Treatment for Diverticulitis Revisited

Is there stuff that you do just because that’s the way you’ve always done it?   I’ll answer for you – yes.

In many circumstances, this makes sense.  For example, I stop my car at red lights just as I have always done.  I recommend that readers do the same as there is an underlying logic for this recommendation.  It is not simply a rote routine that has no rationale.   However, the particular order that we pour ingredients into a pot when making soup, may be more random than rational.   We follow the same order we always have, never pausing to wonder why or if there might be a better way.

And, so it is with many practices and procedures in the medical profession. Let’s return to the medical condition of diverticulitis, which I presented on this blog recently.  Follow the link, if interested.

For the last several decades, this disease has been treated in the same way – with antibiotics.  This means that physicians believe this to be an infectious disease – like strep throat – caused by bacteria.  But, the real reason I think that physicians like me prescribe antibiotics for this condition as because that’s the way we’ve always done it.

Changing established medical practices is like having an ocean liner make a U-turn.  It’s not easy.  For example, when I was a medical student, kids with red ear drums, or otitis, were routinely given antibiotics, assuming that this was a bacterial infection.  But, after a few decades, experts concluded otherwise.

Not Easy to Make a U-Turn

Similarly, I have a strong sense that the established treatment for diverticulitis may be revised.   The classic understanding of this disease was that this was a bacterial infection in the wall of the colon.  The theory was that a tiny puncture would develop in one of the diverticula, which are pouches that are weak points in the colon.  Germs from inside the colon would travel through the puncture site to the outside wall of the colon, which is usually sterile, and an infection would start.  We prescribe antibiotics and the patients generally recover well. 

But, should the antibiotics really get the credit?  What if these patients would have recovered anyway on their own?  I believe many of them would have.   In fact, many patients who have had diverticulitis, often have had episodes that recovered spontaneously without having seen a physician. 

In fact, a prominent gastroenterology professional society recently issued guidelines that expressed that not every case of diverticulitis requires antibiotic treatment.   It may take another 10 years for this recommendation to gain traction. 

I’m not abandoning antibiotics for diverticulitis in my practice yet.  But, I am following the issue closely in the journals.  There needs to be a better reason to do stuff than simple habit and routine – and that includes reading this blog.

Value-based Pricing and Reimbursement in Health Care

I am a conservative practitioner in my specialty of gastroenterology.  Compared to peers, I order fewer scope examinations, prescriptions and CAT scans.  I’ve always believed that a more parsimonious practice of medicine would protect my patients better than would a more aggressive approach.  Sure, this also means that I spend fewer health care dollars on my patients, but this is not my primary motivator.  I practice in this manner because I am convinced that in the medical profession, less is more.

I am somewhat of an iconoclast as many of my colleagues for various reasons practice differently.  They might feel that my medical nihilism is depriving my patients of necessary testing and treatment. Patients over time tend to find physicians who share their philosophy.   Patients who believe that more testing and more medication is the pathway to better health will not be comfortable with a doctor like me.

But, change is afoot!  I predict that within the next several years, if not sooner, that my practice style will become normative.  Why would this occur?   Why would physicians who were heavy on the medical utilization gas pedal suddenly be pumping the brakes?  

It’s the reimbursement, stupid.   Soon, physicians and hospitals will be paid differently.  Value based pricing will become the means of reimbursing health care providers and institutions.   So long, fee-for-service, a system that rewarded the medical profession for excessive and unnecessary care.  Payers will reward physicians and health care systems that deliver favorable outcomes that are cost-effective.   Not surprisingly, when physicians and hospitals have a financial stake in how they practice, the practice style arc bends.   It’s a law of economics that folks spend other people’s money faster than they would their own.   Do you order differently off the menu when someone else is picking up the tab?

I think I'll order the steak tonight.

Changing the reimbursement policies will make sausage making seem appealing.  Remember, every example of excessive medical care is someone else’s income.  It is unlikely that those who will lose out will champion an effort that might cost them money. 

No system is perfect.  Every reform proposal poses conflicts that need to be exposed and addressed.  We all want high quality medicine that is delivered efficiently.  If, however, there is too much zeal in achieving cost savings, then this could adversely affect quality.   We need to ensure that we remain true to our primary mission which is to protect the health of those whom we serve.   The current system desperately needs to be reformed.  But, we want what emerges to be a step forward on a journey that may take a decade or longer to reach the destination.  If we simply exchange one set of problems for another, then we have traded quicksand for falling off a cliff. 

So, let’s look for the pharmaceutical companies, physicians, hospitals, insurance companies, the government, medical device companies, extended care facilities and the public to join hands as they sway in a Kumbayesque moment all pledged to serve the greater good. 

Do I Have Diverticulitis?

I have been treating diverticulitis for 30 years the same way.  When I suspect that a patient has this diagnosis, I prescribe antibiotics.  This has been the standard treatment for this disorder for decades.

I have found that diverticulitis is a slippery entity that has two trap doors waiting for physicians to fall through.

 It is an easy task to miss the diagnosis.  Every physician has done this.

The diagnosis can be erroneously assigned to a patient.  Every physician has done this.

Recognize that the phrase ‘every physician has done this’ includes me.

The diagnosis can be elusive as there is no diagnostic test that secures the diagnosis.  The technology tsunami has covered the medical landscape, as it has run over so many other spheres in our society.  Doctors and patients increasingly rely upon ‘the numbers’.  Want proof?  Do you think there are many physicians today who can actually plug a stethoscope into their ears and hear, let aloneunderstand all of those clickety-clackety heart sounds?  And, if they do, they order an echocardiogram anyway. 

Hey, what's this new fangled contraption?

The medical community and those we serve are hyperfocused on objective data - stuff that can be measured.  Here are 3 examples of seemingly reasonable questions that I believe often miss the mark.  

What did the CAT scan show?  

Did the tumor marker decrease?   

Is my carotid arteries screening test normal?  

A more relevant question, such as, how is the patient doing?, is ignored or relegated to a lower priority status.  Who cares if the tumor marker goes down if the patient doesn’t feel any better? 

So, when diverticulitis is a consideration, a physician actually has to act like a doctor.  Sure, a CAT scan can be consistent with diverticulitis, but many other conditions can precisely mimic this CAT scan appearance.  So, the physician has to make a ‘clinical diagnosis’ of diverticulitis.  This means that the doctor must analyze all of the data – your symptoms, the labs, radiology results – and then make a judgment.  A common error is when the diagnosis is prematurely made based primarily on the CAT scan, without weighing other factors.  A clinical diagnosis of diverticulitis can also be made without a CAT scan or laboratory data.  Yes, the doctor can actually perform old fashion doctoring, which has become rather quaint these days.

In my practice, many patients who come to me complaining that they are experiencing a ‘flare’ of their diverticulitis are mistaken.  There is some other explanation for their stomach pain.  Or, the patient may state that the pain is identical to a prior episode of diverticulitis, but often the original diagnosis of diverticulitis was incorrect or uncertain.  Yes, I admit again there is always the chance the patient is right and I am wrong, but hopefully my decades of training and experience are worth something. 

My points above are certainly not restricted to diverticulitis.  They cross into every medical specialty.   Technology and objective data too often are wag the dog.  Who do you want evaluating your medical symptoms, a physician or Alexa?

Should High Blood Pressure be Treated?

In last week's post, I promised an explanation why many screening and medical treatments offer so little benefit to individual patients.   If you invest the time to digest last week's post and the post before you now, then you will be equipped with new understanding that will enable you to make much better medical decisions.  In accordance with this blog's mission, this is truly a 'peek behind the curtain'.  I grant you that these 2 posts are a little wonky, but try to stay focused.  

Here is the main reason that ordinary people – and even some medical personnel – become confused on this issue.  Studies that assess screening tests and medical treatments are often performed on very large groups of patients.  The reason for this is that smaller studies, for reasons I cannot fully explain here, are simply not felt to be sufficiently reliable.   This is why the Food and Drug Administration would never grant approval of a new medicine based on favorable results from small studies.   If a benefit or a failure is shown in a high quality study with hundreds or thousands of participants, the results will be highly credible.   It was large studies, for example that demonstrated that blood pressure control prevented serious complications. 

Here is the key point.  When a medical benefit is established in a large study, this benefit applies to a large population of people.   When this medical test or treatment is later applied to an individual patient in a doctor’s office, the benefit that this person receives may be miniscule.   This reality is not appreciated by nearly all patients I have treated in nearly 3 decades.  If a patient reads about a study that concludes that losing excess weight will cut the risk of stroke by 30%, the patient is likely to make 2 false assumptions:

He overestimates his risk of stroke.

He overestimates the true risk reduction of losing 10 lbs.

If his risk of stroke is already very low, then reducing it by 30% offers almost no benefit.  Follow the next example.

Will Lowering My BP Save My Life?

Assume a study of 5000 patients with high blood pressure demonstrates that lowering blood pressure 10%, can halve the risk of developing a heart attack.  This sounds like a game changer, but not to an individual patient, such as any person reading this.  The benefit is derived from studying a large population.   Assume that without treatment that 100 patients of the 5000, or 2%, would suffer a heart attack in 10 years.  With blood pressure treatment, only 50 patients would suffer this outcome, a 50% decrease in the adverse event.   Wouldn’t it be true that an individual patient would also have a 50% risk of developing a heart attack?  Yes, but let’s play this out.

A patient comes to the doctor with modest high blood pressure and no other cardiac risks. The patient has read about the landmark study that concludes that treatment would halve his heart attack rate.  Let’s assume, that this person’s risk of developing a heart attack in 10 years is 3%.  That means that this individual already has a 97% chance of staying well without any treatment.  Treating this patient would lower his risk of a heart attack from 3% to 1.5%, representing the 50% benefit we have been discussing.  So, with treatment, he now has a 98.5% probability of avoiding a heart attack.  Would someone enthusiastically take lifelong blood pressure medicine for an additional 1.5% protection when he already was 97% in the clear?   Would most of us welcome this return on investment?  I am not even considering the costs of many of these treatments and the potential side effects.   

When large studies’ benefits are applied to individuals, the benefits calculate out very differently. However, treating hundreds of thousands, or millions of people with elevated blood pressure would save many of them simply because we are dealing with large numbers of people.  A percentage point or two of a million people is a respectable number.  That’s why it makes sense to treat many diseases from a public policy standpoint.  The point is that each individual only enjoys a very modest benefit. 

I hope that readers have found this post – and the blog overall – to offer a very high return on investment.   Your comments are always welcome. 

Does Mammography Save Lives?

I find that the public often exaggerates the benefits of many preventive health measures.  I don’t blame the public for this.  There are several forces conspiring to deceive the average patient into accepting exaggerated claims of various medical tests and strategies.   Of course, the Medical Industrial Complex is a gluttonous beast that must be fed massive quantities of medical testing and treatment if it is to survive.

Most of the public thinks that medical interventions, including mammography, lowering cholesterol levels, blood pressure reduction and even colonoscopy are downright lifesaving.

Recognize that I am in favor of all of these measures, but that the actual benefit to the individual is much smaller than most folks believe.  In the case of mammography, there is uncertainty as to whether it saves lives at all, a view readers can easily find with a rudimentary internet search.  Mammography experts all agree that any benefit of this screening test to the individual patient is very modest.  This is not my opinion; it is a fact.  And yet, most women, including the women in my life, believe that this test offers them solid protection.

Mammography - True Lifesaver?

If I am correct that the individual enjoys only very modest benefit from these routine medical interventions, then how did they gain a permanent foothold in the medical landscape?

Why would physicians zealously recommend tests that were of such limited value?

Why would insurance companies and the government pay for such testing?

Why would patients submit to tests or lifelong medications that offered a very limited benefit?

Why are so many of us unaware of this issue?

As I do not want this post to be double my usual word count, I will provide you next week with a detailed response on this issue.  I strongly urge you to check back here next Sunday for an opportunity to inform and empower yourselves.   I’m not against screening tests or established medical treatments.  I’m for the truth. 

Labor Day 2019

All work is honorable.

Honor everyone's work.

Work with honor.  

The Whistleblower wishes all of you a meaningful Labor Day.