MD Whistleblower

The superscan in the prior posting, which showed a ‘freckle’ in the right lung, has now created an anxious patient and family. This patient’s worry will be heightened when he is sent to a pulmonologist, or lung expert, to evaluate the ‘abnormality’, which was found entirely by accident. The lung specialist will then advise the patient to have periodic CAT scans over the next 2 years to assure that they lesion does not enlarge. Obviously, this exercise diminishes quality of life and costs plenty of money that could be used to help truly sick people. And, if the nodule does increase in size – which even benign lesions can do – then the doctor may recommend surgery just in case it is cancerous. Consider what tens of thousands of Americans endure evaluating abnormalities that should never have been discovered or investigated. Millions of us are walking around with innocent imperfections in our internal organs. In other words, if any of us were to undergo a CAT scan, many of us would have a

I am astonished at the diagnostic accuracy of today’s radiologic technology. CAT scanners today, for example, can detect lesions that were invisible 5 or 10 years ago. As a gastroenterologist, I am routinely referred patients with subtle abnormalities seen in their livers, pancreases and digestive tract. Indeed, every medical specialty has been similarly affected. Pulmonary specialists see patients with tiny lung nodules that would not have been seen with older technology. Oncologists see patients with borderline abnormalities that can only be detected with the latest generation of scanners. Shouldn’t we celebrate this futuristic diagnostic accuracy? I’m not so sure. I believe that these phenomenal technologies harm many more patients than they save. Follow my reasoning. Most of the abnormalities that scans detect today are innocent lesions that will never make a patient sick. Our internal organs are not smooth and perfect. New scanners, like the satellites in space mentioned in the pr

We’ve all seen satellite photographs of the earth that show a portion of the globe from afar without any details of the earth’s surface. Google Earth allows even a computer neophyte like me to zoom in from space to image my own backyard. I’ve even been seen a satellite image of our red family car parked in our driveway! Using this technology, major rivers and mountain ranges, invisible from space, can be brought into view. The closer you zoom in, the more details you will visualize. Look at the skin on your own hand. Now, bring your hand closer and closer to your eyes. With closer inspection, the topography of your skin comes into sharper focus. From a distance, your skin seems smooth and unblemished, but with closer examination, surface irregularities, small scars, pigmented spots, freckles and veins will come into view. Don’t rush off to see a dermatologist STAT! These are the normal imperfections that every physical object has if it is studied at high magnification. What do mountain

One of the most vexing events for patients is when they are told that there is an abnormality on a radiology study. These discussions in doctors’ offices create palpable anxiety for patients and their families, even when physicians try to reassure them that the abnormalities are likely to be trivial. Patients today are frightened that they have cancer. They all know anecdotes of individuals who were falsely reassured and were ultimately diagnosed with a malignancy. I have heard fears of cancer related to me by teenagers who have seen me as a gastroenterologist to evaluate a few drops of blood they observed on the toilet tissue. Their fear is not rationale, but it is real. A few weekends ago, I was asked to see 2 patients on my hospital rounds to offer an opinion on abnormal CAT scans. The first patient’s scan showed an abdominal mass the size of a grapefruit that the radiologist suspected was related to the patient’s prior diagnosis of colon cancer. The second patient’s scan sh

Here are some pointers in how to choose a good physician. Remember, while these tips offer guidance, there is no guaranteed method to rely upon. Ask friends and coworkers who their doctors are and why they like them. Keep in mind that they may like their doctors for the wrong reasons. If a neighbor recommends his doctor, because “he prescribes antibiotics over the phone whenever I want them”, then you may have learned something important – choose another physician. Conversely, a person may be dissatisfied with a doctor who truly performed well. For example, a patient may complain because his doctor wouldn’t give him a refill on addictive sleeping pills. While I encourage canvassing opinions about local physicians, use these recommendations cautiously. Ask hospital nurses for their advice. They see physicians working when doctors don’t know they’re being watched. They are an unrivaled source for obtaining a candid review of medical professionals. They know who is caring and co

If it were easy to know how to choose a good physician, then everyone would have one. As discussed in prior postings, it’s tough just to define a good doctor, let alone find one. There is no surefire way to select a high quality physician. Methods and advice that sound like a winning strategy, just don’t reliably deliver. For example, you are ecstatic to have an appointment with a renowned doctor at a prestigious medical center, but his fame might be from rat research, not from patient care. You feel privileged to consult with a medical school’s chief of surgery, but it may be residents and other training physicians who are actually doing your operation. You feel fortunate to have an appointment for your asthmatic son with a specialist who lectures widely on lung diseases and has authored several textbooks. However, he might be a much more skilled writer and public speaker than he is a treating physician. You are reassured that your cardiologist is a wizard at placing stents in clogged

Here’s a list of attributes that define high quality physicians. This is not a controversial posting. After each entry, you will be nodding in agreement that it is an essential element of a high quality physician’s skill set. Here’s the unsolvable challenge. After reading each listing, decide how you could accurately rate a physician on the specific item and compare him to colleagues. I’ve been a physician for 20 years, and I have no idea how to do this. Perhaps, smarter folks can figure this out, since this is where true medical quality can be found, not in mindless, meaningless and downright dumb data and statistics. Great physicians have many of the following skills and qualities. They are skilled at palpating abdomens and hearing subtle cardiac and pulmonary abnormalities with a stethoscope. They know when not to prescribe an antibiotic. They know when a symptom can be safely observed and not investigated immediately. They know whether a CAT scan finding should be ignored or pursue

You have reluctantly left the blogosphere bubble for an afternoon to view a special exhibit at an art museum. You join a crowd who is gawking at a towering marble sculpture. Is it a true masterpiece or simply the work of a talented local art student? How do you accurately assess the work’s worth and quality? Even art scholars may not be able to agree on the piece’s value or if the work is counterfeit. If there is no sure way to measure its value, should we resort instead to using the sculpture’s weight as a quality surrogate just because it is easy to measure? This is ludicrous, but this is exactly what’s happening in the medical field. Let’s not resort to misleading and inaccurate methods of measuring medical quality because we haven’t figured out yet how to do it right. Each year, physicians and hospitals are subjected to still more ‘quality’ initiatives which burden the medical community without improving medical performance. After 3 years of participating in Medicare’s PQRI (Physic

In medicine, there are many facts and figures that can be easily measured. Here are examples of data that is being diligently recorded and scrutinized by medical number-crunchers across the country. Hospital deaths Volume of hospital and individual physician surgeries and medical procedures Average # hospital days for specific illnesses % of a physician’s practice who have undergone preventative medical testing # minutes the gastroenterologist’s colonoscope spends within the colon (This is not a joke!) A physician’s medical malpractice history Automobile the physician drives. (This is a joke!) # and % primary physician referrals to specialists $$ that physician expends per patient per specific medical condition I could have made this list a lot longer, but you get the idea here. Sure, you can collect and measure all kinds of medical data, but this doesn’t measure medical quality. Since the government and insurance companies have no reliable way to measure quality, they have opted inste

Over the years I have had countless conversations on how to select a competent physician. Advice on this issue is easy to find, but the desired result is more difficult to achieve. In the last posting, I listed many of the recommendations of ‘experts’ and indicated the pitfalls of their advice. The New York Times recently published a column offering their advice on choosing a physician. If you review the piece, make sure to peruse also through the deluge of readers’ comments, including one from your humble blogger. While the Times piece is informative, it does not offer a surefire prescription for selecting a high quality physician. There simply is no easy formula to assess physicians’ competence, like the magazine Consumers Reports might use to rate microwave ovens. Nevertheless doctors are being evaluated and compared by insurance companies, employers, the government and now even on Angie’s List! The reason that this task is so challenging, and the results so suspect, is because tw

Medical quality is like pornography, it's hard to define but we know it when we see it. Every participant in the health care arena - physicians, pharmacists, insurance companies, hospitals, pharmaceutical companies, our government and the public - all support the mission to enhance medical quality. What paralyzes the effort is that no one agrees how to get there or even how to accurately measure medical quality. You can test this yourself. Ask your friends and relatives about the quality of their physicians. You will likely receive glowing testimonials about their 'excellent' physicians. Yet, if you ask the important follow-up question, How do you know your doctor is so good?, then your smooth talking neighbor may start stuttering. Don't be too hard on him. If quality experts can't figure out how to assess medical quality, then I doubt that your neighbor or your Aunt Mathilda can do better. Here's a sampling of tips from 'experts' on how to select a hig

I was flummoxed that the man designated as my trained surgical assistant needed me to ‘talk him through’ the procedure. I wonder if he would be willing to be ‘talked through’ flying an airplane or defusing a bomb for the first time. I’m sure that the patient’s family seated nervously in the waiting room would be reassured by his brash confidence to proceed on their elderly relative. Was I nervous? Not at all because I knew that this man wasn’t going to touch my patient. I relieved him on the spot and arranged for the procedure to be performed by an individual trained to do so. What if I had decided to ‘talk him through’ the procedure? What if he didn’t disclose that he was inexperienced? How much do patients really know about the competence of their physicians and those who assist them? Studies have shown that most patients believe that their personal physicians are highly qualified, but how do they really know this? The scary truth is that they don’t and they can’t. Even experts in qu

This blog launches today, but it’s been germinating in my mind for at least 10 years. I am a full time physician for 20 years and have seen the good, the bad and the just plain ridiculous. I’ve finally decided to blow the whistle. These postings will take readers ‘behind the curtain’ to see an insider’s view of the medical profession. I warn you – much of it is not pretty. My purpose is not to highlight physician billing scams or outright fraud, although if reader comments lead the conversation there, I will respond. I will concentrate instead on what has gone wrong with legitimate medical care in America. There is not a day in my practice that I don’t confront another symptom of our broken health care system, and I am only 1 doctor. Imagine what the collective observations and anecdotes of our nation’s physicians would amount to. I hope that we hear from some of them. It is staggering how much excessive, inappropriate and unnecessary medical care is delivered – nearly all of it justif