Sunday, July 15, 2018

Liberals Attack Brett Kavanaugh and Trash the Neighborhood


We live in frustrating and angry times here in America.  If you are not aware of this reality, then you are:
  • a newborn
  • a plant or an invertebrate
  • in heaven
  • comatose
  • on a deserted island sans electronic devices or wifi
  • living outside of the Milky Way
Peruse the front page of any newspaper or turn on any cable news channel.   You will read and hear about conflicts, outrage, investigations, accusations, threats and denials because this is what we desire and demand.  If we rejected such partisan and inflammatory reportage, the media would modify their content.   I do not accept that the media simply reports what is truly newsworthy; they produce their product to appeal to market forces.  Is Stormy Daniel's news value proportionate to the coverage she has received?  The reason that rags like the National Enquirer are successful is because we read them.

Beyond our collective appetite for darker and salacious content, we are also participants in the various tribal and cultural conflicts that are ongoing with no resolution in sight.  In other words, it's not all the media's fault.  For many interest groups and organizations, the mission is not to compromise or accommodate, but to vanquish and prevail.  Issues are viewed as a series of zero sum games – if you win, then I lose.   Of course, this is absurd. 

Ruth Bader Ginsburg was confirmed in a 96-3 vote in the Senate in 1993.   She was a known liberal, but Republicans properly supported her confirmation as she was qualified to serve.  Liberal presidents nominate jurists who are aligned with their philosophies.  Indeed, this should be a major consideration of voters when casting ballots in presidential elections.  Qualified nominees should be confirmed.  President Obama’s 2 Supreme Court Justices received Republican support, as they deserved.  Recently, Judge Brett Kavanaugh was nominated to assume Justice Anthony Kennedy’s seat.   Although his qualifications and temperament are unassailable, he has been vilified as if he is the anti-Christ.  Just because the Republicans inexcusably deprived Judge Merrick Garland of a hearing, does not justify perpetuating the dishonorable misdeed.  I wonder had President Trump nominated Moses, King Solomon or Jesus, if they would be similarly and summarily rejected by political opponents.


Moses - Clearly not Judge Material

Let me offer readers an oasis, albeit a brief one, from the chaos and the depressing morass that surrounds us.

Go and see Won’t You Be My Neighbor, a film that chronicles the life and work of one of our nation’s treasures, Fred Rogers.   He was an extraordinary human being, who inspired us with his deep humanity, compassion and love.   I found myself near tears during several moments of the film, and I continue to reflect on him his weeks later.  He was an antidote to hate and intolerance.  He made a difference.  We need him now more than ever.  See the film and you will also yearn to join his neighborhood.  

In today's era, if Fred Rogers needed Senate confirmation, could he achieve it?

Sunday, July 8, 2018

Insurance Companies Protect Patients or Profits?

A patient came to see me with lower abdominal pain.  Was she interested in my medical opinion?  Not really.  She was advised to see me by her gynecologist who had advised that the patient undergo a hysterectomy.  Was this physician seeking my medical advice?  Not really.   Was this patient coming to see me as her day was boring and she was bored and needed an activity?  Not really. After the visit with me, was the patient planning to return for further discussion of her medical status?  Not really.

So, what was going on here.  What had occurred that day was the result of an insurance company practice that I had thought had been properly interred years ago. 

The Insurance Reform Hammer - Locked and Loaded.


The woman had pelvic pain and consulted with her gynecologist.  An ultrasound found a lesion within her uterus.  A hysterectomy was advised.  The insurance company directed that a 2nd opinion be solicited.  A second gynecologist concurred with the first specialist.  The patient advised me that the insurance company wanted an opinion from a gastroenterologist that there was no gastrointestinal explanation for her pain.  In other words, they did not want to pay for a hysterectomy that they deemed to be unnecessary.
  • We should applaud the insurance company for its diligence to protect the patient from an unneeded surgery.
  • We should recognize that the insurance company is focused only on promoting medical quality with no concern for saving the company money.
  • We should cite the insurance company for industry excellence for facilitating smooth and efficient medical care.
  • We should tell the obvious truth about what is actually going on here.
This woman’s treatment plan, as recommended by two gynecologists, was halted by a bureaucrat who likely had less medical training than they did.  I surmise that not enough ‘boxes were checked’ on the submitted paperwork to permit the recommended surgery to proceed.   The insurance companies, of course, claim fidelity to a medical quality mi$$ion.  How would they like to be subjected to the same absurd level of scrutiny and oversight that they wield over us?  When the reform hammer comes down on the insurance companies,  my patient might be holding up a sign or a pitchfork, but it won't be to stand up for them.

Sunday, July 1, 2018

Happy Fourth of July


Let's pause for a few moments, amidst the chaos and cacophony of a society tearing at each other, when we shout more than we listen, when we foment more than we forgive and when we hate more than we heal to recall the promise of a nation that was founded with noble ideals as it journeys to form a more perfect union. 
The Whistleblower 




”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.”

John Adams

Sunday, June 24, 2018

Do Insurance Companies Care About Patients or Profits?

Readers know of my hostility toward overdiagnosis and overtreatment.  I maintain that there is probably twice enough money as needed to reform the health care system if unnecessary medical care could be eliminated.  (Yes, I am including colonoscopies in this category!)   The challenge, of course, is that one person’s unnecessary medical care is another person’s income.  

One institution that is routinely demonized are medical insurance companies.  They are described as Houses of Greed who put profits ahead of patients by design.  Every physician who is breathing can relate tales of woe describing frustrating obstacles that insurance companies place before us and our patients.  When one of my patients receives a ‘denial of service’ notification, I am always prepared to discuss the patient’s case with a physician at the insurance company, as this provides an opportunity for me to explain the nuances of the case to a colleague. 

Take the following quiz now.

Which of the following tasks is most difficult to accomplish?
  • Getting an upgrade from ‘coach’ into first class of the plane for free.
  • Calling the IRS to get some personalized advice from a living, breathing human being.
  • Understanding your medical bill.
  • Solving your internet malfunction by consulting the company’s ‘FAQ’ page.
  • Reaching the medical director of a medical insurance company.
Alexander Graham Bell's First Call to Insurance Co Doctor
'Sorry, Wrong Number.'

I know that these companies have medical personnel on the payroll, but finding them requires assistance from intelligence professionals.  They likely arrive at work in disguise and work in a secluded office behind a door labeled ‘Maintenance’.  Years ago, while I didn’t actually connect with a live physician, I was afforded the opportunity to leave my phone number on a voice mail.  If the physician did deign to return my call, it was never at a time that I was available to converse.  Since I do procedures every day, round at the hospital and have a few offices, the probability of the physician reaching me with a single call was equal to the chance that you will be served Surf ‘N’ Turf on your next airline flight.

Yeah, I know I sound frustrated, and writing this blog post has released some of the pressure.  In fairness, there are many times that the medical community and the public take advantage of the insurance companies.  I will share some thoughts on this in an upcoming post. 

If you need to call a doctor, take my advice.  Don’t call the one who works for your insurance company.  Try something when the odds will be more in your favor.  Play the lottery.

Sunday, June 17, 2018

Ohio Limits Opioid Precriptions - The Journey Begins


I have written previously about the raging opioid epidemic here in Ohio.  Attacking and reversing this tidal wave will require many weapons, resources and time.  Opioid addiction is a crafty and elusive adversary that will be difficult to vanquish.  Our battle plan will have to be nimble and adjusted over time, much as military leaders must do in actual armed conflict.

Here in Ohio and elsewhere, physicians must abide by new prescribing restrictions.  Prior to prescribing a controlled pain medicine, doctors are required to check the patients OARRS report on line, which catalogues the patient’s prescription history.  This would alert us if the patient was receiving controlled medicines from various pharmacies that the patient might not disclose to us.  Physicians and the public are encouraged to seek non-narcotic alternatives for pain relief.  If opioids are prescribed for acute pain, there is now a limit on the length of opioid treatment that is permitted.  There are exceptions which require additional physician documentation.  The above restrictions do not apply to chronic pain or pain suffered by individuals with cancer or are in hospice.  Importantly, these rules do not apply to medication-assisted treatment of opioid addiction.


Cure for Addiction Advertised over a 100 years ago.

There has been opposition to the above regulations from patients with chronic pain who are having difficulty getting their pain medicine prescriptions filled.  They are being turned away by their doctors, or told to consult with pain management physicians who have expertise in this discipline.  These specialists are extremely busy and it can be very challenging for patients to secure a timely appointment with them.  For a patient with chronic pain, this can be a vexing and agonizing situation.  And, if this patient proceeds to the Emergency Room, these physicians may be understandably reluctant to accede to a patient’s request for controlled pain medicines. 

I think and hope that these issues will sort out.  One can’t expect that new reforms will be flawless from the outset.  Perhaps, the net we are using now to restrict pain medication use is overly wide, as many initial proposed solutions often are, but we will narrow it with more time and experience. 

There is no law, regulation or policy that does not cause friendly fire casualties or undesirable outcomes.   Our criminal justice system, for example, demands a not guilty verdict, even if an individual has committed a crime if a designated proof standard has not been reached.  Society has accepted a balance in the courts and elsewhere.  We reject using a wider judicial net that would capture more criminals but would ensnare too many innocents.  It's an imperfect system by design.

Since no system is perfect, we should not aspire to achieve this standard.  We have to tolerate some level of error and fallout.  Similarly, the medicines that doctors prescribe are deemed by the Food and Drug Administration to be safe and effective, but we all know that they are neither 100% safe nor effective.

Our opioid strategy is a work in progress.  Surely, we all agree on the destination.  But, the path to reach that point will be marked by many pitfalls, slippery slopes and difficult terrain.  

Sunday, June 10, 2018

Teaching Empathy in Medicine - Lessons from an IV Drug Abuser

We’ve all heard the excuse or explanation that ‘it’s society’s fault’, to explain someone’s failure.  We hear expressions like this often when an individual has committed a crime or simply failed to succeed.  Personal accountability is diluted as we are told that this person came from an imperfect home, had no role models or ample education.

These arguments are often wielded by those who have been favored with society’s blessings and advantages.

As readers here know, I am not politically liberal and regard myself as an independent who usually votes for Republican candidates.  I did vote for Senator Sherrod Brown, one of the most liberal members of the U.S. Senate, a fact that astonished friends and family, as I had concerns about the character of his opponent that I could not overcome.  I am proud of this vote. 

Were you born next to a ladder?

A 19-year-old female was sent to me to evaluate hepatitis C.  She was unemployed.  She had used intravenous needles years ago and resumed using them a few weeks before she saw me.  Hepatitis C was not the immediate medical priority here. 

I felt that I was facing an individual who inhabited an alternative universe from mine.  While I am speculating, I surmise that she faced choices through her life that I never had to confront.  What narrative, I wondered, could this young woman have had that would lead her to her present destination, where she would be self-injecting poison into her body?   I am not relieving her of personal accountability for the decisions that she has made.  Adverse circumstances do not guarantee failure.  Indeed, we all know phenomenal people who have overcome incredible adversity and long odds to achieve and inspire.  I wish that their methods were contagious.  The woman before me, at least so far, was not one of these individuals.

Perhaps, she came into this world unwanted and unloved.  She may not have had adults in her life to build her self-worth and to help guide her.  Maybe, education was a closed pathway for her.  What caliber peer group was available to take her in to soothe her rejection? 

My point is that it’s always easier to judge someone’s failures from higher ground.   Would many of us have reached higher ground if we weren’t born with a ladder that was set up beside us to ascend? 

I’m all for personal responsibility and accountability.   I’m also making a case for empathy, a virtue that has not always been as strong as it should have been in my own life.  

If our ladder breaks and we crash, how would we like to be treated?

Sunday, June 3, 2018

American Cancer Society Wants Colon Cancer Screening at Age 45


Until last week, colon cancer screening for most folks started at age 50.  Why 50?   Why hadn’t the colonoscopy coming of age been set younger to prevent the tragedy of a 45-year-old, or an even younger person, developing colon cancer?   In the past 2 weeks, I had to give a young patient and his wife the sad and serious news that he had colon cancer.  Because of his young age, he never received a screening colon exam, as we routinely do with 50-year-old individuals.  Is it time to make an adjustment?

Our colon cancer screening system is not perfect.  It is not designed to prevent every case.  There have been people in their 20’s who have been diagnosed with this disease, and there is simply no way to capture them in the system.  Experts in disease prevention must carefully analyze disease trends and behavior to find the sweet spot of when to begin screening.  And, money is part of this decision.  Let’s face it.  We don’t have unlimited resources to pay for every worthy medical benefit. 

Determining when to recommend mammography, and how often this test should be done, is a very similar issue.


What Starting Age for Screening is a Bullseye?

Colon cancer prevention experts had believed that age 50 was the proper starting point for screening.  Delaying until age 55 would leave too many people at risk, and starting earlier would save too few folks and wouldn’t be worth the cost or effort.  That is, until now.  The American Cancer Society (ACS) issued new guidelines last week recommending that colon cancer screening start at age 45, a radical change from established dogma.  The reason is that colon cancer in younger people has become more common.   Keep in mind, this recommendation did not emanate from a gastroenterology (GI) organization who might be expected to endorse any system that would benefit GI practitioners like me.   The ACS revised its colon cancer screening guidelines on the merits.  We await responses from other respected medical organizations on this issue.  And ultimately, insurance companies and the government will have to buy in to this proposal.

This bold recommendation, if universally adopted, will save lives.  Maybe yours will be one of them.



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