MD Whistleblower

Missouri, the ‘show me’ state, is showing the country an interesting and novel concept. Judges there will be apprised of the financial costs of various punitive options before issuing a sentence. For example, a judge would be informed that a convicted drug user could be sentenced to 5 years in prison for $50,000, or could do community service with a probationary period instead for a fraction of the cost. Blind justice? This new policy has generated spirited debate. Some welcome the reform, which aims to bring some measure of cost sanity to the justice system. Others oppose the effort arguing that justice must be meted out without regard to financial costs. Is this issue being driven by difficult economic realities? Some are hostile to incarceration for reasons independent of its exorbitant expense. These folks favor rehabilitation and treatment over confinement as a matter of policy. Is there any cost of justice that is too high? I viewed this report through the prism of a practici

Our society thrives on tension and competition. GOP vs Democrats Civil Libertarians vs Eavesdroppers Ohio State vs Michigan Creationists vs Darwinists Ideas, like sports teams, compete to win. We are the referees of these contests. Many of these competitions in the public square are ongoing. Some of these duels are locked in a dead heat. Others are in overtime. Some are ‘challenge matches’ when a vanquished idea wants another shot to change the original outcome. Many of these controversies may never be resolved. In addition, the outcomes may change because we – the referees – have changed. What was considered to be a foul years ago may now be regarded as fair play. The medical profession is riddled with many internal conflicts that will not be easily resolved. Here are a few, and I’m sure readers could add generously to the list.  Primary Care vs Medical Specialists Physicians vs Insurance Companies Obstetricians vs Medical Malpractice Attorneys Fee-for-Service vs Salaried

Two weeks ago, I did what had to be done. Months of procrastination had to end. Fears had to be put aside. Anxiety and misgivings had to be overcome. Second opinions always confirmed the need to proceed. So, when the excuses ran out, I jumped. What decision did I make? Did I… (a) Finally have rotator cuff surgery? (b) Begin electronic medical records (EMR) in the office? (c) Retire from medicine to be a full time ‘Whistleblower’? (d) Agree to a family vacation when we will hike up and down the Grand Canyon sans mules? (e) Agree to become an expert witness for a medical malpractice plaintiff’s attorney? (f) Apply an Obama 2012 bumper sticker on my car? Two weeks ago, our office entered the paperless universe. The era of ink on paper was over. The manner that I had seen office patients for 20 years suddenly evaporated. And, I wasn’t happy about it. For our small group of gastroenterologists, even though we are aware of the potential advantages of computerized charts, we adopted EMR be

Last week, a female patient saw me in the office for the first time to discuss her chronic digestive issues. Luckily for her, my recommendations did not include probing into her alimentary canal with the endoscopic serpents that we gastroenterologists rely upon. As the visit concluded, she advised me that she intended to have a gastric bypass (GIB) procedure performed, and even used the medical term of bariatric surgery. I suppose that she mentioned it because the issue falls within my specialty, and she wanted my reaction to her plan, although she didn’t directly solicit my opinion. Nevertheless, she received it. I am not surprised anymore when the critical medical issue emerges at the end of the office visit. Every physician has this experience regularly. “So, Mrs. Fleets, I think that this new medicine will really help your constipation. My nurse will be happy to arrange your next appointment. Do you have any questions?” “How come I now have trouble breathing when I walk

Physicans in Reverse Gear! Here is some inside dope on the medical profession for patients to ponder. We are all reading these days about improving the process of delivering medical care. This effort aims to raise the level of medical quality, and to minimize errors of omission and commission. This is why all surgeries and medical procedures begin with a ‘time out’, when there is a brief huddle confirming the identity of the patient and the intended operation. This is to prevent scenarios, such as: “Mr. Patella, we replaced the wrong knee, but you would have needed a new one at some point. No need to get out of joint over this – the rehab is on us.” Numerous medical specialties are now using checklists for medical procedures that include a series of steps. For example, if every heart bypass patient needs to proceed through 24 pre-operative steps, including laboratory studies, diagnostic tests, specialty consultations and an informed consent discussion, then a checklist is an e

Photo Credit Leisure Guy, one of my most faithful commenters, opines that I am omitting an important aspect of the tort reform argument. He has implored me repeatedly to read a particular book that I suspect buttresses his views, but this worthy pursuit is simply not near the top of my priority pyramid. Since he’s retired, he enjoys the luxury of burrowing deeply into the base of his priority pyramid. With 4 tuitions to go, retirement is a distant mirage for me. I’m can be a ‘leisure guy’, but only in my dreams. I have written throughout this blog and elsewhere that there are too many frivolous lawsuits against physicians. I have admitted that caps on non-economic damages are not ideal, because they deny some worthy plaintiffs of complete compensation, but I support them because I believe they serve the greater good. I have ranted that there is no effective filter to screen out physicians who should never be invited to the litigation party in the first place. I believe that the cur

We have a classroom in our home. It’s called the dinner table. This is the locale where over the years, my wife and I have tried to teach 5 kids right from wrong. As we parents ourselves still struggle with these issues, it is clear that integrity remains an indefinite element of life’s curriculum. There was a time when this table was an actual classroom, when my wife and I home schooled 2 of our youngsters for about 3 years. I could devote an entire blog to this adventure. Many of our family dinners were seasoned with discussions about integrity. We have discussed and debated the lapse in integrity that has seeped into our educational culture, as well as into society at large. We have reviewed dozens of news accounts detailing ever more resourceful methods of cheating and stealing ideas without attribution. This phenomenon has no boundary and has permeated the medical profession. Euphemisms like ghostwriting cannot camouflage the practice for what it often is – cheating. Yes, I

Do you see or do you observe? Most readers have likely given just a glancing glimpse of the photograph to the left, which I took during recent vacation in Costa Rica. Most, including me, would have recognized that the photograph is a tree, and then moved onto the riveting text. While this identification would be correct, it would not be the whole story. Look more carefully, and see if you overlooked a finding on the photo during your cursory review of it. The health care reform plan, now law, also has many camouflaged elements that were not visible, even to the informed public. In the coming years, as the layers are peeled back, there will be many surprises for the public and for the medical profession, which I hope and pray will remain a profession. The Patient Protection and Affordable Care Act was signed into law in March 2010. No, it won’t be repealed, despite some shrill populist campaigning to do so from the political right. I also doubt that the judiciary will turn it back,

In this post, I will give ordinary folks a ‘peek behind the academic curtain’. I am not an academic physician, but a mere practicing gastroenterologist who spends my days ‘enlightening’ Cleveland colons. Why do some medical studies, which achieve breaking news status, often fall so short of our expectations? Physicians are cynical about these medical milestones, since they are often short-lived. Today’s cure may become tomorrow’s disease. A common practice and serious flaw in medical research is to rely upon a surrogate marker when studying a disease. Let me explain. If you endure the following few paragraphs of literary driftwood, you will understand press reporting of medical studies on a deeper level.  This could directly affect your medical care and generate some interesting conversations during your next doctor visit. A surrogate marker is an event or a laboratory value that researchers hope can serve as a reliable substitute for an actual disease. A common example of this is

When this post hits, I will be out of the country in a rain forest thousands of miles from home. I hope the experience won’t be an opportunity to learn about the tropical diseases I memorized in medical school, and promptly forgot after the test. Prior to leaving, I surrendered my arm to hepatitis A and typhoid vaccines. I hope that they deliver. Of course, if I do get struck by typhoid, then this would have to be someone’s fault. In the medical world, when an adverse event occurs, the interrogative response is often, who screwed up ? Hmmm. This gives me an idea. If I did get sick abroad, who could I hold responsible for the medical misadventure? Who could I sue? As is often pointed out on this blog, I know nothing about the law, rules of evidence or even the most rudimentary aspects of American jurisprudence. So, I need some help from lawyerly readers. Below is my list of potential defendants to blame, if I were to get sick in Central America. I’m sure I have overlooked many ripe ta

Many patients erroneously believe that x-rays and CAT scans have no risk. In their minds, they are non-invasive studies that can cause no harm. Since there are no incisions or anesthesia, they regard the experience as having the same risk as taking a family photograph. How wrong they are.  In my mind the danger from non-invasive radiology studies may surpass the risk of hard core medical treatment. True, radiology tests won’t puncture an organ or a blood vessel, as a surgeon or a gastroenterologist can. Imaging studies do not cause direct damage, but they may lead patients onto the medical battlefield. These diagnostic tests are an insidious force that draws patients into a spiral of direct risk and medical overutilization. Is this post a shot at radiologists? No, it’s a shot at all of us. Remember, radiologists never order CAT scans; the rest of us physicians do. I certainly am distressed with the obsessive manner that my radiology colleagues interpret studies today, identifying inn

Folks across the country are paying hard cash for total body scans, abdominal aortic aneurysm testing, CAT coronary artery scans and carotid artery evaluations to prevent disease or find important lesions early. It’s a seductive argument, and it’s a scam. Ordinary patients don’t understand about pre-test probability and positive and negative predictive values. Indeed, all physicians were taught to consider Bayesian theory when ordering diagnostic tests. This is very tough concept for patients to grasp. A critical principle of proper diagnostic testing can be summarized in a single sentence. If an individual is unlikely to have the medical condition under consideration, then a diagnostic test that yields a positive result is likely to be a false reading. Here is an illustration demonstrating why patients need to understand this issue. While the forthcoming example is hypothetical, I guarantee that every physician has seen very similar patients in their practices. While the pat

Photo Credit More and more, I read about physicians who are ready to give it up. I hear similar views in the physicians lounge and in hospital hallways. These conversations are a modern phenomenon; they did not occur when I entered the profession 20 years ago. They have germinated as a result of rising forces that have demoralized many practitioners. Some of them include: • Loss of autonomy • Loss of income • Loss of stature and prestige • Required ‘Quality’ initiatives • Health care ‘reform’ • Infighting within the medical profession • EMR • Medical liability system • Insurance company hurdles to get paid • General gerbil wheel existance Luckily for me, I am still happy on the job. Of course, I am not immune to the above realities, and would readily accept a vaccine to protect against them, if one existed. I try to focus on the core purpose of being a physician, and work to sequester the noise and static, at least while a patient is seated before me. Since I am a memb

How do you know if a lawyer is any good?  Of course, they've all passed the bar, but now their profession is lowering it.  While most of us strive for excellence, and raise our children to value this virtue, prominent legal educators are establishing a new quality intitiative for their profession.  Who says that lawyers can't reform themselves?  Perhaps, we physicians can follow their bold example and raise the credentials of our pre-medical students.  I’ll present the facts. You be the judge. I have written a dozen posts on tort reform on this blog, which always generate spirited and adversarial retorts from attorneys and their supporters. They accuse me and other tort reform advocates of carrying water for insurance companies. They repeatedly point out that I know nothing about the legal system and are unqualified to opine on its flaws. They deride me when I argue that effective tort reform would reduce the practice of defensive medicine, despite the recent supportive concl

Should the public be shielded from medical information that can mislead it? Many argue against direct-to-consumer (DTC) advertising, which is omnipresent in print and on the airwaves. Opponents of this practice argue that it promotes the use of expensive medications when patients ask their doctors if the ‘drug is right for them’, the tag line that appears at the end of every ad. This phrase is the drug company’s limp disclaimer that it is really the physician who will make the prescribing recommendation. Yeah, right. Of course, DTC ads promote drug sales. Isn’t that the purpose of advertising? Antagonists of this drug pushing state that resources spent on advertising should be used instead to lower drug prices for consumers. Couldn’t the same argument be made about any product being advertised? Should General Motors cease and desist from spending marketing money and divert these funds instead for consumer rebates? Legal products have the right to advertise and market their wares. Per

Photo Credit One of the advantages of marrying an immigrant is having intense exposure to another culture. My wife’s Russian heritage, and her family, have enriched my own life immeasurably. The trip that I took with her and my brother to Russia in 1990, where she served as our personal translator, was unforgettable. During the early years of our relationship, I heard stories about her family that seemed incredible to an American like myself who was raised in ordinary cirumstances in suburbia. In Russia, her father, uncle and close relatives were arrested and imprisoned on absurd charges. Her family, like so many others, was subjected to persecution and anti-Semitism. One would imagine that her family would celebrate when Stalin died in 1953. Instead, I am told that my mother-in-law, whose family had suffered under his brutal fist, was in tears, demonsrating the deep reach that this tyrannical leader had on the populace. He had a cult of personality, an intoxicant that numbed the