Sunday, July 31, 2016

Should Doctors Lie for Patients

Even the most honest among us do not tell the truth all of the time.  We are flawed human beings.  We covet, we gossip, we steal, we lie and we stand idly by. You don’t think you steal?   Have you ever ‘borrowed’ someone else’s idea and represented it as your own?

A few weeks before I penned this, I was presented with 2 opportunities to lie in order to save a patients a few bucks. The first patient wanted a refill for her heartburn medicine, which she takes once daily.  She asked if I would refill the medicine to take twice daily, so she could get double the supply for the same price.  The second patient asked me to write a note that he was at risk for Hepatitis B so that he could get the vaccine for free.   Writing the note would be easy, but claiming that he faced risk of Hepatitis B infection would require some prevarication. 

I’ll assume that Whistleblower readers know how I responded to the above two issues.   However, many patients, and perhaps some physicians, who are so harassed by insurance companies and an uncaring medical bureaucracy are looking for any measure of relief when they can grab it.  Many of them have risked rising blood pressures and panic attacks trying to talk common sense with insurance company ‘customer service’ representative,s who have less medical training than hospital housekeepers, about getting their medications approved.   I’ve been down that tortured road more times than I can count, and I feel their pain. 

I routinely receive disability forms for patients who are seeking this benefit.  I advocate zealously for every patient who has a legitimate claim for any benefit they are entitled to, often making the phone calls with the patient seated beside me.   There are occasions; however, where no matter how hard I squint at the patient’s chart, I just can’t discern any medical evidence of a disability.  Sometimes, I haven’t seen the patient for years.  (Often, disability forms are sent to every physician the patient has seen, so some of these physicians are not appropriate targets.)  

George Washington, not a doctor, didn't lie.

Ethical quandaries can be tormenting.   Let’s say a patient is sent to me to evaluate constipation.   A colonoscopy is scheduled.  Since the procedure is diagnostic to evaluate his symptom, he will have to pay much more out of pocket than if the procedure is coded as a routine screening colonoscopy.    Should I slightly adjust my coding to help the guy out?  

It doesn’t take much effort to rationalize siphoning a few bucks from insurance companies that many of us think deserve it.  Somehow, we don't regard this theft as we would shoplifting or stealing a neighbor's TV.

I could state here that I respect medical insurance companies because of their unwavering devotion to protecting our health and serving the greater good.  But, I’d be lying.  

Sunday, July 24, 2016

Is Medical Marijuana Safe and Effective? Who Decides?

Medical marijuana is a smokin’ hot issue in Ohio.  Marijuana enthusiasts targeted our state constitution again this year with another amendment attempt, which failed.  Instead, our legislature passed House Bill 523, which will legalize medical marijuana use. 

As a physician, with some training and experience in prescribing medicines to patients, these marijuana machinations are medical madness.  Is this how we want to bring new medicines to market?

I think it is absurd that a specific medical treatment – or any medical treatment - should become a constitutional issue.  Do we want to establish a constitutional right to a specific medicine?
Why stop at marijuana?  Why not start circulating petitions for constitutional amendments for screening colonoscopies, mammographies and MRI’s for back pain?  Patients with chronic lumbar disk issues have rights too! 

The Ohio bill specifies an array of medical conditions that could be treated with marijuana, including AIDS, hepatitis C, inflammatory bowel disease, Parkinson’s disease, PTSD and many other illnesses. Is it the legislature’s responsibility to decide that a medicine should be approved for a medical illness?  Do legislators have medical expertise?  Do we want the Senate or House weighing in on approving a new chemotherapy agent or artificial hip?

Will Cure Whatever Ails You?

Might I suggest with just a tincture of cynicism that medical marijuana mania has become a mite politicized? Do we want folks who stand to make money or enhance their political power from a new medicine – who have no medical expertise - to be the ones with a major role in approving its use? Are cannabis con artists using a political pathway because they fear that the medical avenue will less hospitable to their objective?

Once marijuana becomes a legal product, an inevitable outcome, will enthusiasts for its medical use support vigorous testing of its therapeutic value? 

I am deeply skeptical that the medical claims of medical marijuana adherents are supported by persuasive medical evidence. I remain open, however, to submitting marijuana to the same Food and Drug Administration (FDA) testing that all new medicines are subjected to. Let the scientific method with appropriate clinical studies and peer review judge the product for safety and efficacy. If approved, then the public and the medical profession can be confident that the approval was on the basis of science and not smoke.  Shouldn’t those who champion medical marijuana use demand this level of independent scrutiny?  If not, then why not?

Yes, I have heard powerful individual vignettes describing great benefits of medical marijuana. Every physician has similar anecdotes of patients who have achieved significant benefits from unconventional and unapproved medical treatments. But, anecdotes are not science. If medical marijuana is the healing elixir its proponents promise, then prove it. 

Let our politicians do what they do well, whatever that is, and leave medicine to the professionals. 

Sunday, July 17, 2016

Do New Medical Interns in July Threaten Patients?

Would you have elective surgery in the nearby major teaching institution on July 4th?
Why not, you wonder?

Prowling around the hospital wards every July are the fresh faced interns wearing starched white coats, with stethoscopes draped across their shoulders, with pockets stuffed with reflex hammers, K-Y jelly, and various cheat sheets to rescue ailing patients.

These guys know nothing.  How do I know this?  I was one of them.  Luckily, I knew that I was clueless and never pretended that I could treat athlete’s foot or even a splinter.

Imagine you are in a hospital bed in early summer complaining of chest discomfort.  Your nurse summons the intern who speeds into your room peppering you with questions.  Before you finish your answer to a question, another question erupts.  This physician is barely out of his shrink wrap and is understandably anxious that he is witnessing an impending cardiac catastrophe.   With his spanking new stethoscope, he establishes that there is a beating heart nestled inside your chest.   Your heart rate is high, most likely as a result of anxiety from witnessing the intern’s state of near panic.  I’m sure you will calm down when he whips out his Tips for Chest Pain Cheat Sheet which he will use to treat you. 

If the intern tries to test your reflexes with this - run!

Teaching hospitals have an important teaching mission.  This is the venue where physicians learn their trade – on real patients.  New interns start in July and they know nothing.  Sure, there are multiple levels of supervision over them, but these many layers can cause gaps and vulnerabilities in patient care.  The supervising medical resident, himself with only a year or two of experience, has several interns he is responsible for.  He can’t be with every intern every minute.  Sure, the intern can always call for help, but what if he doesn’t know that he needs help?

Patients at teaching hospitals enjoy many advantages.  There is often state of the art equipment and a renowned faculty.  They claim that with so many physicians of different hierarchical levels seeing patients, that this built-in redundancy catches errors and oversights.  This may be true, but as I have expressed, it is also a cause for miscommunications, excessive medical diagnostic testing, errors, exploding costs and gaps and lapses in care.

Imagine you are admitted by your internist and a cardiologist and a gastroenterologist are both consulted, a very common scenario.  Each of these 3 physicians has his own team of fellows, residents and interns.   You could be seen by 10 physicians in a day.  Communication lapses are expected as it is not possible for all of these physicians to know what all colleagues on the case are thinking and planning.

Contrast this with the situation in a community hospital, such as the ones I practice in.  There are no interns, residents or fellows.  I perform my own history and physical examination and take ownership of the patient.  I communicate with the nurses and other physicians on the case personally.  While this system is not perfect, there is much greater accountability to the patient.  There is no one I delegate to.  There aren’t layers of doctors pushing their own agenda to the extent there is in a teaching hospital. 

Our mission in the community hospital setting is patient care, not physician training.  In my experience, having been in both types of institutions, I think community hospitals have an intrinsic quality advantage.  Teaching hospitals would argue this point.   I don’t think it can be argued, however, that there are conflicts of interest in teaching institutions as patients are exposed to excessive medical care in order to provide education and training to young physicians.  This is undeniable.

If a July 4th hospitalization is in your future, you can choose your local community hospital or the Medical Mecca downtown.  If you choose the latter, get ready for some fireworks.

Sunday, July 10, 2016

Supreme Court and the Texas Abortion Law - A Victory for Truth

Readers are not aware of my personal view on abortion, and they won’t be after this post.  While abortion seems on its face to be a complex biomedical issue, interestingly, those with firm views on either side do not describe it as a great moral quandary.  Those who ardently favor abortion rights, and those who oppose them in equal measure, often express that this is not a controversial issue.  For them, it is a clear issue of right and wrong, with each believing that the other side is entirely wrong and misguided.  This observation applies best to those who are toward the poles of the abortion question.  If you believe that an embryo and a fetus are human beings, than abortion is murder.  Not much room for debate here.  If you do not confer personhood on an embryo and a fetus, then a right to abortion is a woman’s right to freedom and autonomy.  Clear cut argument here also
Of course, many thoughtful individual wrestle with this issue and do not grasp it in the black and white terms described above.

I have given this issue much thought over my adult life.  I do not feel that I can contribute to this wrenching public debate.  I have no new point or angle that hasn’t been offered or would change any minds.

I was pleased with the recent Supreme Court decision that struck down Texas law which had resulted in the closing nearly half of the state’s abortion clinics.  My view here is not related to my personal view on the issue.  I applaud the decision because I feel it is a victory for truth.

Our Best Functioning Branch of Government

Texas had required that abortion clinics be certified as ambulatory surgical centers (ASCs) and that providers must have hospital admitting privileges at an area hospital.  If these two conditions were not met, then the center would have to close.  I completely reject the law’s supporters who have claimed that the 2013 state law was to preserve women’s health.  This was unadulterated mendacity.  The law was not to protect women, but to limit abortions in Texas.  We don't expect veracity from our elected officials.  Indeed, politicians and partisans develop wheezing and hives whenever they unexpectedly make contact with the truth.  They should have announced at the bill’s signing the law's true intent – to limit abortions.  If you believe that decreasing abortions is a noble and moral objective, then say so.  If you believe that the unborn child merits all protections that can be legally conferred, then argue your case and try to pass laws that would accomplish it.

From a medical point of view, requiring the abortion provider to have admitting privileges or having the center regulated as an ASC is ridiculous.  Many other medical procedures performed outside of hospitals in Texas were not subjected to these restrictions.  Why not?  Don’t these patients deserve protection also?  The fact that the law has not been shown to have protected a single woman is powerful evidence of its true motive.

Tell the truth.  If you are a teacher who is protesting for a higher salary, don’t tell us that you’re doing it for the kids.  If you’re an older cop who wants to retain the current system that rewards seniority, don’t tell us that this is an issue of public safety.  And, if you’re a gastroenterologist who does colonoscopy for a living, don’t rail against a superior replacement arguing that you’re only protecting your patients. 

Sunday, July 3, 2016

Happy Fourth!!!

”I am apt to believe that it will be celebrated, by succeeding Generations, as the great anniversary Festival. It ought to be commemorated, as the Day of Deliverance by solemn Acts of Devotion to God Almighty. It ought to be solemnized 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.”

Who authored the above?

Hint: His signature demonstrates excellent penmanship!

Sunday, June 26, 2016

Lebron James and Medical Ethics - Let Me Explain.

Medical ethical issues confront physicians daily.  Most of us contemplate ponderous ethical dilemmas, such as end-of-life care care, allocation of the limited supply of organs for transplant or our unequal access to health care.  Many ethical decision points are rather quotidian, not situations that would serve as content for bioethical conferences.

Here are some examples of everyday ethical issues that physicians deal with.
  • A patient asks his doctor to support a claim for disability that is not warranted.
  • A patient asks his gastroenterologist to change his constipation diagnosis after the fact so that his colonoscopy is covered more fully by the insurance company. 
  • An employee in a doctor’s office, whose own doctor is booked solid, requests an antibiotic prescription for a urinary tract infection from her physician boss.
  • A physician falsely claims to an insurance company that he has tried certain medicines on a patient in order to gain approval of a desired medication.
  • A doctor tries to limit diagnostic testing of a patient with no insurance in order to save the patient money.
This past week, I had a request from a patient under very unique circumstances.  I performed a colonoscopy on a young man this past Tuesday.  Prior to the procedure he remarked “that he needs a really big favor from me.”  Such phrasing portends an improper request.   Would he be asking for pain medicines or to sign off that he needed light duty for the rest of the week?  He wanted me to give him a medical excuse for Wednesday, the day after his procedure. 

From time to time, we have requests from patients for work excuses on the day prior to or following their procedure.  Nearly all of these requests are politely, but summarily denied 

The Curse is Broken!

Wednesday, 6/23/16, was not an ordinary day in Cleveland.  There was going to be a once in a lifetime celebration downtown for the triumphant Cleveland Cavaliers, who bested the Golden State Warriors in an epochal championship series.   Contemplate the narrative.  A poor kid from Akron is raised by a single mom under very challenging circumstances.  His talent leads him to the Cleveland Cavaliers where he brings hope to a city that has been cursed with sports failures.   He leaves Cleveland in a clumsy, arrogant and ‘cavalier’ manner for the Miami Heat where he picked up some rings.  The poster boy became a Cleveland doormat.   He returns home to keep a promise.  We lose to the Warriors last year.  Now, we win against them by a whisker in game 7.   Cleveland hasn’t had sports championship team in over half a century.  We have suffered under a curse.

Even folks like me who are not sports fanatics have been swept up into this movement.  We are so proud of our amazing team and the fans who, like Moses, had been permitted to look upon the Promised Land, but not to enter it, until now.

How should I have responded to my patient’s request?