Sunday, February 9, 2020

Do You Need a Patient Advocate?

I wish I could write that medical care today is an optimal, cost-effective and efficient system that consistently provides appropriate and sterling medical care.  I wish I could write that pharmaceutical companies, hospitals and extended care facilities all view patient care as their primary and overriding mission.  I wish I could write that physicians all share the highest ethos of patient advocacy.

It is not possible to achieve these idealistic goals as the individual professionals, corporate entities and the government that comprise the medical profession are imperfect and face numerous conflicts of interests.  Indeed, this blog as devoted considerable space to highlighting these issues.

Here’s a representative vignette from my world. 

I was asked to see a hospitalized patient for an opinion on her low blood count, or anemia.  This is a common request for gastroenterologists as internal bleeding is a frequent explanation for anemia.  This is when we gastroenterologists get a truly ‘insider’s view’ of your intestine with our colonoscopes and other gadgets.  Not every anemic patient, however, needs to be subjected to our probing.  If we judge, for example, that the anemia is not caused by blood loss, then we will hold our fire and request that an appropriate medical consultant be recruited.   Another reason we might keep our scopes securely holstered with a patient who has had true blood loss is if we have safety concerns about proceeding with procedures. 

The patient I saw was ailing and elderly.  She had many chronic medical conditions.  There was no evidence of blood loss explaining her anemia.  Therefore, I advised against proceeding with any scope intrusions.  The attending physician was dissatisfied with my advice and requested that another gastroenterologist, presumably a more compliant practitioner, see the patient.  The doctor reached over me instead of reaching out to me.  

I am not asking readers to support my medical advice.  Perhaps, I was entirely wrong and the attending physician correctly recognized that internal bleeding was the culprit.  Perhaps, she was aware of certain medical facts that I did not know.  Maybe I am a mediocre specialist.  The point is that the next step in the process should have been for the two of us to engage in a conversation so when we could have a dialogue and arrive at a decision that we both felt served the patient’s interest. 

I would have settled for a message by carrier pigeon. 

Of course, conversations between physicians are commonplace.  But, patients would be surprised how seldom conversations between medical colleagues occur.  For example, there are certain physicians who don’t send reports to me when they see one of my patients.

For these reasons and others, there is increasing space in the medical marketplace available for an emerging medical professional – the patient advocate.   These folks can be hired by patients to make sure the medical evaluation is proceeding smoothly and that everyone on the case is fully informed. Isn’t this what we doctors are supposed to do?

Sunday, February 2, 2020

10 Mistakes Democrats Made on Impeachment

I am not going to offer an opinion if the Senate’s anticipated acquittal of the president in the impeachment proceeding will be correctly decided.   I have nothing to add to the millions of words that have already been said, written and dreamt on this issue.  And, even if I had divine inspiration to contribute a new thought, would it change anyone’s mind?

Leaving aside the merits of the case, I do think the Democrats have committed a series of errors that contributed to the GOP’s victory and made it more palatable for senators to support the president.

Flag of the U.S. Senate

  • House members and others have been clamoring for the president’s impeachment since his inauguration.  Indeed, a resolution for impeachment was submitted to the Republican controlled House in December 2017.  This feeds the narrative that the Democrats were fixated on the impeachment outcome long before the Ukraine imbroglio developed.
  • Democrats and others in print and the airwaves were warning us incessantly over Trump’s collusion with Russia.  They presented collusion as if it were an incontrovertible fact.  When Mueller announced there was no collusion, not a single Democrat admitted error.  They simply moved on to obstruction.  This pivot supported the theory that their plan was simply to find or concoct a pathway to achieve their pre-determined goal.
  • If the charges of bribery, extortion and violating the Emoluments Clause of the Constitution were so serious and secure, then why weren’t they included in the articles of impeachment?
  • Why didn’t the House Democrats test the President’s claims of privilege in court for witnesses?  If they judged that this effort would be too inconvenient or lengthy, then why would they expect that this same process would proceed smoothly in the Senate?
  • Why did the House Democrats withdraw the subpoena for Charles Kuperman, who was willing to testify if so ordered by a court, before the court issued a ruling?  What changed their minds?
  • Why did Speaker Pelosi give out pens used to sign the impeachment articles as souvenirs, serving to cheapen such a serious and rare undertaking?
  • If impeaching the president needed to occur with great dispatch, informing us that our democracy was at risk, then why did the House tarry for 33 days before forwarding the articles to the Senate?
  • Why did Speaker Pelosi make futile demands to impact on the Senate trial when the Constitution plainly states that the “Senate shall have the sole power to try all impeachments”?  Did Majority Leader McConnell try to tell the House how to conduct their hearing?  Would they have allowed him to?
  • Should House Managers have declared that the “Senate is on trial” or that if senators voted to acquit that they would be participating in a cover up?
  • Should the House Democrats have emphasized to exhaustion that their submitted case was ‘overwhelming’?  (It was overwhelming to hear the word overwhelming used so often!)  If the case were truly overwhelming, then why would witnesses even be necessary?  Shouldn't the case have been able to stand on its own?

Yes, of course, I could have written a similar post highlighting Republican partisanship, gamesmanship and hypocrisy.  And, I hope readers will comment accordingly.  But my narrower point is that the Democrats’ feeding of their base alienated others and made crossing over less likely for those whose view on the issue was not yet fixed.  So, while they decry the outcome and claim that the trial sans witnesses was illegitimate, they bear some responsibility for this.

Sunday, January 26, 2020

Personalized Medicine - The Future of Medicine

Future doctors will celebrate that they no longer prescribe the same drug at the same dosage for hypertension or pneumonia or arthritis or cancer or many other conditions.  Who knows even if drugs will be the mainstay of medical treatment.  Tomorrow’s treatments will be tailored to one’s age, gender, weight, race, overall medical condition, severity of the medical threat and genetic profile, among other variables.  We don't all wear the same sizes of socks and shoes, but yet medicine today has a one-size-fits-all treatment utility.  A new era, however, is upon us.

What will be the fate of my beloved colonoscopies or heart catheterizations or blood draws or biopsies of tissues?   Fear not.  They will all be available to you, just as Van Gogh paintings or fossils of T-Rex are -  in museums.  The first exhibit will be a diorama of the physician’s office from yesteryear, adorned with some antique artifacts such as a stethoscope, an EKG machine and a reflex hammer. 

Museum Quality

Without question, health care will smash through one barrier after another.  But, the humanity of the profession will be subsumed and sacrificed as the medical technological tsunami bursts forth.  Our health will improve but the health care experience will be unrecognizable.  Indeed, all aspects of our lives will be technologically driven.  Today, Alexa can turn off the lights.  Tomorrow, Dr. Alexa might be cleaning out our arteries. 

And while technology will permit portions of the exam to be transmitted, such as vital signs, heart and lung sounds, skin lesions, etc., I don’t see how a patient’s abdomen can be palpated, at least not yet.

Performing robotic surgery remotely is already a reality and such surgeries and medical procedures from afar may become commonplace.  Individuals may place their smart phones on various parts of their body and transmit information to their physicians.  Patients may be able to use their phones or some other device to do a CAT scan (or whatever technology will replace it) on their own bodies.  And, reminiscent of the once futuristic novel Fantastic Voyage, patients may swallow a trackable pill that can course throughout the body transmitting data about the health of various tissues and organ systems.  Similarly, medications will be customized to each individual that can be directed to the target location.  For example, a medicine for Alzheimer’s disease will be personalized for a specific patient with the drug remaining only in the brain.  These developments will boost drugs' efficacy and reduce adverse drug reactions.   When drugs are free to roam throughout the entire body, obviously there will be unintended and unfavorable consequences.

The routine physical examination may be replaced by spitting into a tube or submitting a cheek scraping for a comprehensive medical analysis.

We can hope and pray that the upcoming technological take over will be guided and restrained when necessary by just and ethical principles.  The revolution is coming and no force can derail it.

Sunday, January 19, 2020

Electronic Medical Records - Broken Promises

I have written, or more accurately ranted, about electronic medical records (EMR) systems throughout this blog.  While the systems have clearly improved since their mandatory introduction into the medical universe, they have still not delivered on many of their promises.

Of course, EMR has brought tremendous advantages to the medical profession and we are all grateful for the technology.  But this progress has exacted a cost.  Many of them are clumsy to utilize.  When the technology breaks down or freezes, the office become paralyzed.  The systems are vulnerable to hackers who can exploit personal medical data or demand ransomware.  Many of the computerized notes  are so filled with pre-populated fluff carried over from prior visits, that it can be challenging to identify new medical information.  I often scroll through several pages in search of the physician’s thoughts and plans.  And a physician who is staring at a computer screen during an office visit will create a very different genre of a doctor-patient relationship. 

But here’s an EMR frustration that I am astonished is still torturing us.  In our digital era, different EMR systems cannot communicate with each other.  Indeed, one of the seductive promises of the EMR prophets was that physicians would have access to all of a patient’s medical data.  Imagine, for example, how useful this would be to an emergency room (ER) physician who is treating a sick patient who has been treated for the same condition elsewhere?

The Medical Records are in there somewhere!  

Every day in my office practice, I see patients with active conditions who have been treated by other physicians and at other hospital systems.  The patient before me with abdominal pain may have been seen for this in an ER a few weeks ago, and then seen by his own primary care physician days afterwards.  Shouldn’t I be able to have real time access to all of this data?  Wouldn’t this help me to make a more accurate diagnosis?  Might this prevent me from ordering an unnecessary medical test?  Is this vexing issue simply insurmountable?  ‘Is there no app for this’?

Patients are as frustrated over this as we are.   “Alexa, please get my this patient’s CAT scan report!”

Sunday, January 12, 2020

There is Too Much Technology in Medicine

As promised, here is the continuation of last week's post where I discussed the loss of physicians' diagnostic skills which have been largely replaced by technology.

Of course, the medical community celebrates the miracles that technology has brought us.  Innovation has improved our lives and will continue to do.  On this issue, there is no debate. But, as with many advances, there is a cost.  Here's my take on the downsides of the technologization of the practice of medicine.  

Could a CAT Scan Do Damage?
Readers, Scan Below!

  • Overreliance on technology has cost zillions of dollars.
  • Much of the overdiagnosis and overtreatment in our health care system – which I have decried on this blog – is caused by medical technology.
  • Technology has strained the doctor-patient relationship.  It is often easier to order a scan than to have a deeper conversation with patient who needs advice and counsel, particularly when physicians’ schedules are jammed.
  • CAT scans and their ilk regularly find unrelated ‘abnormalities’ that would remain dormant for life, but now assume a life of their own as doctors must pursue them. 
  • Technology is not perfect, even though we all tend to regard it as the Holy Grail.  A negative test result may blind us to the truth if we are not vigilant.  A patient with stomach pain and a normal CAT scan can still be in deep trouble. 
  • Patients have taken heed of our technology obsession.  They regularly ask their doctors for testing that they may not need.  Every doctor has had a patient facing him insisting that a CAT scan be done.  The public understandably believes that more testing is better medicine.  Of course, this is false premise but try convincing a patient and their family of this.  I know from my own family; they don’t get it and the medical profession and our payment system is responsible for it. (Patients are more enthusiastic for testing that the insurance companies will pay for)
  • There are financial conflicts of interests that drive the overuse of technology.  Yes, medicine is a business and we would should expect that the normal forces of profit seeking are operative.
  • Technology has not only eroded physicians’ physical exam talents but has also diminished doctors’ skill and enthusiasm in obtaining patients’ medical history, the important narrative that the patient communicates to the physician.   
I often hear and read presentations of patients' medical history where the 3rd sentence is “…and the CAT scan showed…”   This premature intrusion of a technology result - a physician spoiler - immediately prejudices the doctor who should have been given time just to hear the patient’s own story.  If you are told in advance of an important future development in a mystery story, will you still read the book as carefully as you would have otherswise?  The danger for doctors who are given a sneak preview of events is that we become less attentive and vigilant which can lure us into false passages.

Sunday, January 5, 2020

Can Doctors Still Examine Patients?

Does your doctor really know how to use a stethoscope or palpate your abdomen?

Today’s physicians do not have the physical exam skills that our predecessors did.  We can argue if this truth has diminished medical quality – I’m not sure that it has.  But it has completely changed how medicine today is practiced.  The reason for declining physician exam skills is that technology has largely supplanted physicians’ hands, eyes and ears.  In the olden days, the stethoscope was the diagnostic tool for examining hearts.  I spent a month as a medical student with a legendary cardiologist who could make all kinds of cardiac diagnoses right at the bedside using 2 advanced medical instruments known as ears.  Surgeons and gastroenterologists in years past had to make  diagnoses of acute appendicitis and other abdominal emergencies based on feel and their ‘gut’.  Neurologists made accurate diagnoses of stroke just using their clinical skills.

An Advanced Medical Instrument

These days, there is really no need to be sleuth with a stethoscope since any murmur or extra click will be followed by an echocardiogram.  I can’t recall a case of appendicitis in my career that didn’t involve a CAT scan to confirm a surgeon’s suspicion.   And, if a stroke is suspected, a head CAT scan will be arranged.

Since, medical technology has in many cases taken over the physical examination, doctors’ hands-on skills have decayed.  There is much less pressure for our exam skills to be superb since we know that some rescue scan or diagnostic test that does it better will follow.  Conversely, if a physician were seeing a patient with stomach pain, and there was no technology available, I surmise that this doctor would do a more careful exam than he otherwise would.  Get my point?

Are patients better served with more accurate technology to make and exclude diagnoses?  Some have and many haven’t.  We all celebrate how technology in medicine has revolutionized the profession and has saved and improved lives.  I rely upon this every day in my practice.  But we must acknowledge that this progress has exacted many costs.

What’s the harm with ordering a CAT scan?  After all, it’s non-invasive.  Next week, I will address this issue in detail giving you a true ‘peek behind the curtain’, the raison d’etre of this blog.  Feel free to offer your own thoughts on this issue on this post in advance of next week’s full disclosure.