood meal.

Looking ahead is tougher since it’s quite a bit easier to chronicle known facts than it is to predict and guess.  But, isn’t this a more worthy task?  How do these story proposals grab you?

People we’ll lose in 2016.  (Not serious, just want to assure you’re paying attention.)
Why CNN will abandon the omnipresent banner –BREAKING NEWS – in 2016.
Hillary Clinton pledges no e-mailing in 2016.  Will rely upon carrier pigeons for all classified  communications.
Obama announces bold new ISIS 2016 strategy.  Will no longer ‘contain’, but will now ‘restrain’ the jihadist group.
U.S. Airlines announce new 2016 policy to serve customers better.  While the commodious seats have already been narrowed with the pitch reduced (this means just try to lean your chair back), economy seats will now be upholstered with carpet tacks with the pointy ends facing upwards poised to pierce travelers’ posteriors.  Leaving aside questions of hygiene, by industrial engineers have designed these barbs so they will not cause significant blood loss, unless there is air turbulence, which would be God's fault.  Why are they doing this?  This comports to their philosophy of only charging customers for what they want.  For example, if a traveler does not want enough legroom to accommodate the average sized legs of a 6-year-old child, then why should he pay for it?  Similarly, focus group testing has demonstrated that some passengers enjoy the carpet tack experience.  For them, there will be no surcharge.  Why should these thick skinned travelers have to pay for an upgrade that they do not want?  Any traveler who wishes to pay for a smooth seat, is free to do so.  In line with their reasonable pricing policies, the upgrade costs $35 if requested when your ticket is booked, $75 at the gate and $150 when you reach your seat.

Safe travels to all.  Wishing you all the best in the coming year.

Sunday, December 27, 2015

Why Trump is Running

What is politics without a conspiracy?  Here are two facts.
  • Donald Trump is a very intelligent man. (Just ask Vladimir Putin.)
  • Donald Trump says idiotic stuff.
How does one reconcile these two facts?

When a really smart person says really dumb stuff, then something is up.
Why does he regularly issue forth insulting invective and false statements?

Does he truly believe that John McCain is not a war hero?  Does he feel that schoolyard insults against fellow candidates gives him presidential luster?  Is his plan to slam the door on all Muslims a surefire way to make friends and make us safer?  Is mocking a disabled journalist politically savvy? Is describing Hillary Clinton’s urological delay at the recent debate as 'disgusting', a demonstration of his measured temperament? 

Star Quality?

It’s very tough to ascribe such views to an intelligent man, which he is, and often says so.  Who benefits from his volcanic eruptions of rhetorical venom?  Here are the two winners.

Donald Trump.   He is becoming the most famous man in the world.
Hillary Clinton.   For HRC, he’s the gift that keeps on giving.  She prays daily that he will become the GOP nominee.

Is it possible that his campaign was secretly designed and executed to help Hillary gain the White House?  Did Trump and Hillary make a corrupt bargain?  Is this really implausible when you take an aerial view of events?  Is this hypothesis more far-fetched than your own explanation of Trump’s strategy and tactics?

Leave a comment and help ‘make the Whistleblower blog great again’.

Saturday, December 19, 2015

Whistleblower Holiday Cheer 2015!

Jingle bells, jingle bells,
Cruz is ridin’ high,
Jeb is lagging way behind,
But tells us he’s our guy. 

Trump is here, Trump is there,
Trump is everywhere,
Promising we’ll be as great,
As his golden hair. 

Walker’s gone, Perry’s out,
And Jindal, “Not my time”.
Lindsey Graham is begging us,
“Please send me a dime.”

Carly has a pretty face,
Christie’s slimming down.
Pataki sports a comb over,
Santorum wears a frown.

Huckabee, with a smile
Gives fire and brimstone ash,
Carson says, “I stabbed a guy!”
Kasich trolls for cash.

Who among these flapping jaws,
Will be the next to fall?
Who can make the case for ‘Prez’?
Pataki or Rand Paul?

Hillary’s in the catbird seat.
Bernie just can’t hit.
The GOP in unison
‘Oh where, oh where is Mitt!’

Wishing you Joy and Peace!

Sunday, December 13, 2015

Was Granny Sent Home from the Hospital Too Soon?

Over the years, I have heard families bemoan that their relative who was just readmitted to the hospital was sent home too early just a few days ago.   Are they right?

Was Gramps Kicked Out Too Soon?

First, let me say that in some instances they may be correct.  It is certainly possible that the hospital, under increased pressure to kick folks out, may have pulled the discharge trigger too soon.  The hospital is not always right even if their ‘discharge check list’ seemed to be in order.  Of course, patients are not adequately represented by a check list any more than physicians’ quality can be fairly measured in the check off, cook book method that the government and insurance companies are now championing.

The hospital discharge check list may indicate that a patient with pneumonia can be safely discharged home as she has no fever or need for supplemental oxygen.  However, this patient may be 89 years old, riddled with arthritis and needs to attend to a spouse suffering from Alzheimer’s disease.  Is she really ready for home life?

Hospitals these days are more careful than ever about premature discharge, not so much from newfound compassion, but because they will suffer a financial penalty if a patient is readmitted within 30 days under certain circumstances.  For example, if a patient with congestive heart failure is sent home, but then returns 2 weeks later with worsening heart failure, then the hospital will lose money.  This has created a robust outpatient follow-up industry with visiting nurses, physicians and social workers to try to keep folks from coming back to the hospital, at least within 30 days.  (Joke alert: The terminal phrase of the last sentence was in jest.)  I applaud this system which serves everyone’s interests. 

In the hospital, care coordinators cruise through the corridors leafing through charts to initiate discharge planning.  These are nurses who have left the wards for a cleaner administrative function.   Although I did disparage the hospital discharge check list mentality above, and rightly so, I have found these care coordinators to be compassionate and understanding with regard to individual patient circumstances.  They know when to bend some rules, perhaps because they were once hands on nurses themselves. 

Sometimes, a patient needs to be readmitted to the hospital and it’s simply no one’s fault.  It is a difficult concept for many Americans to grasp that an adverse event could occur without an individual or an institution to blame.  Remember, we live in a society where folks sued Burger King alleging the company was responsible for their kids’ obesity.   I counsel families that when we are sending their relative home, particularly when they suffer from chronic diseases or other incurable conditions, that we do so based on what I and the others on the team know at the time.  We are not clairvoyant.   If we had this power and knew that the patient would become more ill 3 days hence, we wouldn’t sent him home.  It’s may not be quite fair, but would be quite understandable, to wonder if a patient who is readmitted should never have been discharged home in the first place.   There are some patients who are so fragile, that they can tilt backwards anytime and for very small reasons. 

What we know for sure is that life and illness are unpredictable. 

Sunday, December 6, 2015

Am I Too Old for a Colonoscopy?

Most of us are familiar with the concept of medical guidelines.  These are sets of criteria that are supposed to ‘guide’ physicians facing certain medical circumstances.

As physicians know, and often lament, guidelines over time morph to become mandates.  Even though by definition, a guideline is voluntary, many hospital oversight committees and insurance companies require physicians who deviate from guidelines to explain their actions.

The U.S Preventive Services Task Force guideline states that folks 75 and older should not receive screening colonoscopies.  The  reason is that medical studies have demonstrated that the benefits of colon cancer screening in this age group is not justified by the risk and expense of the effort.  Of course, there is an age when colonoscopy does not make sense, but I’m just not sure what this
magic number is.

Too Old for a Colonoscopy?

Consider these two hypothetical patients.

(1)   A 78 year old man in excellent health has never had a screening colonoscopy.  Should he be denied this as it will violate the guideline even though this guy has a decent chance of living another decade

(2) A 60 year old comes to my office from his dialysis session dragging his oxygen tank behind him.  He’s never had a colonoscopy.  Does a screening study really make sense here?

Guidelines and all their ilk are a one-size-fits-all approach to a profession that needs to individualize its advice to living, breathing human beings.  There’s more absurdity to come.  Insurance companies and the government are increasingly tracking physicians to assure that they are following all appropriate guidelines.  Those who deviate face the prospects of decreased reimbursements and being highlighted publicly on websites  and elsewhere as being deficient.

How easy do you think it would be to argue your case to an insurance company that a particular guideline didn’t apply to a particular patient?   Having had the thrill and pleasure of  dealing with medical insurance companies and the government, I can answer this in a quiz format, one of my preferred educational tools. Please arrange the following 4 actions in increasing order of difficulty.

(1) Stumbling into a bee hive while walking in the woods.

(2) Swallowing glass shards.

(3) Watching C-SPAN for 24 hours without interruption.

(4) Reversing a claim of Medical Guideline Violation