Sunday, March 14, 2021

Tolerating Uncertainty in Medicine

Uncertainty makes everyone anxious, although each of us has a unique threshold for uncertainty tolerance.  In other words, different folks may react quite differently if they are confronted with the same set of facts. 

Consider this hypothetical.  Two patients who are of similar age and enjoy excellent health undergo a CAT scan for a stomach ache.  By the time they follow-up with their physicians to review the results, their symptoms have resolved and they feel perfectly well.  A small spot is seen in the liver which the radiologist suspects is an innocent cyst, but he cannot state this definitively.  Each of the patient’s physicians explain that minor accidental findings like this are common and are very unlikely to pose any health threat.

Patient #1: “Ok, doc. I feel great and if you’re not worried, neither am I.”

Patient #2:  “Are you sure it couldn’t be serious, like a cancer?  Should I have it cut out just to be safe?”

First of all, let me give readers an inside tip on how to pose inquiries to your doctors.  If you begin your question with,  “Doctor, are you sure that…”, the physician’s response will be, “No, I can’t be 100% sure…”  If you begin your inquiry with, “Doctor, is is possible that…”, your doctor will answer, “Yes, anything is possible…”

Life is a casino.  We play the odds every day.

There are no guarantees in medicine or in life.  Uncertainty is everywhere and we all have our own uncertainty tolerance levels.  While there is no correct uncertainty threshold, your own level will determine if you spend most of your time at peace or on edge.  If you demand certainty, for example, then you will be forever seeking more testing and evaluation to eliminate doubt, and you may never reach your destination.  This principle may also apply when making investment choices , considering legal advice, buying a used car, eating street food abroad, considering an extended warrantee on an appliance as well as choosing among medical treatment options.   If I reassure a patient that his colonoscopy is normal and published data suggest that the chance that a lesion was missed is about 5%, will the patient accept the test’s inborn imperfections?  Will I?  Should everyone undergo 2 colonoscopies in order to decrease the miss rate?  How much effort and resources are worth achieving small incremental benefits?  I’m only posing the question here.

And individuals who have excessive risk tolerance may risk unfortunate outcomes.  Cashing in retirement funds for chips to place on the roulette wheel would make most folks uncomfortable. 

A patient I saw recently is eligible to receive the COVID-19 vaccine but does not wish to proceed.  He is aware of the safety and efficacy data but is concerned over potentially unknown adverse reactions that may emerge over time. This is not a right or wrong issue; it’s a matter of judgement.  He isn’t certain that he his making the right choice, but he is certain which option feels more comfortable at present.  Many others would decry his decision as a risky roll of the dice.  Remember, however, we’re all gamblers as we journey through life placing our daily bets and hoping at least most of them pay off.  


Sunday, March 7, 2021

Lockdowns and COVID-19 - Is the Cure Worse than the Disease?

 There’s been lots of talk about lockdowns lately.  This issue, like masks, has become politically contaminated.  It’s been one of the fascinating lessons of the Pandemic of 2020 – the recognition that issues that would seem to be ‘immune’ to political interference became instead potent partisan weapons.

Consider two rather distinct reactions to the recommendation to don a mask when frolicking about in public.

Citizen #1:  Of course, I will mask up.  This will keep me and others safer.  In a small way, I feel I’m doing my part on the journey to the other side.

Citizen #2:  Mask?  Hell no!  Just more encroachment by the government to rule our lives.  

Similarly, locking down the economy, both here and abroad, has provoked bitter reactions from all sides.

'No mask for this patriot!'

As I have written, I feel awful about the hundreds of thousands of businesses who have closed or are barely hanging on.  I also feel that their plight has not been given the attention it merits from the national press.  We have been regularly informed – as we should be – about the health risks of the virus and the need for all of us to behave responsibly.  But I do not think we have been as fully informed about the economic pain and irrevocable consequences that the nation is enduring.   Additionally, the press tends to villainize political leaders who argue for loosening up on their lockdowns and laud those who call for tight control.  Many businesses who have faced stringent restrictions have been infuriated as other businesses in their communities have been permitted greater latitude for reasons that defy common sense. 

There is a balance between maximizing public health and mitigating economic catastrophe and good people can disagree on where to draw the line.  While I don’t pretend to know how to thread this needle in motion, I do think that both sides deserve consideration and respect.  For example, if hypothetically we were to adopt a total national lockdown, we might stifle the virus much faster but have little to return to afterwards with a nation facing collective bankruptcy.  And the converse is also true.

I also feel that if all of us had uniformly adopted the public health measures advocated by medical experts a year ago, that many lockdowns could have been avoided or have been less onerous  That’s on us.  If folks are packing into bars and clubs at night, what do we expect local and state authorities to do?

Texas and Mississippi have recently opened up their economies in a big way with bravado.  They have been vilified and I share the concern of the critics.  If the COVID-19 cases rise, as many expect, then these political leaders will deserve all the vicious incoming they will receive.  But if no viral surge develops and an economic surge results, will the critics and the press admit they were wrong and celebrate the success?

Sunday, February 28, 2021

Imagining the Post-Pandemic Workplace

Millions of Americans are working remotely during the pandemic.  Many of them would have never believed that they could perform their jobs away from the office.  I’m one of them.  But we all now acknowledge that the basic structure and function of the workplace has been forever altered. This transformation was inevitable, but the pandemic was a potent catalyst to bring it about at, shall I say, ‘warp speed’? Did we really believe that in a world with remote robotic surgery, driverless cars, personalized genetic medicine, exploration of Mars, Alexa and the explosion of artificial intelligence, that we would continue to commute to brick-and-mortar offices each day?   It was only a matter of time before the physical workplace would be recalibrated.  

The disruption has been monumental and to a great extent irrevocable.  While I do believe that there will be some backward adjustment after the pandemic has largely resolved, I do not expect a return to the status quo ante.  Do you think that DoorDash will be out of business then?

And as occurs after every disruption and innovation, there will be winners and losers.  The printing press came about in the 15th century.  Good idea?  Probably yes, but it may have been a job killer for many.

Johannes Gutenberg - Job Killer

Many industries are very nervous now.  If you have earned your fortune up to now in commercial real estate, you may not welcome the prospect that your high-priced office space will no longer be in high demand.  Indeed, huge companies are leaving NYC in search of more economical alternatives.  Will stage theaters and cinemas ever return to full capacity now that most of us have enjoyed these experiences from home?  The hospitality industry has taken a body blow and will do its best to stagger up in the coming year or two.  Would you want to be an investor in a sports stadium now?  Investors may need to factor in that future pandemics may be lurking.

But it’s a good time to be in the vaccine business.  If your manufacturing company could adapt to produce personal protective equipment (PPE), you probably could have run 3 shifts of workers.  Remember when we couldn’t find sanitizer left on the shelf?  Those companies really 'cleaned up'.  Grocery and restaurant delivery services can barely keep up with the demand.  And with all of us hunkered down in our homes, it has been a good season for Netflix and other streaming services.  On-line retail was already doing well pre-pandemic, but they have reached the stratosphere.  How do you think Zoom fared this year?

We are all aching to return to ‘normal’, but the normal of tomorrow will be quite different from the normal of yesterday.  And just when we start to get used to the new normal, guess what will happen?

Sunday, February 21, 2021

The Importance of the Medical Receptionist

I am writing this now, prior to the pandemic, from my new favorite coffee shop not far from where I live and work. It’s called Couchland and is located in Wickliffe, Ohio.  As the name suggests, every seat is comfortable.  The large space has several couches and plush armchairs that beckon customers to sink in and stay a while.  This is quite different from many of the other coffee shops I patronize, where upon entering, I scan the room like a seasoned detective to see if any of the few comfortable chairs that are present are still available. Otherwise, I must enjoy the discomfort of a hard wooden chair, a larger version of what I sat on in 3rd grade. 

It’s a cat and mouse game as customers compete for premium seating in an adult version of musical chairs.  And, there are rules of etiquette that at times require adjudication.  For example, is it permissible to plop your backpack on a favorable available seat before standing in line to order?

When I stroll into Couchland and gaze upon the surfeit of comfortable options, my mood leavens. In other words, I like the vibe.

The initial impression upon entering an establishment is so critical.   This is just as true for physicians’ offices as for a coffee emporium.   In many ways, the medical receptionist is the keystone of the operation.   (Recall from your grade school days would happens to an arch if the keystone is removed.) The receptionist sets the tone and will largely define the patient’s experience.   The job is easy when patients arrive in a friendly and carefree manner.  But his or her professionalism is tested when patients, who may be ill and anxious, are challenging to handle. 

I have been so fortunate in my career to be surrounded by such a capable and caring staff.  I credit them to a great measure with whatever success I have enjoyed.  And, if there is a day when I have missed the mark, my staff’s attentive manner can help to minimize its effect. 

Indeed, I have heard many times in my career that a patient has left a physician whom the patient really likes because of what is described as rude or dismissive treatment from the doctor’s staff.
So, if you are one of those folks who ‘sets the tone’, I salute you.  And, if you are one likes me who depends upon them, I say thank you.

I've really missed Couchland during these days when I have been hunkered down sipping java on my own couch.  But soon I hope to once again sink into one of their comfy couches, reading my newspaper and sipping a cafe mocha. 

Sunday, February 14, 2021

Should We Pay People to Get Vaccinated for COVID-19?

I read recently that Kroger, who runs a grocery store chain, has joined with other retailers in paying employees who receive a COVID-19 vaccination.  The $100 payment should serve as an incentive for employees to roll up their sleeves.

There is an ongoing debate whether employers can or should mandate COVID-19 vaccinations for their employees.  The state of play now is that employers are encouraging, but not requiring vaccines, as mandating vaccines creates legal exposure for employers.  For example, if you require that an employee is vaccinated against the worker’s wishes, and a complication occurs, is the employer responsible?  Can an employee be disciplined or terminated for failure to vaccinate if there are no vaccines available within a reasonable distance?  And mandating vaccinations may be complicated when workers are unionized.

The right to refuse treatment is a bedrock medical ethical principle that I support.  For example, if I advise an individual with acute appendicitis to proceed with surgery, this patient has a right to decline, assuming that the patient is competent, and I have properly informed the patient of the risks and benefits of the reasonable options.

This right, along with all of our rights, is not absolute.  If refusing medical treatment has a public health dimension, then the issue becomes more complex.  And the terrain can be murky.  If a parent refuses to have his school age child vaccinated against communicable diseases, this right collides against the rights of other children and personnel in the school.   Indeed, it is for this very reason that school districts can require students to be vaccinated.   If a parent objects, then they are free to home school their youngster.

How much will you pay me to mask up?

This is why the failure to wear masks when advised to do so is not just a personal decision.  It puts other as risk.   I don’t object if someone chooses to become inebriated at home.  But it’s quite different if this individual decides to operate a motor vehicle on city streets. 

While no vaccine or medical treatment is 100% safe, and there may be unknown vaccine risks that will emerge later, I recently received the 2-shot Moderna series enthusiastically.  The only incentive I needed was my belief that I would be much less likely to become infected and to infect others.

If a hundred bucks is a necessary incentive, and a business has the will and resources to expend on this effort, then good for them.  We’re familiar with similar strategies, such as paying kids to do homework.

Should we also pay people to be honest or to be polite or to stop at red lights or to be on time for appointments or to observe speed limits?  What should the per diem reimbursement be for wearing a mask?

In other words, should we pay folks to do stuff that they should be doing for free?




Sunday, February 7, 2021

Where is Biden's Bipartisanship?

 There are many concepts and activities that we understand, but yet we have difficulty defining. 

In 1964, Supreme Court Associate Justice Potter Stewart in an attempt to define pornography and obscenity stated that ‘…I know it when I see it.’   Indeed, this phrase has been embedded in pop culture and is used in circumstances far removed from it’s initial prurient reference.

How would one define bipartisanship?  If a bill passes with the votes of 100% of one political party and captures only 1 or 2 votes of the opposition, can the outcome fairly be regarded as bipartisan?  How much support from the other side must exist before the ‘B-word’ can be invoked?  While I don’t have a precise threshold in my mind on this issue,  I don’t think that just a couple of votes is sufficient.

Joe Biden was elected in part because of his promise to pursue unity and bipartisanship.  How many times have we all heard about his decades of reaching across the aisle?  He pledged to us during his campaign, and reiterated forcefully in his inaugural address that he will work as hard for those who didn’t vote for me as those who did.

'I give you my word as a Biden.'  Hmm...

I suggest that there is a widening gap between President Biden’s performance and his prior pledges.  He has issued dozens of executive actions with more to come despite telling us in the campaign that he opposed the overuse of this technique.  It's always edifying to monitor how folks’ views ‘evolve’ when they are governing and no longer campaigning.  (Think of all those candidates who campaigned for term limits until they were elected.)

I am disappointed that President Biden has basically shut out the Republicans in the crafting of his $1.9 billion stimulus bill.  First, there are real policy disagreements on his proposed bill even among Democrats.  Larry Summers, a top economist in the Obama administration, has publicly stated his concerns on the economic risks of the plan.  Ten serious Republicans – not partisan bomb throwers – came to the White House to share their views on the issue with president.  Clearly, this was for show as the Democrats have been racing alone and in lockstep to ram the bill through using the reconciliation process, a mechanism to pass the bill without the need for a single GOP vote.  Couldn't they have pursued a bipartisan compromise first?  The Democrats didn't even to through the motions of consultations here making clear that a partisan victory was their modus operandi.

Is this what we can expect henceforth?

What happened to the unity thing?  The stimulus bill was such a ripe opportunity for the Biden team to make good on their campaign promises to us.  There was a deal to be made here, or at least attempted in good faith.

What is unity?  I’ll know it when I see it, and this isn’t it.