Sunday, October 27, 2019

Do You Really Need Plastic Surgery?

We live in an era where plastic surgery is routine.   Indeed, in many parts of the country, plastic surgery is an expected rite of passage.   Years ago, face lifts and ‘tummy tucks’ were done on those in middle age who were trying to experience a surgical time machine.  Now, folks in their 20’s are having all kinds of work done, not to recreate a prior image, but to create a new one.

The traditional scalpel in only one of many tools used to perform body design work.  There is a smorgasbord of injectable fillers that plastic surgeons, dermatologists and other physicians provide to a public who is zealously combating every wrinkle.  Once a person is of the mindset that the only good wrinkle is a dead wrinkle, he will commit himself to a lifelong odyssey of cosmetic work.  These folks are generally never fully satisfied with how they look.  They are always finding imperfections that they target for correction.

I enthusiastically recommend readers to read Nathaniel Hawthorne’s short story, The Birthmark, which speaks so elegantly to this issue, despite that it was published in 1843.

There is an important role for plastic surgery in the medical arena.  These talented professionals perform amazing work in reconstructing folks who have suffered trauma and accidents.  I also recognize that cosmetic surgery provides significant benefits to many patients.  However, it is beyond dispute that our society is preoccupied with physical appearance and is striving for an idealized an unrealistic level of beauty.   Many folks blame Barbie who convinced generations of girls and women that she was the paragon of beauty and attractiveness.   

Ladies, slip into these comfy slippers!

A few days before I penned this post, I read about women who bring designer shoes to podiatrists so they can have surgery that will permit them to wear their choice of stylish footwear.   Indeed, there are foot surgeons who specialize in these procedures.   My reaction?  Outrageous.   We’re not referring here to correcting podiatric deformities.   Can a doctor defend performing surgery on healthy feet so that a pair of shoes, probably not designed for a human, can fit in?  I am sure that there are analogous absurd examples of surgeries and procedures involving other body parts that should embarrass the medical profession.

Patient demand doesn’t justify medical excess.   Physicians need to call out abuses in our own house.  I expect that those practitioners who are bringing disrepute to the profession will claim that they are fulfilling an important medical function.  I say, if the shoe fits…

Sunday, October 20, 2019

Physicians and the Art and Power of Observation - Has This Bird Flown?

Medicine is for the birds, or it should be.  Hear me out.

A day before I wrote this, I was on the trail in northwest Ohio, binoculars in hand, trying to tell one warbler from another.  This was the final weekend of The Biggest Week of birding in Magee Marsh on the shore of Lake Erie.  Birders converged here from neighboring states and even from foreign countries to participate in this ornithological adventure.  My companion and I were new to the game.  Indeed, my birdwatching prowess had consisted of being able to successfully identify a blue jay at the feeder on our deck.  I had now entered a different universe.

There were serious birders afoot equipped with photographic and telegraphic equipment that looked like stuff that James Bond might have used.  Birds flitted about that heretofore would have generated no interest on my part.  When a rare warbler was spotted, the excitement raced through the birders like a brushfire, causing a crowd to gather to view the feathered phenom.  And, there were polite disputes among experts who were debating the true identity of the creature before them.  All in all, this was good clean fun.

Birders need knowledge and patience.  In addition, the most accomplished among them must have discerning powers of observation.  Here’s how I spotted a bird.  I simply came upon real birders who were all aiming their scopes and binoculars in one direction, and then tried to spy their target.  The skilled birder, the first on the scene, does not have this advantage.  He carefully scans the trees and foliage trying to find small birds, which are obscured by leaves and branches or camouflaged.  This looks easy, but it isn’t.  Many times, I had trouble finding the bird even when several birders next to me were staring at it.  This didn’t ruffle my feathers as I knew I was a few rungs below the beginner class.

You have to know what to look for, which is the distinguishing skill.  The pro knows the flora and which birds are likely to hang out there.  He sees the subtle moving of a small branch and knows this is not from the wind.  He knows the birds’ voices as individual arias, not as idle whistling.  He tunes out the visual and auditory static.

Easy to Spot 

Not so Easy

The power of observation used to be a honed skill of the medical profession.  Prior to the takeover of the profession by medical technology, physicians could deduce much simply by carefully observing the patient.  While medical educators may state that this skill is still valued, taught and practiced, this quixotic view isn’t part of the reality of medical practice today.  During my days in medical school, I recall learning from experts who could ascertain important medical information by examining a patient’s fingernails.  Palpating the pulse, and appreciating its nuances and subtleties, was an art, and not simply a means of determining the heart rate.  As a medical student, I watched Proctor Harvey, a giant in cardiology, use a stethoscope to hear sounds and make accurate diagnoses that are beyond the skills of nearly all of today’s physicians.   A patient’s speech, gait and skin often held important clinical clues for the physician detective.

I don’t’ think that medical quality is worse today because today’s physicians are not trained to observe.  Instead of observing, we test.   Nearly every heart murmur is subjected to echocardiography, as but one example.  The consequences of overtesting has been overblogged here at MDWhistleblower.  Readers know my serious concerns about overdiagnosis andovertreatment. Technology has both raised and lowered medical quality in this country.

I am wistful when I recall physicians and teachers from two generations ago, who could solve a case with their eyes and ears.  They would have been incredible birdwatchers. 

Sunday, October 13, 2019

Colonic Hydrotherapy. Is it Time to Bend Over?

From time to time, patients asks my advice on colonic hydrotherapy, vigorous sessions of enemas that aim to cleanse the body of toxins that are reputed to cause a variety of ailments.   The logic sounds plausible to interested patients.  Over time, toxins accumulate and leech into the body wreaking havoc.  Indeed, using the label ‘toxins’ already suggests that these are noxious agents.  If one accepts this premise, it is entirely logical that cleansing the body of these injurious agents would have a salutary effect.

Not surprisingly, the health benefits of hydrotherapy usually target very stubborn and vague symptoms and conditions that conventional medicine do not treat adequately.  It makes sense that if your own physician is not making sense of your chronic fatigue, for example, that you would entertain other options.  I get this.  Who wouldn’t want to enjoy having more energy, better concentration, an enhanced immune system or delayed aging?  But, in medicine and in life, just because one pathway seems blocked, doesn’t mean that an alternative pathway will be a better avenue. 

Let the Cleansing Begin!

The reason that I do no actively recommend hydrotherapy is because there is absolutely no persuasive and credible medical evidence that it is effective.  While their advertising materials may boast of ‘clinical studies’, there is no firm scientific basis for their claims.  And, these sessions can be costly as patients are often advised that several visits are necessary to address years of toxin build up.

If gastroenterologists did believe that the treatment works, we would be offering it in our ambulatory surgery centers along with our standard endoscopic amusement activities.  (A cynic might suggest here that if medical insurance covered these treatments, then we would!) 

It may very well be that practitioners of this treatment believe in the therapy and genuinely want to provide healing.  And, I have no doubt that many who undergo hydrotherapy feel better.  I’ll never talk a patient out of success from my or anyone’s treatment.  If a hydrotherapy patient were to tell me that his depression has eased, I would express great satisfaction over this.

I admit readily that I, along with every other breathing physician, prescribe treatments and remedies for which no supportive medical evidence exists.   We physicians may sanitize this fact by claiming that our action is an example of ‘the art of medicine’, but we are more likely hoping for the placebo effect.  

Physicians who deviate from evidence-based medicine shouldn’t casually criticize other practitioners who practice off the grid, particularly when patients have great faith in complimentary and integrative medicine.

However, all of us who claim to be healers should aspire for supportive scientific evidence for our recommendations, and we should admit to patients when such evidence is lacking. 

If you opt for periodic colonic cleanses, and you perceive a personal benefit, then be aware that you are engaging in an ‘art’, and not a science.  

Sunday, October 6, 2019

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.

Sunday, September 29, 2019

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. 

Sunday, September 22, 2019

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?