MD Whistleblower

Okay, readers, how many of you desire to have a feeding tube inserted into your belly one day? Some of you? A few of you? All of you? Not me, that’s for sure. So, if there comes a time when I cannot speak for myself, let this blog post serve as a statement of my philosophy that I do not wish to be subjected to everything that medicine may have to offer. If I am enjoying no meaningful life, and if I am not giving pleasure to others… I placed yet another feeding tube (PEG) in a patient this week. This is often an unsatisfying experience for me as I am not always serving the patient’s interest. Usually, the patient is not capable to express his own views and the decision is properly delegated to the family or to a designated medical power of attorney (POA). In this instance the tube was medically indicated and I reviewed the procedure and the alternatives with the 3 daughters in a conference room. The daughters were uncertain how to proceed. The ladies were clearly vexed. One of them w

I see many patients with hepatitis C (HCV).  None of them are under treatment and they all feel quite well. Why don't I treat them?  After all, potential consequences of HCV include: Cirrhosis Hepatocellular carcinoma. or liver cancer End stage liver disease with all the trimmings Liver transplantation Death One would think that a portentous list like this would justify any treatment, even hazardous therapies.  But, I've never seen it this way, and my hepatitis C patients are all doing well under periodic observation. Yes, I know that the disease can be serious.  I recall one patient with advanced disease whom I referred for consideration of a liver transplant many years ago.  There may have been a few others along the way who received treatment for the disease also. The vast majority of hepatitis C patients I see in my community practice feel entirely well and the diagnosis is discovered by accident.  In other words, these patients did not exhibit symptoms or abno

Volcano - A Metaphor of Evil This past week, I awoke to read a chilling headline in tall black letters that announced that some innocents were shot by an assailant who himself was still a boy. We read these headlines and watch related images every day as the volcanoes of evil around the world never stop spewing out their merciless lava. Why this happens is a question that tests the most erudite theologians, who must try to comfort us and help us to understand what can never be explained. This wanton murder was not a suicide bombing in Baghdad or a Taliban ambush on NATO troops in Afghanistan. This shooting occurred in Chardon, Ohio, a small town less than half an hour from my home. I remember being there a few years ago for their maple syrup festival.  A 17-year-old kid allegedly came to Chardon High School and in a few moments changed the lives of many thousands of innocent people. As I write this, I am still plagued with deep sadness and sharp anger. I cannot fathom how a mind

Did Washington Chop Down the Cherry Tree? Courtesy of National Archives …resolve to be honest at all events; and if in your own judgment you cannot be an honest lawyer, resolve to be honest without being a lawyer. No need to identify the authorship of the above quotation, which should be known by all discerning readers, such as those who feast on the weekly Whistleblower offering. For those who have suffered a cognitive lapse, I will provide 4 identity clues. Take a guess after each clue. If after the 4th clue, you are still clueless, then politely request a 5th and 6th clue in the comments section, and they will be provided to you. (1) He had a high pitched voice. (2) He was prone to depression and melancholy. (3) He was an ambitious and successful attorney. (4) He was known as ‘the rail-splitter’. Honesty in medicine is a fundamental pillar of our profession. However, physicians and scientific investigators have the same moral failings as the rest of our species. While

Inauguration Day Presidential election seasons are always exciting times for Americans. Read the newspaper any day for a reminder of how much we take for granted here. Every four years we have the opportunity to hire, rehire and fire a commander-in-chief. Of course, our system is not perfect, and is often downright maddening. But, most of us would not trade our system for another. The presidential election year is especially exciting when you can share it with your kids. I cannot calculate or even recall how many dinnertime discussions we had where all of us would debate the issues and evaluate the candidates. It was great fun to watch the kids engage in the electoral process. While I lean toward the political right, I tried to be a fair (and balanced) moderator during these dinnertime debates. My prediction is that 3 of the 5 will be Democrats, 1 will be a Republican (but doesn’t know it yet) and the 5th kid could go either way. As we know, one’s political affiliations tend to ch

Leadership is convincing folks to follow a new and uncomfortable path. Folks have to believe that the new direction will ultimately serve their interests, even if it feels awkward and unsettling at first. This works when there exists a foundation of trust between leader and followers. Otherwise, there will be doubt as to the motives of the leader who will be suspected of serving his own parochial interests, and not the greater good.  Consider some examples. If your boss has always been stingy, it may be difficult for him to convince workers that the 'new and improved' health care plan is better for their families. If a presidential candidate receives $400 haircuts, can he convince the hoi polloi that he understands the common man and his travails? If a religious leader is discovered siphoning donations into his private accounts, will folks still call the ‘prayer line’ to offer a tithe? When trust in the leader is squandered, distrust lingers and will frustrate and impede f

His signature is, 'Your're Fired!'. Photo by Gage Skidmore Rarely, I have fired patients from my practice. Why do I do this? You might think that we send out termination letters to patients who haven’t paid their medical bills. We don’t. We try to work with these folks and will keep seeing them as long as they are making the barest effort to address their financial responsibilities. If they refuse to make any payment, or won’t return our billing office’s phone calls, or are hostile to our staff. then we may withdraw as their physician, provided there is no medical urgency present. Our office will see patients who have no medical insurance so that these folks have access to medical care. The process of terminating a professional relationship between physicians and patients is well presented in EverythingHealth , one of my ‘must read’ medical blogs. The more typical reason why we fire patients from the practice is because of continued behaviors and actions which place t

Pharm Tractor Mining Physician Data Drug reps come to our office fairly regularly, but not as often as they used to. Some of them look like regular folks, but many still look a lot like Barbie and Ken. These guys have a tough job. It’s hard to cultivate relationships when you can’t pay off physicians with free trips or offers of remuneration for serving as a ‘consultant’. Remember ‘dine and dash’? Despite these prior excesses, I do not disparage pharm reps, many of whom are ethical professionals who have developed vertical knowledge on a narrow niche of medicine. I have learned from them, but I remember that they are salesmen. Caveat emptor. Drug reps face other challenges beyond the ban on ballgame and theater tickets. We physicians are often constrained by insurance company formularies that dictate what we can prescribe. The insurance companies would balk at that statement and would offer a lawyerly response that, of course, we physicians can prescribe any drug that we believe

Some time ago, I rented a car during a visit to another city. I chose among the various categories of vehicles which are listed from the last expensive to the most costly. Here were my choices. • Economy • Compact • Intermediate • Standard • Full Size • Premium • Luxury As I have pointed out on this blog with regard to medical care, people spend other people’s money much more easily than they spend their own. This is why I have argued that patients need to have some ‘skin in the game’ to serve as a brake on profligate medical spending. There may be other effective brakes to consider, but diagnostic and therapeutic restraint demanded by patients is a potent and reasonable option. In the rental car case, I was not on someone else’s expense account, but was handing over Kirsch cash. I chose a standard sized vehicle. Of course, I could have saved $$$ by driving off in an economy vehicle, but rental cars are priced like movie popcorn. For a few dollars more per day, you c

I regard myself as a spirited patient advocate. (What doctor doesn’t?) When facing a patient, I try to focus entirely on the patient’s interest. My advice is hopefully not tainted by the patient’s insurance status or external influences. A patient without medical insurance should receive the same medical advice as a corporate CEO, although the former may reject the medical advice for financial reasons. As Whistleblower readers know, I am a conservative practitioner of the art and science of gastroenterology. I first developed this medical world view as an intern and resident, and remained a parsimonious practitioner even after completing a gastroenterology fellowship at an institution where patients were routinely subjected to a tsunami of testing. I don’t pull the colonoscopy trigger easily or order many imaging studies. I prefer to prescribe a tincture of time instead of a test. Most patients appreciate this measured approach, although some prefer the tsunami. I don’t practice

We live in a free society. One of our most treasured freedoms is our right to free speech. This means that we are free to advertise goods and services to potential customers, although commercial speech does not enjoy the same constitutional protection as does noncommercial speech. Some advertised products are good for us and others aren’t. In many cases, the worth and value of the product are in dispute. Nevertheless, if a product is legal, the manufacturer is entitled to advertise and to lure customers. While an advertisement may not be false, it may not be the complete truth either. We expect that these pitches will be buffed and sanitized to present the product in a favorable light. That’s why they’re called advertisements, and not testimony. It would be absurd for a company to include negative material about its products in its promotional materials, barring a legal requirement to do so. While issuing product warnings and legal disclaimers may be a laudable public interest mane

A hundred bucks doesn’t buy much these days. A crisp Ben Franklin can be exchanged for 50 Big Macs A Broadway show ticket A night in a New York City hotel (just joking) A college textbook (paperback) Your life Your life? Yes, 5 crumpled Andy Jacksons can save your life, as was reported earlier this year in a front page article in The Plain Dealer, Cleveland’s only daily newspaper. University Hospitals is now offering a $99 spiral computed tomography (CT scans) of the chest in individuals who are at increased risk of developing lung cancer. The rationale is that if cancers can be detected early, then the cure rate for surgical removal is very high. Gary Schwitzer, medical blogger and press watchdog, tries to bring some balance to the distorted media coverage of CT lung cancer reportage. The test is not covered by insurance, so consumers will have to hand over 10 Al Hamiltons to get in the door. I’m a deep skeptic of this effort, and predict that with some more time, the