Sunday, October 15, 2017

I'm Taking a Knee on Journalism

Thanks to NFL players, our national anthem is getting more attention than ever.  Keep in mind that many of us could not recite its words without error, and fewer of us have the range to sing it.  Even fewer can cite the historical event being described.  This is the latest, but not the last, example of a solvable issue that is being exploited to divide us.  I lament that so many of controversial issues ricocheting in the public square are similarly solvable, and yet remain combustible.

The media stokes these conflicts, in my view.  Listen critically to how CNN and other networks package and deliver the news.   Not only is the reportage suffused with editorial content and slant, but it sows overt division and partisanship by design.  

Consider the following two hypothetical questions from a TV reporter.  Which one would the network be likely to air?

“Senator, what is your plan for tax reform?”

“Senator, the leader of the opposing party attacked your tax policy as a cruel attack on working families.  Is he right?”

The 2nd example, in my opinion, improves television ratings at the expense of journalistic professionalism.   

Many cable ‘news’ broadcasts have become extended panel discussions where folks along the political spectrum talk over one another spewing forth predictable drivel in a rhetorical food fight.   Again, these performances may be spirited and entertaining, but they are actually a demonstration by the networks that conflict sells. 

Knees in the News!

The ‘take a knee’ issue has been morphed from its original intent to protest against racial injustice in the criminal justice system to venerating the anthem and the flag.  Of course, there was a pathway forward had calmer minds and listening ears prevailed.  Why solve a problem when conflict can advance your agenda?   Peoples’ positions can harden despite that they have lost sight of the actual issue before them.

Are NFL players who are ‘on the clock’ in uniform permitted to protest on the sidelines?  Although I am not an attorney, I am not certain that sideline player protesting is constitutionally protected, as would speech be in the public square.   Would owners be entitled to issue a restraining directive if the players' actions were driving away fans and profits?  Would a racist player be permitted to engage in a hateful gesture while in uniform on the sidelines?  Lawyers reading this post can enlighten us if an owner can lawfully require that all players stand respectfully during the anthem. 

 In our medical practice, if our staff all wore shirts with a message that stated, ‘I SUPPORT EUTHANASIA’, would the physician owners have a right to limit this speech?

Regardless of one’s view on the legality or propriety of taking a knee, this issue did not have to have sliced the country apart.   I am not hopeful in the short run. As long as our leaders profit from our divisions, and with the public’s insatiable appetite for conflict,  the end zone will remain far out of reach.

Sunday, October 8, 2017

Why Are You Seeing A Gastroenterologist?

I write to you now from the west side of Cleveland in a coffee shop with my legs perched upon a chair.  Just finished the last Op-Ed of interest in today’s New York Times.  Do I sound relaxed?

I rounded this morning at both of the community hospitals that we serve.  There is not a day that goes by that doesn’t have blogworthy moments.  If I had the time and the talent, I would post daily instead of weekly.   Read on for yet another true medical insider’s disclosure.

Gastroenterologists, as specialists, are called upon by other doctors to address digestive issues in their patients.  For example, our daily office schedule is filled with patients sent by primary care physicians who want our advice or our technical testing skills to evaluate individuals with abdominal pain, bowel issues, heartburn, rectal bleeding and various other symptoms.  The same process occurs when we are called to see hospital patients.   If a hospital admitting physician, who is usually a hospitalist, wants an opinion or a test that is beyond his knowledge or skill level, then we are called in to assist. 

The highest quality referring physicians are those who ask us a specific question after they have given the issue considerable thought.  Contrast the following 3 scenarios and decide which referring physician you would select as your own doctor.
  • “Dr. Gastro.  Just met this patient for the first time with a month of stomach aches.  Please evaluate.”
  • “Why did your doctor send you here?” queried Dr. Gastro to the patient.  “No idea,” responded the patient.
  • “Dr. Gastro, please evaluate my patient with upper abdominal pain. I thought it might be an ulcer, but the pain has not changed after a month of ulcer medication.  The pain is not typical of the usual abdominal conditions we see.  Do you think a CAT scan of the abdomen or a scope exam of the stomach would be the next step?  Open to your suggestions.”
Sometimes, we have to deduce the reason the patient is seeing us!
As readers can surmise, I favor primary care and referring physicians who give thought prior to consulting me.   There are many reasons today why primary care physicians pull the specialty consult trigger quickly.  Sometimes, busy internists simply don’t have the time available to deeply contemplate patients’ symptoms.   Physicians have also referred patients to specialists with the hope of gaining litigation protection by passing the patient up the chain, although the medical malpractice crusade has eased over the past few years.  Oftentimes, patients drive the specialty consultation process by asking to be sent to specialists. 

More often than you would think, we see patients in our office or in the hospital when neither the patient nor I have a clue why they are there.  This adds excitement to our task.  In addition to being diagnosticians, we must also serve as detectives, divining the reason that the patient is before us!

Sunday, October 1, 2017

Does Secretary Tom Price Deserve Forgiveness?

What is the explanation for Tom Price, a physician and current Secretary of Health and Human Services, taking private charter flights costing taxpayers hundreds of thousands of dollars?  Keep in mind that when Price was a conservative congressman from Georgia, he would have railed against such fiscal profligacy.  Is it hubris?  Entitlement?  Or, do folks who ascend to positions of power simply rationalize that such excesses are absolute necessities for getting the job done?

By the time this piece is posted, Dr. Price, an orthopedic surgeon, may have been surgically excised from the government without anesthesia. 

While his behavior is not quite Watergate, it was wrong.  And, if it was not wrong, it demonstrated impaired judgment.  And, if was not simply a repeated exercise of misjudgments, then it exhibited bad optics.  And, if it somehow passed the optics test, it was just dumb. 

Would Price have been able to explain these expensive charter flights to average folks, half of whom elected the president to drain the swamp?

I watched Price’s reaction to all of this in several interviews.  Yes, he agreed to pay ‘his share’ of the flight costs, which represented a small fraction of the total costs incurred.  He stated that his department would desist from private charter flights in the future.  He admitted that the ‘optics were bad’ and that previous cabinet secretaries have engaged in similar behavior without suffering repercussions.  He didn’t appear to me to be a man consumed with guilt. 

Sounding the shofar, a call to repentence.  

Personally, I don’t think that Price thinks that he did anything improper.  He never clearly states that he was wrong.  Admitting that he had an ‘optics issue’ is not the same as a confession.   Pointing out that prior government officials committed similar acts with impunity doesn’t sound like a man who knows he has done wrong. 

If he did feel that his flights were proper, then why would he pay back the government anything or stop future charters?    He could have resigned simply because the president was angry and displeased, without offering a pseudo-confession to a transgression he did not believe he had committed. 

Yesterday at sundown, ended the Jewish Day of Atonement, Yom Kippur.  This culminates a 10 day period of reflection and penitence.   We are instructed to beseech forgiveness from the people in our lives before petitioning the Almighty for absolution.  We cannot receive atonement unless we have first admitted our errors, repented for them and strive not to repeat them.  While I am not a rabbi, I doubt that the Almighty would grant us a pardon if we looked skyward and cried out:  “My Lord, forgive me for demonstrating bad optics!”

Sunday, September 24, 2017

Why Graham-Cassidy Bill to Replace Obamacare Should Fail

The Graham-Cassidy bill – the latest Repeal and Replace iteration - still has a pulse, but its prognosis is grave.   While we physicians generally avoid predicting outcomes, my sense is that this bill will be buried in the coming days.  I presume that once its passage becomes mathematically impossible, that the bill will be pulled.

Of course, failure to Repeal and Replace is a horrendous embarrassment and exposure of the Republicans who have been campaigning and crusading against Obamacare with religious zeal these past 7 years.   These patriots knew they could safely rail against the Affordable Care Act (ACA) – throwing red meat to their base – knowing that the bills would never pass while a Democratic president occupied the White House.   How ironic it is that now that the GOP have congressional majorities that they couldn’t get it done.  Not only could they not run the ball into the end zone, but they repeatedly fumbled at every opportunity into the hands of waiting Democrats. 

It seems to me that the GOP efforts to ram though a New & Improved health care program was all politics and very little policy.   The objective was to get a 'win'. Numbers were massaged.  Special deals were offered.  The non-partisan Congressional Budget Office was bypassed.  False promises were made.  Doomsday predictions were declared.  All this is public knowledge.  Imagine what was happening beyond our view. 

I have been consistently hostile to Obamacare, which I have regarded as a waystation on the path toward full government takeover.  Readers are referred to various rants on this subject in the Health Care Reform Quality category along the right margin of your screen.  But my animus toward the ACA doesn’t mean that I’ll support anything offered up as a replacement.

Someone deserves a thumbs up here.  

I didn’t like it when the Democrats passed the ACA without a single Republican vote.   This partisan victory created a chasm that divided the parties and the country which lives still.  While the Democrats will claim that no Republican would work with them then (really?), they could have made some compromises to draw in some GOP legislators and still pass the bill.  Was it simply beyond the Democrats’ ability or willingness to include tort reform in the bill, for example?  How different would our political landscape be now if both sides had contributed to health care reform?

I don’t have a firm opinion on the merits of Graham-Cassidy, but I do not like the process of trying to jam it through before the end of the month so the GOP can utilize the reconciliation process, where only 51 votes are needed, rather than 60 votes.   A decent bill should be able to withstand congressional vetting and inquiry and should be able to draw 10 or so Democrats on board, assuming naively that they would be permitted to vote their conscience. 

I think that Lindsey Graham knew in his heart that his closest friend in the Senate, John McCain was going to give the thumbs down again.   I give him a thumbs up for being the principled and heroic statesman that we so desperately need.  

Sunday, September 17, 2017

Why Are Drug Prices So High? Explanations Welcome

Most of us do not know the basics of economics, although we should.  It impacts every one of us every day that we are alive.  Yet, for most of us, once we get beyond the law of supply and demand, our knowledge of the subject starts to vaporize.  I can't explain fiscal or monetary policy.  While I regard economics as a science, it seems that experts routinely interpret data differently, which confuses beginners like me.  What are novices to think when one expert hails our continued job gains while another laments our anemic recovery?

The Puppeteers

I have a general feel for market forces.  If consumer demand for an item rises, then I will expect to pay more.  If I want to make a purchase at an independent appliance store, then I will expect to pay more in return for superior customer service.  If the item is manufactured in China, it will likely cost me less as this factory is not burdened with worker protections, environmental regulation and union wages.

The above common sense realizations do not compute in the medical universe.  My fees, which I do not control, are unrelated to supply, demand or quality of the product.  Moreover, medical costs are a mysterious enigma which confound physicians and our patients.  Why does the cost of a simple bandage for a hospital patient remind us of the defense department’s $400 hammer?  Why can’t I, a gastroenterologist, give a straight answer to the question, ‘how much does a colonoscopy cost?’

Reimbursement strategies in medicine are changing to a system that will pay physicians and hospitals for the ‘value’ of their service, rather than the quantity.  Like any slogan, it will sound appealing but will bring forth a bevy of burdens that will create foreseeable controversies and challenges.  Stay tuned.

Let me share an absurd medical economic observation that occurred a few days prior to this writing.  I received a phone call over the weekend from one of my patients who was suffering from a recurrence of C difficile (C. diff) infection and needed antibiotic treatment for this as soon as possible.  The drug of choice was Vancomycin (Vanco).  Physicians know that the cost of this medicine is often prohibitive.  The patient and I made phone calls to area pharmacies in an effort to find the most affordable option.  Let me juxtapose below results from two different pharmacies.

Pharmacy #1                  Pharmacy #2

Vanco Cost                        $110                             $2,500

Okay, my economist friends, explain this discrepancy to me, if you can.  Good luck.   

Would it make sense to you if a Big Mac costs $3 at one McDonalds and $500 at another? 

Sunday, September 10, 2017

Hospital Acquired Infections and C. diff. Is My Hospital Safe?

If any reader has heard of C. difficile, affectionately known as C. diff, than I presume you have had closer contact with this germ than you would have liked.  It’s an infection of the colon that can be serious, or even fatal.  There isn’t a hospital in the country that isn’t battling against the infection.  

We are not winning the war against this crafty and cunning adversary. 

We Need Better Weapons Against C. diff

While the infection is not new, the strength and seriousness of current strains of the germ have tilted the odds against doctors and our patients.  The infection usually is a ‘side-effect’ of antibiotic treatment, but it can also be contracted from infected surfaces and people that reside in hospitals and extended care facilities and nursing homes.  For example, nowadays a patient can be admitted to a hospital and pick up the germ from hospital personnel who are contaminated from contact with an actual C. diff patient.  For this reason, C diff patients are kept in a form of isolation to protect against spreading the disease.  When a C. diff patient is discharged, the room must be scrupulously cleaned.  Hospital housekeepers today have an incredibly important job for reasons that need not be explained.  While my intent is not to frighten readers, every room in your hospital has likely housed a C diff patient at one time or another. 
  • Imagine the consequences if hospital rooms are not cleaned fastidiously every time?
  • Imagine the risk to patients if personnel do not observe proper handwashing techniques?
  • Imagine the hazard from overuse of antibiotics which are a known risk of C. difficile?
C. diff is not a simple infection like a urinary tract infection that can be easily wiped out. It can be severe and stubborn. The germ has a spore form where it stays protected within a type of armor and can survive on surfaces for months.  This is why it is so tough for hospitals who are striving every day to destroy these millions of microscopic germs who resist attack and hide in waiting.  It’s not really a fair fight.

Some patients carry the infection for life.  Many have died from it.  It’s especially tragic when a patient battles against C. diff which resulted from antibiotics that were not necessary in the first place.  Think of this when your dentist insists on giving you antibiotics because you have a heart murmur of have an artificial joint, neither of which is supported by medical evidence.

There’s a new treatment called fecal transplantation, where healthy donor stool is introduced into the C diff patient’s digestive system and cures an infection that seemed to be chronic and incurable.  In my view, this is a game changer and I predict that every hospital in America will offer it in the forseeable future.
My advice?  Refuse any antibiotics advised by any physician, including me, unless the doctor makes a case for them beyond a reasonable doubt. 

Sunday, September 3, 2017

Labor Day 2017

Couldn't cover every tool or trade here, but a shout out to all.   All work is honorable.

Warm wishes from the Whistelblower.

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