Sunday, May 9, 2021

Taking a Moment to Say Thanks


If we are lucky, then we have someone in our lives who loves us no matter what, who makes us feel a little smarter than we are, who sees a resemblance between us and some swashbuckling actor who looks nothing like us, who laughs at our jokes, who delights when we call or visit, who takes great pride in our accomplishments, who overlooks our flaws and who reassures us that the obstacle that has unexpectedly confronted us can be overcome. 

Thanks, Mom!

(And to moms everywhere.)

Happy Mother's Day!

Sunday, May 2, 2021

Choosing the Right Doctor for You.

As my readers know, I have been a parsimonious practitioner during my entire career.  By this, I mean that I believe that less medical care leads to superior medical outcomes.  I have devoted several dozens of posts on this subject within this blog.  This is my medical philosophy.   Other physicians who see the world differently would challenge me suggesting that I deny patients necessary diagnostic tests and treatments.  Personally, I think that I have the better argument, but so do they.

Interestingly, over time patients tend to select and stay with physicians who share similar philosophies.  For example, a patient who believes that regular diagnostic testing, frequent labs, a CAT scan now and then, prescriptions for various symptoms is unlikely to remain my patient because of a philosophical gulf between us.   If that individual, for example, expects antibiotics – as his former physician obediently provided – for what the patient believes is ‘diverticulitis’, and I demur, then this patient will be dissatisfied.  Assuming that I am correct that antibiotics are not needed, it remains a difficult task to disabuse such a patient from his belief.   First of all, many patients want medication despite the absence of supportive medical evidence.  And, if a previous physician has prescribed medicine for the very same symptoms, it stands to reason that the patient expects a similar response from me.   What I regard to be overdiagnosis and overtreatment, is described by these patients as thorough and appropriate medical care.  

Sir William Osler
Physician, Teacher, Philosopher and Parsimonious Practitioner 

Conversely, if a patient is circumspect about exposing himself to the medical industrial complex – subjected to diagnostic tests, medications and specialist consultations – then he will not mesh with a doctor who uses the medical accelerator more than the brake.

These philosophical distinctions I raise can also cause tension within the medical team.  A gastroenterologist may believe that his patient should have surgery the next morning.  The gastroenterologist’s partner sees the same patient the next morning and has a different view, even though the patient’s status has not changed.  And, just add some seasoning to this stew, the surgeon on the case may disagree with both of them.

Individuals need to consider philosophy when hiring a physician, an attorney or a financial planner.   How comfortable are you with risk?   Are you action-oriented or more deliberative preferring to see how events play out?   Do you worry that failure to act risks a worse outcome?  How many opinions do you need to feel secure?    Do you prefer advisers who mirror your own view or do you welcome a challenge?

It takes time to gauge your doctor's medical philosophy and your comfort with it.  But it is an essential element of the doctor-patient relationship.  Most patients have accepted, with great assistance from the medical profession, that more tests and treatments define higher quality care.  I've spent a career trying to explain to my patients why I disagree so passionately.

One of the first duties of the physician is to educate the masses not to take medicine.
Sir William Osler, 1910.

Sunday, April 25, 2021

Was the J & J Vaccine Pause Necessary?

 I am not a public health expert.  But I have learned this past year that one need not have any public health knowledge in order issue advice and opinions.  How ‘bout some hydroxychloroquine with a bleach chaser?

I trust our public health experts and have largely hewed to their advice, although I’m not sure that they have hit the bullseye every time.  As expected, they have modified their advice over time in response to new knowledge.  This is not a flip-flop – this is how science works.

And millions of folks have completely rejected their advice for all kinds of reasons.  We’ve all seen photos of patrons who were piled into bars or kids on spring break who were recklessly partying on.  Masks optional.

Others, in contrast, were pushing back on the Center for Disease Control and Prevention (CDC) arguing that the rules were not strict enough.  We’ve seen the teachers’ unions refuse to return to classrooms despite CDC guidance assuring that it was safe to do so, as long as proper mitigation strategies were in place.   It seemed that teachers were not satisfied with the prospect of low risk; they wanted no risk.

The Johnson & Johnson vaccine was placed on pause after a handful of recipients developed serious blood clots in the brain.  As of this writing there have been 15 cases out of nearly 8 million people who were vaccinated.  You can do the basic math and calculate what the odds of suffering this serious event would be.  I’ll give you a hint.  It’s about 1 in 500,000.

First, there is yet no conclusive proof that the vaccine is responsible for these blood clots.

J & J Vaccines Can Kill!

I think that pausing the vaccine, which was heralded by highly charged public health expert warnings which were further heightened by the media, was disproportionate to the facts.  This issue was not reported in proper perspective.  Even if the vaccine were directly responsible for the blood clots, this risk is miniscule compared to the known benefits of the vaccine.  The J & J vaccine is extremely effective and reduces the risk of COVID-19 infection, hospitalization and death.  

We need some rationality here.  If we pull back from an activity that has a 1 in 500,000 chance of a catastrophe, does it make sense if we still engage in so many other activities that have similar odds? Feel free to research your risk of a serious car accident, getting struck by lightning, taking a new medication, undergoing routine surgery, traveling abroad, participating in high school or college athletics, riding a motorcycle, camping in the wilderness, swimming in the ocean and various other activities that we all routinely engage in.

A dose of perspective and proportionality if you please?

Couldn’t our health experts have simply announced that they were rigorously monitoring an extremely rare and unproven side effect of the J & J vaccine, but that all of the evidence overwhelmingly showed that the benefits far outweighed the risks?  Instead, they announced a ‘pause’ which may have cost lives and scared everyone.  Was this a pause in good judgment?








Sunday, April 18, 2021

Is My New Doctor Qualified?

When one applies for a job or a position, it is expected that the interviewer will assess if the applicant has the necessary skill set and experience. Doesn’t this make sense?  Consider these examples.

A clarinetist applies for a position in a symphony orchestra.  While many criteria will be assessed, he will surely need to audition to demonstrate his musicianship.  Would he ever be hired without playing a note?

A college student wants to join the swim team.  The applicant can expect to show off her speed and technique as she cuts across the pool.  Would any coach accept a new swim team member without watching her swim?

A journalist for a town paper applies for a job at a large metropolitan newspaper.  The interviewing editor will surely review the applicant’s prior work product to gauge his competence and suitability for the new position.  Would an editor bring on a new reporter without ever reviewing his writings?

A college graduates applies to the State Department as a translator.  Would such a hire ever occur without determining if the applicant has the requisite language skills?

Want the job?  
You'll have to show you know how to use this.

So how does the medical profession hire on new medical professionals?  I should certainly know this since I’ve been in the trade for 3 decades and have had enough job interviews to know how the process works.  I’ll ask readers to peruse the following 5 sample gastroenterologist applicant questions. Can you spot the ones I was asked during my prior job interviews?   

Which antibiotics do you typically prescribe for diverticulitis?

What is your age cutoff for offering screening colonoscopies?

What is your complication rate for colonoscopy and other medical procedures?

When is the right time to prescribe steroids in Crohn’s disease?

Does a patient who is having a gallstone attack and a fever need to be hospitalized?

Which ones were I asked?  None of the above.  For reasons I cannot easily explain, I have never been asked any medical question during any prior job interview.  Similarly, when I have interviewed job applicants myself, I have never queried them on any medical issue.  The profession, at least in my experience, assumes that physician applicants have all of the necessary medical skills and knowledge, even though this does not seem to make much sense.  Shouldn’t the applicant at the very least be asked to review case histories of assorted patients and to comment?  It seems it’s a lot tougher to get a job as a clarinetist than as a gastroenterologist.  Does this put your mind at ease?





Sunday, April 11, 2021

Overutilization of Colonoscopy - An Unusual Suspect

A week or so before writing this post, a patient came to my office requesting a colonoscopy.  Nothing newsworthy so far.  An individual wanted a service that our practice routinely provides.  Yet, I was reluctant to accede to her seemingly reasonable request.   She wanted a screening examination of her colon in search of a benefit that humans have pursued for as long as humans have existed – peace of mind. 

I have found that ordinary folks are often confused by the meaning of the term screening.  Screening exams can be performed on various organs of the body.  When a physician uses the term screening, it means that the patient is not having any symptoms whatsoever.  For example, if I advise a colonoscopy on a patient who is having rectal bleeding or diarrhea, this is considered a diagnostic exam, not a screening test.   

"You're paying the bill?  I'll have the steak!"

Why does this matter?  Insurance companies often reimburse screening and diagnostic exams differently.  Often, but not always, a patient’s financial obligation is higher for a diagnostic exam, when symptoms are present.   There have been occasions when a patient had contacted us after receiving the insurance company bill for a diagnostic colonoscopy, asking if we will ‘revise’ our documentation stating that the test was a screening exam.   Even an infrequent Whistleblower reader would know our response to such a request.

The patient who wanted a screening colonoscopy felt entirely well.  Her bowel pattern was unchanged.  She had no special risk factors for developing colon cancer.  My review of her record indicated that she was due for a screening colonoscopy in 3 years, not now.  I advised her of this, but she wanted to proceed anyway.

We have freedom of commerce in this country.  I can purchase goods and services according to need, desire or even whim.   If a person wishes to buy a meal, a vehicle, an appliance or a vacation, the seller’s role is not to discourage the transaction or point out that the buyer is making a foolish or unnecessary purchase.   Isn’t an individual who wants a colonoscopy, and is properly informed of the risks and benefits of the test, and is made aware that she is not yet due, entitled to the exam?

I thought that she was.  But, I didn’t think that her insurance company should pay her bill.  I explained to her that I would schedule her for the requested exam, but that she should expect that her insurance company would hold her financially responsible for the entire bill.  

Once the patient understood that the cost would be hers, she elected to wait an additional 3 years, as I originally advised.   The lesson?  When folks have skin in the game, they make different decisions.  In my view, this concept needs to be systemically incorporated into our health care system.  

If you are out to dinner at an upscale restaurant, and an insurance company would be paying the bill, would you order differently?

Sunday, April 4, 2021

Are We Ready for the Next Pandemic?

 While most of us prefer order and routine, life can turn course unexpectedly and randomly.  Of course, we all know this.  For many of us, our occupation, our choice of mates or where we live are the result of some chance occurrence, not the product of diligent planning.   Indeed, this reality adds some excitement and wonder into our existences.  Would we really want to live according to a prescribed routine like a train schedule?   For me, I am most satisfied when my days include my daily routine pleasures seasoned with some spontaneity.  I suspect that this is true for most of us.  However, we differ in the ratio of random/routine that we prefer.   Some of us plan a trip, for example, with each day carefully planned while others prefer to simply land in their destination and explore untethered to a guidebook or a rigid schedule.

And no force can set order aside more forcefully than nature.  Here is the scene from our window earlier this week.  Does this look like a typical spring day?  Apparently, Mother Nature has her own order of things.

Is Mother Nature Out of Order?

There are certain tasks for which a specified order is the optimal option.  When an airline pilot is preparing for take off or when a surgeon is preparing for surgery, each of these professionals proceeds through a check list of requirements to verify that all safety protocols have been followed so that the risk of a misadventure is minimized.  These safety checks have been devised over time with revisions performed as necessary.  They are born from experience.  Each item on the list is to prevent a specific adverse reaction which was at higher risk of occurrence prior the check list era.  For example, prior to a medical procedure, it is now mandatory for the medical team to verify the identity of the patient.  Any idea why this ID verification came about?

We don’t want airline pilots simply to bring spontaneity to their flights letting them ‘wing it’.  “Maybe today will fly this bird right over the coast so the folks can get a great view.” 

We are still trying wrest ourselves free from the gripping tentacles of the pandemic.  And one of the lessons, which we still haven’t learned is that there is a specific order of measures and mitigation that must be followed to prevail.  As we look around the world, we see that some nations are much closer to the end zone than are others.  Europe is behind the U.S. and we should be much farther ahead than we are.   If we had followed public health directives early and consistently, opening up the economy and schools according to science, rejected distracting political interference, where might we be today?   Has this experience persuaded to use the pandemic check list next time?