Sunday, December 29, 2019

Can a Doctor Do a Medical Procedure Without Consent?

Some time ago, I performed a colonoscopy on a patient who was having serious internal bleeding.  He had already received multiple transfusions since he was admitted to the hospital.  After obtaining informed consent for the procedure, I performed the colon exam.   I encountered blood throughout the entire colon, but saw no definite bleeding site, raising the possibility that the source of blood might be higher up than the colon, such as from the stomach.  I had not considered this possibility when I met the patient, but this was now plausible.  Can I proceed with the upper scope test, which the patient did not consent to, while the patient is still sedated from the colon exam?

Could the Stomach be the Culprit?

Seasoned gastroenterologists can usually predict the site of internal bleeding based on numerous medical facts, but there are times that we are surprised or misled.  Patients don’t always behave according to the textbook presentations we learned. 

At this point, which of the following options are most reasonable?
  • Do not scope the stomach now as the patient is still sedated from the colonoscopy and cannot give consent.  Once the patient has awakened and recovered, discuss the new diagnostic hypothesis and obtain informed consent to examine the stomach to look for a bleeding site.
  • Forge ahead with the stomach scope exam while the patient is still sedated.  Assume informed consent and proceed.
I opted for the latter option.  Ethically, I felt that I was on terra firma as the patient had already consented to a colon exam to evaluate the bleeding.  It seemed absurd that he would have consented for a colonoscopy but withhold consent for a stomach exam that was now deemed essential to pursue the same diagnostic mission.   Moreover, the patient had received multiple transfusions so there was clearly a medical urgency to identify the bleeding site.

Assuming consent for a subsequent procedure that was not initially anticipated is rational and defensible if the test is clearly in parallel with the medical evaluation and there is a medical exigency present.  Presuming informed consent, however, is an exceptional event.  Physicians are not permitted to go rogue. 

The blood in the colon didn’t come from the colon, as I had wrongly suspected.  It came from a duodenal ulcer just beyond the stomach, which I easily spotted with the stomach scope exam. 

This patient didn’t go by the book.  Sometimes, we physicians need to deviate from established policies also. 

Sunday, December 22, 2019

Whistleblower Holiday Cheer 2019!

‘Twas the night before Christmas,
And all through the House,
All the creatures were plotting,
Claiming Trump was a….RAT!

We have Schiff and Nadler
And, of course, Madame Speaker,
Who are as transparent,
As the Anonymous leaker!

Our Democracy might fail,
Our Dem statesmen teach,
So what choice do they have
But to hold hands and impeach.

When Mueller fell flat,
They all felt the pain,
But, the Lord heard their prayers
And POOF – came Ukraine!

With so many versions
How could we know
If Trump really offered
A quid pro quo.

The witnesses swore
Trump’s plan was – Extort!
Jim Jordan responded
With a loud bleating snort.

And with all of this static
Some can’t be heard,
When the candidates speak,
We hear nary a word.

So Warren and Bernie,
(And Blitzen and Dasher)
Have been squelched and muzzled.
By the Candidate Crashers.

When it all ends
And the Senate says, No!
No minds will change.
I told you so!

While the republic survives,
And impeachment will fail,
This won’t be the end
Of this harrowing tale. 

It’s easy to break
And harder to build
Has hope for our healing
Already been killed?

Let’s join together
In this land of plenty,
As we strive to get through

Joy and Peace!

Sunday, December 15, 2019

'Doctor, What Would You Do?'

There’s a phrase that every physician hears repeatedly from patients, that requires a nuanced response.

Doctor, what would you do if you were me?

There are variations on this inquiry, such as ‘what would you do if I were your father’, but they all are aiming at the same target.  The patient, or often the patient’s family, asks the doctor what advice the physician would choose if he were in the patient’s place.  For example, if the physician were the patient would he opt for:
  • Surgery
  • Chemotherapy
  • Experimental treatment
  • Watchful waiting
  • A second opinion
  • A third opinion
  • Alternative medicine
  • Acupuncture
  • Hospice
'Doctor, what would you do?
Patients erroneously believe that this form of inquiry is the magic bullet of finding out what the physician’s truly best advice is for a particular medical circumstance.  After all, if the doctor would recommend a treatment for his own mom, then surely this must be the best option.

Except, it isn’t.  Here’s why.

Physicians, as members of the human species, cannot be as objective with regard their own families or themselves as they are with their own patients.  This is why wise physicians do not treat family members.  Indeed, every physician has heard vignettes of inferior care that was rendered by a doctor to a close family member.   The reasons for this are beyond what I can express here, but the core of the explanation is tainted physician judgement resulting in delayed diagnoses and incorrect treatments.  When a close relative recently approached me to discuss recurrent stomach aches, I gave her good advice.  Make an appointment with a doctor.

Another circumstance when physicians are known to provide inferior care secondary to judgement lapses is when the doctor is treating a celebrity or VIP.

If you ask your doctor what he would do if he were you, the doctor’s response should be an explanation of why he can’t give you the answer you seek.

Sunday, December 8, 2019

Are Female Gynecologists more Sensitive than Males?

Would you rather be right, wrong or interesting?  

When I was a medical student rotating on the OB-GYN rotation, the issue arose if female OB-GYNs were more sympathetic to patients than their male colleagues were.  Before reading on, what's your opinion here?

There was a view that females in this medical specialty would have more empathy for patients as they may have experienced menstrual cramps, pelvic pain and childbirth.  No man can relate to these symptoms and they might be expected to be more dismissive or distant over these ‘minor hormonal disturbances’.  In other words, men just don't get it.

A discrete GYN exam 200 years ago

It is true that one who has ‘walked the walk’ may connect more closely with one who hasn't.  For example, since I have never suffered from an addiction, I can never counsel a drug addict or alcoholic with the same street cred as one who has triumphed over these afflictions.

The chief of the OB-GYN department at my medical school was sitting with us students as this discussion unfolded.  The chief was a veteran physician and had trained several scores of OB-GYN physicians.  While this is not a scientific study, in this physician’s opinion, male gynecologists and obstetricians in the training program were consistently kinder and more understanding to patients than female physicians were.  The chief speculated that females, contrary to prevailing intuition, might be less empathic as they’ve had menstrual cramps, etc., and' they’re not that bad’.  Men, in contrast, might be more sympathetic to female pains and conditions as they tended to be spooked by symptoms that they will never have.

I am not offering an opinion on the issue, but am simply relating one chief's view.

Do you think the chief was male or female?  Might this have influenced the chief’s conclusion?

Is the chief right or wrong?   Can’t say, but it was interesting and I’ve never forgotten it, even 30 years later.

Sunday, December 1, 2019

Is Everything Offensive?

I will digress from this blog’s medical quality theme to let off the gaseous form of H20, also known as steam.  I wouldn’t consider this to be a rant, a genre that I have offered previously.  But, it’s more than just venting to my readers.  So, it’s somewhere between a rant a and a vent.  

In my world, I try hard to challenge myself and others.  It’s the way I’ve always been.  I love the debate, the argument and the rhetorical fencing.  I feel satisfied if I can change someone’s mind and I particularly relish when someone can change mine.  Let the better argument prevail.  Of course, contestants in this arena must be willing change their views and give an opposing argument a fair hearing. 

There have been instances during these colloquies, and at other times, that I have inadvertently offended someone.  At times, this occurred because my words were clumsily selected.  On other occasions, the recipient may have been overly sensitive and had a low offense threshold.  I have also had the experience where my seemingly innocent words hurt someone as I was not aware of some personal experience that rendered the individual understandably sensitive.   For example, if someone recently lost a loved one, they may not find a cemetery joke to be amusing.

But, do you agree that it seems easier than ever to offend folks these days? 

I am growing tired of Offensomania, an epidemic of offenses being perceived in nearly every corner of our society.  Folks are now ‘deeply offended’ after reading a newspaper article, attending a lecture, seeing a TV advertisement, witnessing a claim of intolerance, watching cable news, reading about educational curricula, viewing artwork and hearing normative political discourse.

'You have offended me.  En garde!'

Reasonable disagreement on the issues of the day should be expected and welcome, but why does every little think provoke claims of offense?

Does a day go by without some person or organization threatening a protest or a boycott?  A corporate executive can lose his or her job over an utterance or a tweet from years back in order to mollify the offended 'victims'.  Think about that, losing your job because of some silly stuff you said or did years back, particularly when standards may have been different?  I wonder if Al Franken agrees with me on this point?

I’ve read thousands of newspaper columns and I never recall feeling offended by any of them, though  I’ve certainly disagreed with many of them.  I’ve read hateful and ignorant words, especially in the past 2 years.  Sadly, I expect to read more of them in the next year.  But, they won’t offend me.  That’s not to suggest that contemptible views don’t merit a vigorous response – they do and I hope to be part of that voice.  But, I won’t claim to have been personally offended. 

I truly believe there are folks out there who are contriving offense to serve some other interest.  Think this over the next time - which will probably be today or tomorrow - that someone is professing some great offense over some item or event.  Do you really believe the offense is real?

There was a joke back in my college days.  A young student sees a protest on campus.  “Hey, I’m joining with you guys.  Whatever you’re protesting, I’m against it too!”

I know that true offenses occur because I’ve been a perpetrator and a recipient. But there’s a false epidemic that is fueling many agendas, careers, campaigns and organizations.  And, yes, this deeply offends me. 

Sunday, November 24, 2019

Thanksgiving 2019

Behold the denizen who has bravely entered our property so close to Thanksgiving!

Wishing all of you a great holiday.